V. Chakravorty1,2, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 3New Jersey Medical School,Department Of Surgery,Newark, NJ, USA
Introduction: Although fascial closure of a midline incision is a part of nearly all abdominal operations, the “ideal” or “best” method remains controversial. Numerous randomized controlled trials (RCT) have evaluated different methods of fascial closure with regards to time required and complications, but lack of consensus leads most surgeons to be guided by experience, anecdote, and training. This meta-analysis critically analyzes all existing RCTs to establish an evidence based approach to fascial closure which limits complications (dehiscence, surgical site infection, and incisional hernia).
Method: A comprehensive search of PubMed, Google Scholar, and the Cochrane and NIH registry of clinical trials assessing continuous or interrupted fascial suture closure of a midline laparotomy was performed. Outcomes analyzed were fascial dehiscence, surgical site infection, incisional hernia development, and time required for closure.
Results: 15 studies involving 9,539 patients were identified. No significant difference in fascial dehiscence (p=0.801) or incisional hernia rates (p=0.407) were observed between continuous and interrupted fascial closure. Wound infection rates were significantly higher with continuous compared to interrupted technique (RR 1.248, CI 1.074 to1.45; p=0.004). Time required for wound closure was significantly lower with continuous (14.1 min) compared to interrupted closure (22.3 min) (Z=-4.119; p<0.001). Subgroup analysis identified that a significantly lower rate of fascial dehiscence occurred with non-absorbable suture placed in a continuous fashion (1.37%) than with interrupted absorbable suture (5.18%) (p=0.02). Subgroup analysis of wound infection and incisional hernia rates showed no significant difference between the 4 different suture techniques (absorbable/non-absorbable and continuous and interrupted).
Conclusion: Continuous fascial closure required significantly less time than interrupted suture technique. Dehiscence and incisional hernia rates were not significantly affected by suturing technique; however analysis of different suture material identified a clear advantage for continuous non-absorbable closure over interrupted absorbable closure. Delayed or non-absorbable suture material placed in a continuous fashion offers significant advantages in terms of time, dehiscence rate, and a slightly lower incisional hernia rate (7.3% vs. 8.82%, p=NS), but a slightly higher wound infection rate (8.1% vs. 6.36%, p=NS) compared to absorbable interrupted suture. Additional studies controlling for wound classification, # of prior laparotomies, suture type/size, ASA class, and co-morbidities are required for more precise recommendations on optimal laparotomy fascial closure technique.
