To evaluate the knowledge of abdominal wall closure in a cohort of specialist general surgeons who are members of the AEC and to see its adequacy with current recommendations. Sub-analysis in terms of years of specialization.
Material and methodsIndividual questionnaire of 21 questions on abdominal wall closure in elective and urgent context.
ResultsA total of 371 responses were received from specialist surgeons who are members of the AEC. Closure of the median laparotomy is performed with continuous suture in 99.7% and with slowly absorbable materials in 95.4%. 88.4% of surgeons report using the ratio equal to or greater than 4:1 between suture length and incision length (SL:IL) and short stitches. These results are equivalent in transverse and urgent elective laparotomy. 85.2% of the respondents systematically close trocars of 10 mm or more and 30.7% use prophylactic mesh in high-risk patients. Surgeons with less than 10 years of experience use the ratio ≥ 4:1 SL:SI and short stitches more than surgeons with more experience (93.4% vs 84.9%; P = .013).
ConclusionsAbdominal wall closure among general surgeons who are members of the ACS is adequate and adjusted to the recommendations with a tendency to improve among surgeons with less experience. There is an opportunity for improvement in the use of prophylactic mesh in high-risk patients.
Evaluar el conocimiento de cierre de pared abdominal en una cohorte de cirujanos generales especialistas miembros de la AEC y ver su adecuación con las recomendaciones actuales. Subanálisis en cuanto a años de especialización.
Material y métodosCuestionario individual de 21 preguntas de cierre de pared abdominal en contexto electivo y urgente.
ResultadosSe han recibido un total de 371 respuestas de cirujanos especialistas miembros de la AEC. El cierre de laparotomía media se realiza con sutura continua en un 99,7% y con materiales de absorción lenta en un 95,4%. Un 88,4% de los cirujanos refiere utilizar la relación igual o superior a 4:1 entre la longitud de la sutura y la longitud de la incisión (LS:LI) y puntos cortos. Dichos resultados son equivalentes en laparotomía electiva transversa y urgente. Un 85,2% de los encuestados cierran los trócares de 10 o más milímetros sistemáticamente y un 30,7% utilizan malla profiláctica en pacientes de alto riesgo. Los cirujanos con menos de 10 años de experiencia utilizan más la relación ≥ 4:1 LS:LI y puntos cortos (93,4% vs 84,9%; P = ,013).
ConclusionesEl cierre de la pared abdominal entre los cirujanos generales miembros de la AEC es adecuado y ajustado a las recomendaciones con una tendencia a mejorar entre los cirujanos con menor experiencia. Existe oportunidad de mejora en el uso de malla profiláctica en pacientes de riesgo.
The rate of incisional hernia is not negligible, being 12.8% at 24 months in a systematic review and meta-regression study that includes 14,000 patients.1 Presentation of an incisional hernia leads to poorer quality of life and increased healthcare costs.2,3 Furthermore, the subsequent repair of an incisional hernia will entail possible hernia recurrence of between 13% and 35%, depending on follow-up, a percentage that increases with each new repair.4–6
Against this backdrop, our efforts must focus on prophylaxis of the appearance of incisional hernia, starting with good closure of the abdominal wall. This review of abdominal wall closure is based on the recommendations on wall closure issued by the European Hernia Society in 2015 and its subsequent joint update with the European and American Hernia Society in 2022.7,8 The recommendations issued are as follows: (1) closure of the elective midline laparotomy with continuous suture with slow-absorbing monofilament, applying the ratio equal to or greater than 4:1 between the length of the suture and the length of the incision (LS:LI) and also using short stitches (also known in the literature as “small bites,” which consist of making stitches 5 mm apart from the midline and 5 mm between stitches)9; (2) closure of the laparoscopic trocar holes whenever they are 10 or more millimetres; (3) use of prophylactic mesh in at risk patients, understanding at risk patients to be those with abdominal aortic aneurysm or those who are obese. There are no recommendations regarding the closure of elective transverse laparotomy, nor regarding the type of closure of trocar holes or emergency laparotomies, nor is there sufficient evidence to make recommendations regarding the calibre of the suture or the size of the needle used for closure.
ObjectivesTo assess the knowledge of elective and emergency abdominal wall closure in a cohort of specialist general surgeons who are members of the AEC and to analyse the degree of adequacy in relation to the referenced abdominal wall closure guidelines. Sub-analysis to be made regarding years of specialisation of the surgeons participating in the survey.
Material and methodsA survey of 21 multiple-choice questions, without the possibility of free response, about abdominal wall closure in all types of laparotomies and in elective and emergency contexts was distributed online and through the AEC to specialist general surgeons who were members of the AEC.
The survey was distributed twice. The first distribution was made on 06/05/2024 and closed on 03/06/2024 to all AEC members who gave their consent to receive communications: 2936 members. The second distribution was made on 03/06/2024 until 20/06/2024, only to AEC members who gave their consent and who were also registered in the AEC Abdominal Wall Section: 1058 registered members.
The survey consisted of five blocks of questions on abdominal wall closure in (1) elective midline laparotomy, (2) elective transverse laparotomy or laparoscopic assistance, (3) trocar holes, (4) prophylactic mesh in risk situations and (5) emergency laparotomy (Appendix A).
ResultsIn the first round of the survey a total of 249 responses were received (8.48% of those requested) and in the second round, 122 (11.53%). A total of 371 specialist AEC member surgeons responded to the survey. Fifty-nine per cent of the surgeons who responded to the survey had over 10 years’ experience as a specialist. Respondent distribution in terms of the subspecialty was as follows: 44% Abdominal Wall; 21% Colorectal; 11% Oesophagogastric and Bariatric; 9% Hepatobiliary-pancreatic; 8% Emergencies; 4% Breast, and 3% Endocrine.
First and second survey blocks: elective laparotomy closureTables 1 and 2 describe the results of the survey on elective laparotomies (midline and transverse), with continuous closure being the preferred choice (99.7% and 96.2%, respectively), with slow-absorbing suture in more than 90% of cases, and the suture size chosen by half of the surgeons being 2/0. The ratio ≥ 4:1 LS:LI and short stitches were used by more than 85% of the respondents. The left-hand column of Table 1 records the percentages of recommendations of the referenced guidelines. Table 2 does not include the percentage of adequacy, since no recommendations are issued in the guidelines for this type of laparotomy. In any event, the type of closure and the material used are super-imposable with that of elective midline laparotomy.
First survey block: elective midline laparotomy.
| Survey question | Multiple response | n (%) ‡ | % Adequacy ¥ |
|---|---|---|---|
| 1. Type of closure | Continuous | 370 (99.7%) | 99.7% adequacy |
| Loose sutures | 1 (.3%) | ||
| 2. Suture material | Non absorbable | 5 (1.3%) | 95.4% adequacy |
| Short lasting absorbable | 7 (1.9%) | ||
| Long lasting absorbable | 354 (95.4%) | ||
| Other | 5 (1.3%) | ||
| 3. Suture calibre | 1 | 79 (21.3%) | No recommendation |
| 0 | 105 (28.3%) | ||
| 2/0 | 185 (49.9%) | ||
| Other | 2 (.5%) | ||
| 4. Ratio ≥ 4:1 LS:LI and short stitches | Yes | 328 (88.4%) | 88.4% adequacy |
| No | 43 (11.6%) |
Second survey block: transverse or laparoscopic-guided incision laparotomy closure.
| Survey question | Multiple response | n (%) ‡ |
|---|---|---|
| 1. Type of closure | Continuous | 357 (96.2%) |
| Loose sutures | 14 (3.8%) | |
| 2. Suture material | Non absorbable | 6 (1.6%) |
| Short lasting absorbable | 22 (5.9%) | |
| Long lasting absorbable | 335 (90.3%) | |
| Other | 8 (2.2%) | |
| 3. Suture calibre | 1 | 67 (18.1%) |
| 0 | 113 (30.5%) | |
| 2/0 | 189 (50.9%) | |
| Other | 2 (.5%) | |
| 4. Ratio ≥ 4:1 LS:LI and short stitches | Yes | 319 (86.0%) |
| No | 52 (14.0%) |
Regarding the closure of trocar holes measuring 10 mm or more, this was systematically performed by 85.2% of surgeons, with loose sutures of long-lasting absorbable material in 49.9% of respondents, with a 0 calibre in the majority (Table 3). With respect to trocar holes themselves, the referenced guidelines only recommend that trocar holes measuring 10 mm or more should be closed, but do not specify how they should be closed.
Third survey block: trocar hole closure.
| Survey questions | Multiple response | n (%) ‡ | % Adequacy ¥ |
|---|---|---|---|
| 1. Systematic closure > 10 mm | Yes | 316 (85.2%) | 85.2% adequacy |
| No | 55 (14.8%) | ||
| 2. Type of closure | Continuous | 79 (21.3%) | No recommendation |
| Loose sutures | 292 (78.7%) | ||
| 3. Suture material | Non absorbable | 3 (.8%) | No recommendation |
| Short lasting absorbable | 174 (46.9%) | ||
| Long lasting absorbable | 185 (49.9%) | ||
| Other | 9 (2.4%) | ||
| 4. Suture calibre | 1 | 77 (20.8%) | No recommendation |
| 0 | 164 (44.2%) | ||
| 2/0 | 126 (34.0%) | ||
| Other | 4 (1.1%) | ||
| 5. Ratio 4:1 LS:LI and short stitches | Yes | 121 (32.6%) | No recommendation |
| No | 250 (67.4%) |
n = number of surgeons surveyed with the mentioned response (%) in brackets the percentage they represent of the total.
Adequacy of the closure measure recommended in the Abdominal Wall Closure Guidelines, there is only a recommendation on the first page of this block.7,8
Prophylactic mesh in patients at high risk of incisional hernia is applied by 30.7% of respondents. In this section, the referenced clinical guidelines only indicate patients with abdominal aortic aneurysms or obesity as risk factors for the adoption of prophylactic mesh.
Fifth survey block: emergency laparotomy closureRegarding emergency laparotomies, 90.6% of the surgeons surveyed did not change their usual clinical practice, closing with continuous suture in 98.9% and with long-lasting absorbable material in 94.1%. The clinical guidelines do not issue recommendations on the closure of emergency laparotomies.
Closure based on years of specialisation and sub-specialisation in abdominal wall surgeryIf we perform a sub-analysis based on the years of specialist experience of the surveyed surgeons, surgeons with less than or 10 years of professional practice as a specialist more frequently close elective midline laparotomies following the ≥4:1 LS:LI ratio and short stitches than surgeons with more than 10 years and it would seem that they preferred finer suture sizes of 2/0, on more occasions, although this is not statistically significant. No significant differences were observed in the systematic closure of trocar holes measuring 10 mm or more, nor in the use of prophylactic mesh (Table 4).
Monitoring recommendations based on the years of experience of the surveyed surgeons.
| Aspects in the different survey blocks with recommendations in the guidelines regarding Abdominal Wall Closure, based on the years of experience of the specialist surveyed | |||
|---|---|---|---|
| Less than or 10 years as a specialist n = 152 (%) ‡ | More than 10 years as a specialist n = 219 (%) ‡ | P¥ | |
| Elective midline laparotomy with continuous sutures | 152 (100%) | 218 (99.5%) | .404 (N.S.) |
| Elective midline laparotomy with long-lasting absorbable sutures | 146 (96.1%) | 208 (94.9%) | .941 (N.S.) |
| Elective midline laparotomy with 2/0 calibre sutures | 84 (55.2%) | 101 (46.1%) | .083 (N.S.) |
| Midline laparotomy with ratio ≥ 4:1 LS:LI and short stitches | 142 (93.4%) | 186 (84.9%) | .013 * |
| Systematic trocar hole closure ≥ 10 mm | 124 (81.6%) | 192 (87.6%) | .104 (N.S.) |
| Use of prophylactic mesh in at risk patients | 46 (30.3%) | 68 (31.1%) | .909 (N.S.) |
In the sub-analysis according to the main dedication to abdominal wall surgery, which corresponds to 44% of the respondents, there were no statistically significant differences in any of the fields analysed: continuous closure (99.4% vs. 100%), long absorption (94.5% vs. 96.1%), ≥4:1 LS:LI ratio and short stitches (87.1% vs. 89.4%), closure of trocar holes ≥ 10 mm (84.0% vs. 88.1%) or prophylactic mesh (28.2% vs. 32.6%).
DiscussionThe main finding of the study was the very high level of compliance with the referenced guidelines in the closure of elective midline laparotomy among the specialist general surgeons surveyed, regardless of their specialty in abdominal wall surgery. These results are much better than those reported 10 years ago in a similar cohort in Spain in which only 57% of surgeons used slow-absorbing sutures and only 43% used a ≥4:1 LS:LI ratio for closure, not to mention that up to 66% of surgeons used full sutures in emergency midline laparotomy.10 Furthermore, there appears to be a trend towards less experienced surgeons having better training in abdominal wall closure, with a significant percentage of surgeons with less than 10 years of experience using a ≥4:1 LS:LI ratio and short stitches for closure (93.4% vs 84.9%; P = .013). We believe that this improvement has been due to a greater awareness among general surgeons in abdominal wall closure, supported by a wide range of courses offered by the AEC in Abdominal Wall Closure Training for first-year residents. Although it is not possible to know the number of respondents who had taken the courses, since 2014, approximately 250 residents have been trained per year, spread across 12 locations, which would correspond approximately to the number of General Surgery positions offered in Spain per year, so a large number of residents since 2014 would have received the training. The results of our survey are comparable to other more recent surveys in Europe and the United States,11–13 as well as at state level14,15 (Table 5).
Summary of abdominal wall closure survey studies.
| Author (year) | Location | Type of laparotomy | Specialty of the survey participants | Number of surgeons who responded | Number of questions | Degree of compliance of the respondents' responses to the recommendations of the main Abdominal Wall Closure guidelines, describing the number of respondents who answered correctly. (N.P.) Question not asked in the aforementioned survey. | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Elective midline laparotomy continuous | Elective midline laparotomy Long-lasting reabsorbable | Use of 4/1 ratio and short stitches | Systematic trocar hole closure of more than 10 mm | Use of prophylactic mesh in at risk patents | ||||||
| Pereira9 (2013) | Catalonia | Midline and transverse (Elective) | General surgery (specialists and resident physicians) | 140 | 20 | 80% | 57% | Ratio 4/1:43% | N.P. | 37% |
| Short stitches :N.P. | ||||||||||
| Fischer10 (2019) | USA and Europe | Midline and transverse (Elective) | General surgery, 75% vascular and urology surgeons and 25% gynaecology | 497 | 14 | 80.8% | 80.8% | Ratio 4/1:78.7% | N.P. | 15.3% |
| Short stitches:71.8% | ||||||||||
| Bloemen11 (2019) | Holland | Midline (Elective) | General surgery (specialists and resident physicians) | 402 | 24 | 98% | 93% | Ratio 4/1:36% | N.P. | N.P. |
| Short stitches:17% | ||||||||||
| Paulsen12 (2020) | Denmark | Low midline (Elective) | Gynaecology and general surgery | 252 | 18 | N.P. | N.P. | N.P. | N.P. | N.P. |
| Pereira13 (2021) | Catalonia | Midline (Elective) | General surgery, vascular and urology (specialists and resident physicians) | 44 | 11 | 74.8% | 83.9% | Ratio 4/1:51.8% | N.P. | 81.6% |
| Short stitches:81.7% | ||||||||||
| Pous-Serrano14 (2023) | Spain | Midline, transverse and trocar (Elective and emergency) | General surgery (sub-speciality in colorectal surgery) | 53 | 25 | 96.2% | 100% | 84.9% | 50.9% | 24.5% |
| Juvany (2024) | Spain | Midline, transverse and trocar (Elective and emergency) | General surgery (specialists) | 371 | 21 | 99.7% | 95.4% | 84% | 85.2% | 30.7% |
Regarding the calibre of the suture material used, although it has been demonstrated in three clinical trials that closure with short stitches is correlated with a lower eventration rate, there is no evidence regarding which calibre of the suture material should be the most appropriate. In all three trials long-lasting absorbable suture materials of 2/0/016–18 were used. The use of 2/0 calibre material is around 50% in the closure of all laparotomies, with an increasing tendency being observed among less experienced surgeons, although without statistical differences (55.2% vs 46.1%; P = .083). Although to date there is no direct and clear clinical evidence regarding the calibre of the suture material, we think that it could be a point to be taken into account among general surgeons.
Regarding trocar hole closure, 85.2% of the surgeons surveyed systematically close holes of 10 or more millimetres. This is of some concern since 14.8% of surgeons do not close them, bearing in mind that the rate of incisional trocar hernia may reach 25%–27% at and 1.5 and 3 years follow-up with trocar closure of short-duration absorbable material.19,20 As a result, it is particularly important to pay attention when placing trocars and in their appropriate closure.20 The type of material used to close trocar holes could also be a matter of debate, since although there is not enough evidence to recommend any slow-absorbing material, it would be expected that, as with the closure of elective midline laparotomy, this could help to reduce the rate of incisional hernias of trocar holes. Despite this, only 49.9% of surgeons close trocar holes with long-lasting absorbable material.
Finally, perhaps the most controversial issue in the survey results is that 69.3% of the surgeons surveyed admit not using prophylactic mesh in patients at high risk of eventration. Although this mesh use is e low, the percentage is higher than in the survey carried out among surgeons in the United States and Europe in which only 15.3% used prophylactic mesh in patients at risk.10 There is sufficient evidence that the use of prophylactic mesh is cost-effective in most studies and does not significantly increase complications of clean/contaminated elective surgery,21 and a non-absorbable synthetic mesh can be used safely in both elective and emergency surgery, significantly reducing the rate of incisional hernia, both in elective surgery22–25 and in emergency surgery.26–29
The main limitation of the study is the low 12.6% response rate among surgeons to whom the survey was sent. However, it would seem that the low response rate of most of this type of online survey would not greatly affect the validity of the results.30
ConclusionsThe closure of the abdominal wall among the general surgeons who are members of the AEC in Spain is adequate and matches guideline recommendations, with there being a tendency to improve among less experienced surgeons. The point that generates the most controversy is the use of prophylactic mesh in patients at risk. We observe a growing interest among general surgeons in the correct closure of the abdominal wall that will very probably translate into a lower incidence of incisional hernia in a few years. And we must not forget that the best treatment of incisional hernia is precisely this, its prevention.
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Julio Gómez-Menchero
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Salvador Pous-Serrano
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Belen Porrero
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Carles Olona
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Antonio Ríos
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Jacobo López-Trebol
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Alberto López-Farias
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Luís Tallón-Aguilar
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Pilar Hernández-Granados
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Manuel López-Cano
The following is Supplementary data to this article:
