Development of incisional herniation after midline laparotomy

Abstract

BackgroundIncisional herniation is a common complication after abdominal surgery associated with considerable morbidity. The aim of this study was to determine whether incisional hernia is an early complication, in order to understand better the aetiology of incisional hernia formation.MethodsThis study involved the secondary analysis of a subset of patients included in a large RCT comparing small and large tissue bites (5 mm every 5 mm, or 1 cm every 1 cm) in patients scheduled to undergo elective abdominal surgery by midline laparotomy. The distance between the rectus abdominis muscles (RAM distance) was measured by standardized ultrasound imaging 1 month and 1 year after surgery. The relationship between the 1‐year incidence of incisional hernia and the RAM distance at 1 month was investigated.ResultsSome 219 patients were investigated, 113 in the small‐bites and 106 in the large‐bites group. At 1 month after surgery the RAM distance was smaller for small bites than for large bites (mean(s.d.) 1·90(1·18) versus 2·39(1·34) cm respectively; P = 0·005). At 1 year, patients with incisional hernia had a longer RAM distance at 1 month than those with no incisional hernia (mean(s.d.) 2·43(1·48) versus 2·03(1·19) cm respectively; relative risk 1·14, 95 per cent c.i. 1·03 to 1·26, P = 0·015).ConclusionA RAM distance greater than 2 cm at 1 month after midline laparotomy is associated with incisional hernia. Closure with small bites results in a smaller distance between the muscles.

Does small bite closure reduce the incidence of incisional hernia compared to standard mass closure for midline laparotomy?

“…A total of 5 high-quality studies were used to generate this review, 4 RCTs, 3 studies showed a statistically significant difference in the incidence of incisional hernia in favour of the small bite technique, but in all studies the incidence was higher in the large bite group. All studies have large sample size, and 3 were double-blinded and multicentric, while the other 3 studies [ 4 , 5 ] were single centre and not blinded. Follow up period of 12 months amongst most the studies was relatively short, given that incisional hernia can develop years after primary operation [ 13 ].…”

Small bite closure in midline laparotomy; A practice to reduce the surgical site infection, wound dehiscence, and incisional hernia

“…[15] The incidence of incisional hernia is significantly lower in small-bite closure than large-bite closure in other studies found in the literature. [13,16]…”

Fascial Closure

“…In hand surgery, a gap formation of 2 mm is associated with tendon ruptures and scarring. Similarly, 12 mm of gapping of a laparotomy closure over the first 30 days after repair is associated with a 94% chance of incisional hernia formation [43].…”