@Loop & Insights

8/14/2019 @Loop & Insights

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Poland

Loop suture in abdominal wound closure

advantages or illusions?

S. Dbrowiecki. S. Pierciski. A. Kapaa. S. Prywiski. W. Szczsny. W. Gnika.J. Pypkowski. J. Szopiski. D. Sosnowski. J.Szmytkowski. P.Wierzchowski. J.

Andruszkiewicz

Dept. of General & Endocrine Surgery, Collegium Medicum,

Bydgoszcz, Poland
http://www.umk.pl/en/university/patron/http://www.umk.pl/en/university/http://www.umk.pl/en/university/http://www.umk.pl/en/university/http://www.umk.pl/en/university/


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PDS IIEthiconNeedle Type

NeedleShape

NeedleLength

MaterialSutureLength

CT 1/2

Circle

40mm Violet

Monofil

ament

36"

~90cm

Absorption time

180 210 days


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Bohanes T. Role of modern absorbable suture materials indecreasing the occurrence of early complications after laparotomy.

Rozhl Chir. 2002; 81: 24-6Results: PDS loop & Vicryl - less freq. early complication, lessinfection;

burst abdomen and hernia - more frequent in Silon group; PDS loopvs Vicryl - no difference between group

Conclusion: Running, mass closure is the best method of lap woundclosure

Hoch J.. Murinova D. Laparotomy closure with continuouspolydioxanone sutures Rozhl Chir. 1995;74:198-200.

Results: PDS loop suture utilized in 166 laparotomies; fast, simple,and safe method

Engelova D.. Antos F.: Surgical wound dehiscence and a techniquefor laparotomy closure with continuous loop sutures. Rozhl Chir.1995;74:172-5.

Results: frequency of a burst abdomen: silon 2.2% vs PDS loop1.2%


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RCT: polyglactin 910 (Vicryl) vs

polydioxanone loop (PDS loop)

340 pts. elective procedure,

layered abdominal closure

Results: at FU 2y 2.9%

incisional hernias


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Research design

Pts with the elevated risk of the complications in laparotomy wound healing

Standardized technique of laparotomy wound closure

End points:

Primary: wound dehiscence. incisional hernia

Secondary: infection, edema, erythema, seroma, suture sinus, and pain

FU: examination at the outpatient department at 1, 3, and at least at 12 ms

after the surgery


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Inclusion criteria

age > 65 y

BMI > 30 neoplasmatic disease (life expectancy >1 y)

hipoalbuminemia 2.5 h

anemia < 10g%

sepsis with abdominal origin

pneumonia or COPD

hemodynamic instability

combine

dindicatio

ns


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Surgical technique


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A B

C

Surgical technique

obligatory: mass closure, running

suture, monofilament, PDS 2-0

randomization: single vs loop

suture

registered values : wound length,

suture length, number of loops

calculated variables : SL/WL,

loops distance, width of sutured


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Patients Indication to surgery

32 diseases; the most frequent:

42 ca colonis

41 morbid obesity

33 different path. of biliary tract

19 dig. tract perforation

7 ca ventriculi

6 abdominal trauma


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Evaluation

P-ts lost to FU

following 1 ms 8 pts

3 ms 17 pts

12 ms 27 pts

Statistical analysis:

Kaplan & Meier product-limit method comparing two andmultiple samples

Cox's Proportional Hazard Model

Mann-Whitney U Test


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laparotomy localisation; wound drainage; skin closure technique; skin healing on discharge

no difference

ns

nsns

Difference

13.211.912.5 (2-79)Hospitalization (days)

M/F; ASA; lap wound healing risk factors (surgical vs medical vs combined); urgent vs elective

treatment; indication to surgery no difference

13.513.813.6 (6-37)Possum scale points

56.955.456.3 (21-92)

Age years; mean

(range)

10085185Pts number

SingleLoopAll

Groups comparison


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Results the whole group


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5510Deaths

5510Burst abdomen

171027Incisional hernia

PDS SinglePDS LoopAll

Results in the compared groups


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Cumulative prop. of surviving w/o burst abdomen or hernia

months


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Cumulative prop. of surviving w/o burst abdomen


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Cumulative prop. of surviving w/o incisional hernia


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Not always more - means better


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Poland

Insights into individual technique of

post-laparotomy wound closure

S. Dbrowiecki, S. Pierciski, A. Kapaa, S. Prywiski, W. Szczsny, W. Gnika, J. Pypkowski,

J. Szopiski, D. Sosnowski, J. Szmytkowski, P. Wierzchowski, J. Andruszkiewicz

Dept. of General & Endocrine Surgery, NCU College of Medicine, Bydgoszcz,

Poland
http://www.umk.pl/en/university/patron/http://www.umk.pl/en/university/http://www.umk.pl/en/university/http://www.umk.pl/en/university/http://www.umk.pl/en/university/


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OROR

What matters more?

vertical midline incision, 12 ms FU 5% - 15% incisional hernias (= 50%

whole hernias)

burst abdomen up to 3%; mortality rate > 25%


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Israelsson LA:The surgeon as a risk factor for

complications of midline incisions. Eur J Surg.

1998;164(5):353-9

CONCLUSION: The suture technique, monitored by the

SL:WL ratio, is the most important factor for variability in

the incidence of incisional hernia among surgeons in

continuously sutured midline incisions. The suture

technique may also help to explain the variability in rates

of wound infection.


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SL / WL

The width of the

sutured fascia margin

The distance of the

subsequent suture loops


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Research design

Pts with the elevated risk of the complications in laparotomy wound healing

Standardized technique of laparotomy wound closure

Endpoints:

Primary: wound dehiscence. incisional hernia

Secondary: infection, edema, erythema, seroma, suture sinus, and pain

FU: examination at the outpatient department at 1, 3, and at least at 12 ms

after the surgery


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Inclusion criteria

age > 65 y

BMI > 30

neoplasmatic disease (life expectancy >1 y)

hipoalbuminemia 2.5 h

anemia < 10g%

sepsis with abdominal origin

pneumonia or COPD

hemodynamic instability

combine

dindicatio

ns


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Patients n=185

IV = 29(17,1%)

III = 26(15,3%)

II = 89

(52,4%)

I = 26

(15,3%)Contamination

Other =92

(49,2%)

BMI = 41(21,9%),

Cancer =53(29%)

Indication to

procedure

IV = 6(3,5%)

III = 64(37,4%)

II = 93 (54,4%)I = 8(4,7%)

ASA

Urgent =121(65,6%)

Elective = 64(34,4%)

Procedure

Mean age 56.3 (21-92)M = 91

(49,2%)

F = 94

(50,8%)

Gender


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Patients Indication to surgery

32 diseases; the most frequent:

42 ca colonis

41 morbid obesity

33 different path. of biliary tract

19 dig. tract perforation

7 ca ventriculi

6 abdominal trauma


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Surgical technique


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A B

C

Surgical technique

obligatory: mass closure, running

suture, monofilament, PDS 2-0

randomization: single vs loop

suture

registered values : wound length,

suture length, number of loops

calculated variables : SL/WL,

loops distance, width of sutured


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Study group

12 physicians: SD, AK, SP, WSz, WG,

JP, SPi, JSz, KSz, DS, PC, IN

4 consultants, 8 residents


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Perioperative variables

Wound length, suture length, number of suture loop accros the

wound

SL/WL; SL/loop fascia margin, WL/loop suture distance

Technical variables

Pts: age, sex, ASA, perioperative Possum score, wound healing

complication risk factors, indications to surgery (BMI vs carcinoma vs

other)

Elective vs urgent treatment

Laparotomy localisation (median vs paramedian)

Wound contamination class


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Wound closure detalis vs patients age


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Wound closure detalis vs Possum score


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Perioperative variables vs wound closure

Varibles suture distance fascia margin

indication to surgery p=0.001 p=0.02

risk factors p


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Conclusions

Simple measurements and counting during wound closure allows on insight

into a individual surgical technique.

Surgeons differ considerably in details of their surgical technique even

during the standardized closure of a operative wound

Surgeons repeatability of simple manoeuvres is small/moderate (muscular

memory is poor)

There are probably numerous factors (patient, illness, laparotomy) which

influence beyond our consciousness the execution of a surgical technique

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