Prophylactic Retention Sutures in Midline Laparotomy in High-Risk Patients for Wound Dehiscence: A Randomized Control Trial

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Zhamak Khorgami. "Prophylactic Retention Sutures in Midline Laparotomy in High-Risk Patients for Wound Dehiscence: A Randomized Control Trial". Journal of Surgical Research. 2013. 180(2):238-243.
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Clinical Question

Among high-risk patients, do prophylactic retention sutures reduce the risk of wound dehiscence compared to standard fascial closure?

Bottom Line

Retention sutures are a beneficial prophylactic strategy for at-risk patients to reduce the risk of fascial dehiscence, which carries significant morbidity.

Major Points

Retention sutures are stitches placed from the fascia to the skin and anchored externally to redistribute horizontal tension away from the midline. Reducing midline tension improves the conditions for fascial healing. Routine use of this technique use is not recommended, as the risks include inadvertent damage to underlying intestine, skin maceration, increased incisional pain, and local wound infection [1] . However, its use has been described prophylactically in elective and trauma scenarios.[2]

This prospective RCT assessed the prophylactic use of retention sutures in preventing dehiscence in midline laparotomy of 300 high risk patients undergoing emergency and elective surgeries. The authors report a decrease in dehiscence from 13.5% to 4.1%, resulting in fewer operations. Evisceration rates were equal, likely related to it being a rare event. No differences existed between wound infections, length of stay, and in-hospital mortality. The median followup of 5 months was too short to adequately assess incisional hernia rate.

Guidelines

  • European Hernia Society guidelines on the closure of abdominal wall incisions. [3]
    • No recommendation can be given due to insufficient data (3 studies, 2 favorable, 1 negative)

Design

  • N = 300 patients enrolled, 150 control, 150 intervention

*N = 148 control, 147 ultimately analyzed

  • Setting: two centers associated with Tehran University Medical Sciences
  • Enrollment: double blinded, central randomization from 2008 to 2010
  • Follow-up: median 5 months, 3-15 months
  • Analysis: Student t-test, Mann-Whitney U test
  • Primary outcome: Wound dehiscence, determined by physical exam, ultrasound

Population

Inclusion Criteria

  • incision length ≥ 10cm
  • 2 or more risk factors for wound healing
    • poor nutritional status (cachexia/hypoalbuminemia)
    • emergent surgery
    • intra-abdominal infection
    • extensive-stage malignancy
    • corticosteroids (>10mg/day prednisolone or equivalent for 3/12 months)
    • uremia
    • hypotension (SBP < 90)
    • HgB < 10
    • ascites
    • prolonged ileus
    • chronic pulmonary disease
    • jaundice, bilirubin > 3mg/dL
    • diabetes
    • age > 60 years

Exclusion Criteria

  • age < 18 years
  • Incision length < 10cm
  • death within 2 weeks not related to wound dehiscence (N = 2 control, 3 intervention)


Baseline Characteristics

Data presented for the Intervention Group
  • Age (years) 57 ± 16.4
  • Gender (Male) 81 (55.1%)
  • Type of Surgery
    • Trauma 10 (6.8)%
    • GI Obstruction 16 (10.9%)
    • GI bleeding 8 (5.4%)
    • Malignancy 58 (39.5%)
    • Intra-abdominal infection 34 (23.1%)
    • Other Causes 21 (14.3%)
  • Length of incision (cm) 20.4 ± 5.6
  • Number of Risk Factors 3.4 ± 1.2
    • Age > 60 69 (46.9%)
    • Poor nutritional status 31 (21.1%)
    • Emergent Surgery 58 (39.5%)
    • Intra-abdominal infection 38 (25.9%)
    • Malignancy 83 (56.5%)
    • Corticosteroid Use 4 (2.7%)
    • Uremia 4 (2.7%)
    • Unstable Hemodynamics 8 (5.4%)
    • Hg < 10 78 (53.1%)
    • Preicted abdominal distention 26 (17.7%)
    • Pulmonary disease 12 (8.2%)
    • Jaundice 21 (14.3%)
    • Diabetes 23 (15.6%)

Interventions

  • Control group: #1 nylon 1cm from linea alba with 1cm intervals, locking every 5cm. Skin closed with interrupted 3-0 nylon
  • Intervention: in addition to control protocol, #1 nylon retention sutures every 10cm starting from inferior part of incision containing skin, subcutaneous tissue, rectus, fascia 5cm from midline
    • Retention sutures removed 3-4 weeks when loose and no longer under tension

Outcomes

Comparisons are Intervention Group vs. Standard Closure.’’

Primary Outcomes

Wound Dehiscence
4.1% vs. 13.5% (RR 0.3; 95% CI 0.12-0.73, P=0.007)

Secondary Outcomes

Evisceration
0.7% vs. 2.7 (RR 0.25; 95% CI 0.03-2.22, P= 0.371)
Wound Infection
12.8% vs. 15.6% (RR 0.83; 95% CI 0.47-1.46, P=0.51)
Reoperation due to wound dehiscence
3.4% vs. 13.5% (RR 0.25; 95% CI 0.10-0.65, P= 0.003)
Postoperative hospital stay
20.4 ± 5.6 vs. 21.3 ± 6.9, P=0.332
Incisional hernia
1.4% vs. 2.7% (RR 0.5; 95% CI 0.09-2.7, P=0.684)
In-hospital mortality
4.1% vs. 5.4% (RR 0.75; 95% CI 0.27-2.12, P=0.785)
Postdehiscence mortality
0.7% vs. 2% (RR 0.33; 95% CI 0.03-3.19, P=0.622)
Visual Analogue Scale for Pain Measurement
Day 1 7.4 ± 1.6 vs. 7.3 ± 2.3
Day 2 6.2 ± 1.8 vs. 5.8 ± 2
Day 3 4.5 ± 1.7 vs. 4.1 ±1.2
Day 4 3 ± 1.7 vs. 1.8 ± 1, P<0.001


Subgroup Analysis

  • No subgroup analysis

Adverse Events

  • One superior dehiscence with only exposed omentum was managed conservatively

Criticisms

  • Follow up too short to assess incisional hernia rate
  • no comparison to alternative options such as use of prophylactic mesh or delayed closure techniques [4]
  • Study conducted prior to the STITCH trial, which found that 5mm advances and distance from the skin with focusing only on the aponeurosis were superior to 1cm advances and en-mass closure

Funding

  • Tehran University of Medical Sciences

Further Reading

  1. Rink AD et al. Negative side-effects of retention sutures for abdominal wound closure. A prospective randomised study. Eur J Surg 2000. 166:932-7.
  2. Agarwal A et al. Reinforced tension line suture closure after midline laparotomy in emergency surgery. Trop Doct 2011. 41:193-6.
  3. Muysoms FE et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 2015. 19:1-24.
  4. Huang Q et al. Techniques for Abdominal Wall Closure after Damage Control Laparotomy: From Temporary Abdominal Closure to Early/Delayed Fascial Closure-A Review. Gastroenterol Res Pract 2016. 2016:2073260.