Wound Closure Technique and Acute Wound Complication in

Gastric Surgery for Morbid Obesity

Dezie AJ, Silvestri F, Liriano E, Benotti P American College of Surgeons, September 2000

Journal Club

Department of Surgery

Prince of Wales Hospital

Study Design

• Prospective, randomized study of midline fascial closure technique in gastric bariatric patient

• Conducted between 1991-1998

• 331 consecutive morbidly obese patients

• 2 groups randomized:– Group 1: Continuous fascial closure (n=172)– Group 2: Interrupted fascial closure (n=159)

Study Design• Patients randomized intraoperatively by odd/even MRN

at time of fascial closure

• Randomized suture material (Nylon vs PDS)

• 4 different surgeons performing surgery

• Wounds monitored for 30 days post-op

• End points– superficial wound complications (superficial infections, seromas

and haematomas)– Deep wound complications (deep surgical infections and fascial

dehiscence)

Fascial Closure Technique

Table 1

Conclusions

• No significant differences between techniques in incidences of superficial complications

• Continuous fascial closure were associated with fewer deep complications

• Similar outcomes were observed with both monofilament suture materials

• Continuous fascial closure reduces major acute wound complications in morbidly obese patients undergoing gastric operations

• Strengths– Reasonable patient numbers

– Prospective randomized trial

– Comparing surgical technique and suture material

– Clear endpoints

• Weakness– Inclusion criteria not stately clearly

– Randomization method (not double blinded)

– Ordered categories to show adequacy of randomization technique (patient factors, co-morbidities)

– Identification of complications by surgeons (bias)

– Data collection ?independent source

Meta-analysis of techniques for closure of midline abdominal incisions

• Date of Most Recent Update: 2004

• NHS Centre for Reviews and Dissemination. University of York, York, U.K.

• Abstract and Commentary for: van't Riet M, Steyerberg E W, Nellensteyn J, Bonjer H J, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions.

• British Journal of Surgery. 2002; 89(11):1350-1356.

• 15 studies reviewed (6566 patients)

Results of the Review • Continuous closure using rapidly absorbable versus non-absorbable

sutures (1 RCT, n=751): rapidly absorbable sutures resulted in significantly more incisional hernias (P=0.001), but less suture sinuses (P<0.001) and prolonged wound pain (P=0.003)

• NO statistically-significant difference between the two suture types for any other outcome measure.

• Continuous closure using slowly absorbable versus non-absorbable sutures (5 RCTs, n=2,669): non-absorbable sutures resulted in significantly more wound pain (P<0.005) and suture sinuses (P<0.02)

• NO statistically-significant difference between the two types for the incidence of hernias, wound dehiscence or infection.

Results of the Review

• Interrupted rapidly absorbable versus continuous slowly absorbable (4 RCTs, n=1,992): there was no statistically- significant difference between the groups for any of the outcome measures

• Interrupted non-absorbable versus continuous rapidly absorbable (1 RCT, n=105): there was no statistically-significant difference between the groups for the incidence of hernias, wound dehiscence, or wound infection

Results of the Review

• Continuous versus interrupted (any suture type): the pooled analysis did NOT show any significant difference between the two techniques for incisional hernias (odds ratio 0.9, 95% confidence interval: 0.6, 1.2, P=0.40), or the incidence of wound dehiscence or wound infection (no results presented).

• Analysis of the suture length to wound length ratio (3 RCTs): two studies reported that an increased suture length to wound length ratio of 4:1 or even 6:1 resulted in a significant decrease in the incidence of incisional hernia.

Author's conclusions

• To reduce the incidence of incisional hernia without increasing wound pain or suture sinus frequency, slowly absorbable continuous sutures appear to be the optimal method of fascial closure.

• Adequate suture length (suture length to wound length ratio of at least 4:1)