Hernia DOI 10.1007/s10029-014-1268-y
ORIGINAL ARTICLE
Wound dehiscence: outcome comparison for sutured and mesh reconstructed patients P. Petersson • A. Montgomery • U. Petersson
Received: 28 October 2013 / Accepted: 23 May 2014 Ó Springer-Verlag France 2014
Abstract Purpose Treatment guidelines for abdominal wound dehiscence (WD) are lacking. The primary aim of the study was to compare suture to mesh repair in WD patients concerning incisional hernia incidence. Secondary aims were to compare recurrent WD, morbidity, mortality and long-term abdominal wall complaints. Methods A retrospective chart review of 46 consecutive patients operated for WD between January 2010 and August 2012 was conducted. Physical examination and a questionnaire enquiry were performed in January 2013. Results Six patients were treated by vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) before definitive closure. Three patients died early resulting in 23 patients closed by suture and 20 by mesh repair. Five sutured, but no mesh repair patients had recurrent WD (p = 0.051) with a mortality of 60 %. Finally, 18 sutured and 21 mesh repair patients were eligible for follow-up. The incidence of incisional hernia was higher for the sutured patients (53 vs. 5 %, p = 0.002), while mesh repair patients had a higher short-term morbidity rate (76 vs. 28 %, p = 0.004). Abdominal wall complaints were rare in both groups.
P. Petersson Department of Clinical Medicine, Aarhus University, Aarhus, Denmark A. Montgomery U. Petersson Department of Clinical Sciences, Malmo¨, Faculty of Medicine, Lund University, Lund, Sweden A. Montgomery U. Petersson (&) Department of Surgery, Ska˚ne University Hospital Malmo¨, 205 02 Malmo¨, Sweden e-mail: [email protected]
Conclusions Suture of WD was afflicted with a high incidence of recurrent WD and incisional hernia formation. Mesh repair overcomes these problems at the cost of more wound complications. VAWCM seems to be an alternative for treating contaminated patients until definitive closure is possible. Long-term abdominal wall complaints are uncommon after WD treatment. Keywords Abdominal wound dehiscence Burst abdomen Vacuum-assisted wound closure and meshmediated fascial traction Mesh Suture Incisional hernia
Introduction Abdominal wound dehiscence (WD), or burst abdomen, is defined as a rupture of the wound and a separation of the abdominal wall layers including the fascia, and occurs in up to 5 % of patients after laparotomy [1–4]. In case of emergency operations for peritonitis, even higher incidences may be anticipated [5]. A WD can be partial or complete and sometimes leads to evisceration [2, 6]. Surgical re-closure of the abdominal wall, by suturing, mesh repair or temporary closure with later definite closure, is often necessary. A non-surgical, conservative treatment strategy may be an option in some cases but will invariably result in incisional hernia development [7–9]. Abdominal wound dehiscence has far-reaching consequences and is a potentially life-threatening complication. Mortality rates vary between 0 and 56 %, with the highest incidence reported in WD patients treated with mesh in infected surgical fields [7, 10–14]. Recurrent WD has been described in 4–44 % of sutured patients while mesh repair seems to prevent this complication [14–16]. Incisional hernia incidences for sutured patients have been reported to
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be between 14 and 67 % [7, 17] and 3 % for non-absorbable mesh repairs, provided no mesh infection occurs [16]. If absorbable meshes are used or the patients are treated conservatively without surgical re-closure, the incisional hernia incidence will be close to 100 % [8, 9, 15]. In a recent study, quality of life and perception of body image in patients treated for WD was evaluated [18]. Most patients were treated conservatively in this study. An incisional hernia rate of 83 % was reported and significantly lower body image scores as well as lower scores for physical and mental function were seen when compared to patients who had undergone laparotomy without complicating WD. In 2010, van Ramshorst et al. [4] presented a review on therapeutic alternatives for WD treatment where they concluded that the large variety of treatment options and divergent outcome variables presented make it difficult to evaluate the results. Clinical treatment guidelines are largely lacking. At the Department of Surgery, Ska˚ne University Hospital Malmo¨, the retromuscular mesh technique has been the standard operation for abdominal wall hernia for many years and the advantages as well as pitfalls of the technique are well-known [19]. A novel temporary open abdomen closure technique, with high definite closure rates has been described and evaluated [20–22]. Both these techniques have, over the last years, been implemented into the treatment of WD at the department. Besides conservative treatment for patients not suitable for surgical re-closure, the following three surgical treatment methods have been used in a fairly concurrent way: (1) suturing, (2) open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) followed by either suturing or retromuscular mesh repair or (3) direct reconstruction with retromuscular mesh repair. The primary aim of this study was to evaluate late incisional hernia development after WD treatment using either suture or retromuscular mesh repair as final closure treatment. Secondary objectives were to evaluate incidence of WD recurrence, short-term morbidity (especially wound complications), mortality and long-term abdominal wall complaints.
groups’’. After closure of the VAWCM-treated patients, either by suture or mesh repair, the two ‘‘primary closure groups’’ were defined as the sutured and the mesh repair groups. Finally, the two ‘‘final closure groups’’ were formed consisting of surviving patients that were finally closed with suture or mesh repair and eligible for long-term follow-up according to Fig. 2. Surgical techniques Suture Suture with either a slowly absorbable or a non-absorbable suture (0–0 or 2–0, polydioxanone or polypropylene) was used in patients when the fascia quality was judged sufficient to hold the suture. The studies and results of Israelsson and Millbourn et al. [23, 24], showing benefits of using a suture length to wound length ratio (SL/WL) of at least 4:1, are well-known but wound or suture length was not routinely measured. VAWCM When intra-abdominal swelling prohibited closure of the fascia or other circumstances (e.g., deep wound infection) made it inappropriate to complete a primary closure, open abdomen treatment with VAWCM was used. The technique is described in detail elsewhere [20], summarized below and in Fig. 1. A 30 9 30 cm polypropylene mesh (ProleneÒ; Ethicon, Johnson & Johnson, Somerville, NJ, USA) was cut to fit the curvature of the fascial edges and divided into two halves. The mesh was sutured to the
7 6 5 4 3 2
Material and method All consecutive patients treated for WD after midline laparotomy at the department, between January 2010 and August 2012, were identified by searching the diagnoseand operation-code registries. Exclusion criteria were WD after non-midline incisions and non-surgical treatment. Patients were treated with either suturing, VAWCM or mesh repair and the groups were named ‘‘WD treatment
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1
Fig. 1 Schematic figure over the vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) treatment technique; 1 bowel, 2 visceral protective layer, 3 the rectus muscle fascia, 4 mesh sutured to the fascial edge and in the midline, 5 polyurethane sponges placed over the sutured mesh, 6 occlusive self-adhesive polyethylene sheet, 7 connector for negative pressure application
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fascial edges on each side in an inlay position to bridge the gap. The visceral protective layer of the negative pressure therapy system (V.A.C.Ò abdominal dressing system; KCI, San Antonio, TX, USA) was applied intra-abdominally. The mesh halves were sutured in the midline, superficially to the visceral protective layer, with some traction. After minimizing the wound gap, by pushing the skin edges towards the midline, two polyurethane sponges were placed over the sutured mesh and the wound was covered with occlusive self-adhesive sheets. Finally, a continuous topical negative pressure was applied. The negative pressure therapy system was changed and the mesh tightened every second to fourth day depending on conditions. When fascial edges could be brought together the mesh was removed and the fascia was closed by either suturing (as described above) or with a retromuscular mesh, depending on the quality of the fascia. Mesh repair Patients with fascia evaluated not suitable for suturing and with no indication for VAWCM treatment were reconstructed with a retromuscular non-absorbable mesh repair. The anterior rectus sheets were bilaterally incised medially along the ruptured fascial edges and the retromuscular spaces were dissected. In case of heavily torn or ischemic fascia, debridement was performed. The abdomen was closed by suturing the retromuscular rectus sheets in the midline. A heavy-weight polypropylene (ProLiteÒ Mesh, Atrium Medical, Hudson, NH, USA) or polyvinylidene fluoride mesh (Dynamesh-CICATÒ FEG Textiltechnik mbH, Aachen, Germany) was positioned behind the rectus muscles. The mesh was sutured to the closed retromuscular rectus sheets in the midline. The anterior rectus sheets were closed to cover the mesh, or if this was not possible, sutured to the mesh. All suturing, besides closure of the skin, were done with a non-absorbable running 2–0 polypropylene suture. Chart review A chart review was performed and data retrieved in accordance with Tables 1, 2, 3 and 4. In case a CT scan had been performed, it was examined for possible abdominal wall hernias.
position during relaxation, straining and coughing. Incisional hernia was defined and measured according to the European Hernia Society definitions [25, 26]. If there was a discrepancy in findings of an incisional hernia between chart notation, physical examination and CT, the latter was considered the most sensitive. Follow-up time was defined as the time between hospital discharge and the latest physical examination, CT scan or the date for the last chart notation revealing presence or absence of an incisional hernia. The examining physician was not blinded regarding the operation method. Pain Questionnaire The validated Ventral Hernia Pain Questionnaire was used in a modified version (modified VHPQ) after approval of the inventors [27]. The questionnaire consists of 21 questions designed to reflect how the patient experiences his/her wound/scar with regard to complete wound healing, pain, cosmetics, social limitations and if he/she felt content with the present result. If the patient suffered from pain, further questions for characterizing the pain in terms of frequency, duration, use of pain medication and impact on the patient’s ability to perform certain activities, were asked. At the visit, the patients were asked to fill out the modified VHPQ. Exclusion criteria for participation in the modified VHPQ were dementia, mental functional disorder or non-Swedish speaking. Patients not able to attend the physical examination were contacted by telephone and the questionnaire answers were obtained. Ethical approval and statistics The study was approved by the Regional Ethics Committee at Lund University, Sweden. Quantitative variables were expressed as median (range) and comparison between groups analyzed by Mann–Whitney U test or Kruskal– Wallis test, as appropriate. Qualitative data was analyzed by Pearson’s v2 test or Fisher’s exact test, as appropriate. p \ 0.05 was considered significant. All statistic analyses were performed using Statistical Package for Social Sciences (SPSSÒ) version 20 (SPSS, Chicago, IL, USA).
Physical examination
Results
Patients alive in January 2013 were invited to visit the outpatient clinic. A physical examination of the abdominal wall was performed according to a protocol where incisional hernia and related symptoms were evaluated. The abdominal wall was palpated in the upright and supine
WD treatment groups A total of 48 patients were treated for WD and 46 were included according to inclusion criteria (Fig. 2). Twenty-two patients were treated with suture, six with
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Hernia Table 1 Patient characteristics for the three WD treatment groups Suture (n = 22) Age
76.5 (60–90)
Male gender
17/22 (77 %)
a
BMI
26.0 (18.1–32.7)
VAWCM (n = 6) 76.5 (63–87) 3/6 (50 %) 19.5 (18.4–29.5)
Mesh repair (n = 18) 73 (38–88) 12/18 (67 %)
p value 0.4021 0.4042
26.4 (15.2–33.5)
0.1851
Comorbidity Diabetes mellitus COPD/Asthma Malignancy
b
c
Immunosuppression
3/22 (14 %)
0/6 (0 %)
2/18 (11 %)
1.02
2/22 (9 %)
1/6 (17 %)
3/17 (18 %)
0.5952
10/22 (45 %)
1/6 (17 %)
8/18 (44 %)
0.5422
3/22 (14 %)
1/6 (17 %)
3/18 (17 %)
1.02
20 (19–26)
21.5 (15–31)
0.8001
1.5 (0–4)
0.8991
Serum albumin levelsd
24 (16–27)
Sum of comorbidities per patient
e
2 (0–4)
Index operation Colorectal surgery
1.5 (0–4)
14/22 (64 %)
3/6 (50 %)
14/18 (78 %)
0.3802
12/22 (55 %)
4/6 (67 %)
10/18 (56 %)
0.9222
5/22 (23 %)
2/6 (33 %)
3/18 (17 %)
0.6172
8/22 (36 %)
5/6 (83 %)
15/18 (83 %)
0.0062
20/22 (91 %)
6/6 (100 %)
17/18 (94 %)
1.02
3/22 (14 %)
3/6 (50 %)
1/18 (6 %)
Median days (range) between index-OP and rupture diagnose
8 (2–17)
7 (5–20)
7 (4–14)
0.7071
Median days (range) between WD diagnose and operation
0 (0–9)
0 (0–2)
1 (0–4)
0.3731
Emergency surgery Contaminated wound at index OP (perforation or gangrene) WD operation Complete rupturef WD due to fascial tear
g
Patients with complicating factor(s)
1
h
Kruskal–Wallis test
2
Fisher’s exact test
a
BMI: Body Mass Index. Suture: n = 19, VAWCM: n = 5, mesh: n = 17 Suture: n = 22, VAWCM: n = 6, mesh: n = 17
b
0.0552
c
Malignancy = present disease, indication for operation
d
At the time of rupture diagnose. Suture: n = 11, VAWCM: n = 5, mesh: n = 16
e
Comorbidities: dementia, Parkinson’s disease, cardiovascular disease, stroke, asthma/COPD, cortisone or other immune-modulating treatment, connective tissue disease, hypertension, warfarin treatment, prostate cancer epilepsy, cancer in the own medical history, diabetes mellitus, aortic aneurysm, liver cirrhosis, Crohn’s disease drug addiction, renal failure
f
Complete rupture defined as rupture of more than half of the wound
g
Other aetiologies for WD were fracture of the suture or a slipped knot
h
Complicating factors: bowel perforation, intra-abdominal infection, abscess in the wound/rupture area, small intestine fistula, distended bowel
VAWCM and 18 with mesh repair. Demographic characteristics for the three ‘‘WD treatment groups’’ are shown in Table 1. The only significant difference between the groups was the extent of the WD. Complete rupture was more frequent in the VAWCM and mesh repair groups compared to the sutured group (p = 0.006). Among the sutured patients, 14 had a partial rupture. Six had only the ruptured part sutured and eight had the entire length of the wound sutured. Neither hospital stay nor mortality was significantly different between the WD treatment groups (Table 2). After WD treatment with VAWCM, the five surviving patients were closed with either suture (n = 2) or mesh repair (n = 3). Average duration of the open abdomen treatment for the VAWCM patients was 7 days (3–20 days).
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Primary closure groups After closure of the VAWCM-treated patients, the two ‘‘primary closure groups’’ were formed: suture (n = 23) and mesh repair (n = 20), as shown in Fig. 2. Five patients (22 %) in the sutured group had a recurrent WD compared to none in the mesh group (p = 0.051). Of the five patients with a recurrent WD, three had initially a partial rupture. Of those, two had only the ruptured part sutured and one was sutured in the entire length of the wound. Three of five patients (60 %) with a recurrent WD died. Cause of death was cardiac failure in all three patients. Of the two surviving patients, one was treated with VAWCM and thereafter closed with mesh, and the other was unfit for additional surgery and conservatively treated until discharge.
Hernia Table 2 Short-term outcome and long-term follow-up results Wound dehiscence treatment groups
Suture (n = 22)
VAWCM (n = 6)
Mesh repair (n = 18)
p value
Hospital stay after index-OP, median days (range)
22 (9–74)
26 (18–64)
21 (12–54)
0.3383
Hospital stay after WD operation, median days (range)
10 (4–64)
15.5 (5–56)
11 (5–43)
0.5413
Mortality
1/22 (5 %)
1/6 (17 %)
1/18 (6 %)
0.5041
Outcome
Primary closure groups
Suture (n = 23) (%)
Mesh repair (n = 20) (%)
p value
5/23 (22) 3/5 (60)
0/20 (0) –
0.0511 –
Outcome WD recurrence Mortality after recurrence Final closure groups
Suture (n = 18) (%)
Mesh repair (n = 21) (%)
p value
Wound complications
5/18 (28)
15/21 (71)
0.0102
Over-all morbidity
5/18 (28)
16/21 (76)
0.0042
Outcome
Long-term follow-up
Suture (n = 15) (%)
Mesh repair (n = 20) (%)
p value
8/15 (53)
1/20 (5)
0.0021
1/9 (11)
1/14 (7)
0.641
Outcome Incisional hernia a
Postoperative abdominal wall pain 1 2
Fisher’s exact test Pearson’s v2 test
3
Kruskal–Wallis test
a
Suture: n = 9, mesh: n = 14
Table 3 Postoperative complications for the final closure groups
1
Fisher’s exact test
2
Pearson’s v2 test
3
Mann–Whitney U test
a
Postoperative wound disruption of skin and subcutaneous tissue
b
Calculated only for patients with complication
c
Four patients exceeding 100 days of treatment
Suture (n = 18)
Mesh repair (n = 21)
p value
Aspiration pneumonia
0/18 (0 %)
3/21 (14 %)
0.2351
Suspected anastomotic insufficiency
0/18 (0 %)
1/21 (5 %)
1.01
Intra-abdominal infection
1/18 (6 %)
2/21 (10 %)
1.01
Seroma/serous leakage
2/18 (11 %)
10/21 (48 %)
0.0142
Hematoma
1/18 (6 %)
1/21 (5 %)
1.01
Positive wound or intra-abdominal cultures
2/18 (11 %)
11/21 (52 %)
0.0062
Wound infection
1/18 (6 %)
8/21 (38 %)
0.0231
Treatment with antibiotics
2/18 (11 %)
9/21 (43 %)
0.0282
Postoperative NPWT
0/18 (0 %)
4/21 (19 %)
0.1101
Partial mesh-extirpation
–
1/21 (5 %)
–
Prolonged healinga
1/18 (6 %)
7/21 (33 %)
0.0491
Days until wound healing, median days (range)b
21 (7–76)
77 (30 to [432)c
0.0113
Any complication
5/18 (28 %)
16/21 (76 %)
0.0041
Complication
Final closure groups After treatment of the WD recurrences the patients were divided into the two ‘‘final closure groups’’ resulting in 18 sutured and 21 mesh repair patients, as shown in Fig. 2. None of the patients in either group were treated with planned NPWT at the time of wound closure. Short-term
morbidity and wound complication rates were significantly higher in the mesh group (Tables 2, 3). There was no difference in wound complication rates between the different types of mesh (polypropylene 9/11, polyvinylidene fluoride 6/10, p = 0.361). Of the 39 patients in the final closure groups, six had been treated with VAWCM at some point. Two of
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Hernia Table 4 Selected questions from the abdominal wall complaints questionnaire Suture (n = 9) (%)
Mesh repair (n = 14) (%)
p value
Do you feel any abdominal wall pain right now?
0/9 (0)
1/14 (7)
1.01
Have you felt any abdominal wall pain during the last week?
1/9 (11)
1/14 (7)
0.641
Do you find your abdominal scar cosmetically disturbing?
3/9 (33)
3/14 (21)
0.6431
Du you consider your abdominal scar socially inhibitory?
1/9 (11)
2/14 (14)
1.01
Do you experience stiffness or rigidity from the abdominal wall?
0/9 (0)
2/14 (14)
0.5021
Are you satisfied with the final result of the treatment?
6/9 (67)
12/14 (86)
0.3431
1
Fisher’s exact test
Fig. 2 Study flow diagram. Total in-hospital mortality was 13 % (6 of 46 pt.). NPWT negative pressure wound therapy, VAWCM vacuumassisted wound closure with mesh-mediated fascial traction. aTreated conservatively
these were finally closed with suture, whereof one had a wound complication. The corresponding figures for those finally closed with mesh were four and three, respectively. When the patients who, at some point, had been treated with VAWCM were excluded from the wound complication calculation, 4 of the remaining 16 patients in the suture group had a wound complication compared to 12 of the remaining 17 patients in
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the mesh repair group. This difference was significant (p = 0.009). Follow-up After discharge, a total of 39 patients were eligible for follow-up. The follow-up rate was 90 % (35/39 patients discharged from hospital) without difference between
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groups. Four patients were lost to follow-up due to dementia or poor physical condition (n = 2) and declining visit (n = 2). The median follow-up times for incisional hernia observation in sutured and mesh repair patients were 619 days (205–1,042) and 405 days (40–953), respectively (p = 0.046). Incisional hernia rates were 53 % for the sutured, compared to 5 % for mesh repair patients (p = 0.002). Of the 39 discharged patients, 29 were identified as possible for follow-up with the modified VHPQ. Patients were excluded due to dementia (n = 5), mental functional disorder (n = 1), non-Swedish speaking (n = 1), and death after discharge (n = 3). Six patients were lost to follow-up due to declining visit and interview (n = 5), and missing contact information (n = 1), resulting in a questionnaire follow-up rate of 79 % (23/29). Answers were obtained either at the physical examination (n = 17) or by telephone interview (n = 6). There were no significant differences in reported postoperative abdominal wall complaints between the groups (Tables 2, 4).
Discussion Wound dehiscence is as old a phenomenon as laparotomies. Despite this, scientifically based treatment guidelines are largely lacking [4]. Suturing has traditionally been the most common treatment option for WD, but may not be the optimal technique due to high recurrent WD rates with corresponding high mortality and high incisional hernia rates. As van Ramshorst et al. [4] concludes, suture could be a valid treatment method for a young population with few complicating factors, and in patients were the cause of the WD is a technical problem (e.g., a slipped knot). In patients with gross contamination or infection, however, suturing might be associated with a higher risk of recurrent WD since an inflamed and weakened fascia is less likely to hold the suture. Alternatives to suturing should be considered in these situations. Some authors present conservative treatment as a good and safe option for these patients. The end result will of cause be a large ventral hernia that would need later reconstruction [7–9]. The use of mesh for WD closure in the contaminated or infected wound is not without risk. van’t Riet et al. [11] concludes that the use of mesh (absorbable or nonabsorbable) in WD patients with intra-abdominal infections is associated with a high mortality rate (up to 83 %) and high frequency of mesh removal. They reported on patients operated for WD between 1988 and 1998, when knowledge of new methods for open abdomen treatment, as well as today’s mesh technology were lacking. The complicated WD patients might benefit from a period of open abdomen treatment with VAWCM before definite closure. Acosta
et al. [22] have demonstrated the effectiveness of VAWCM, also in contaminated patients, which partly could be explained by the ability of the abdominal dressing to drain intra-abdominal pro-inflammatory fluid [21]. At the Department of Surgery, Ska˚ne University Hospital Malmo¨, a standardized retromuscular mesh technique for incisional hernia repair and the VAWCM technique for open abdomen treatment have been used for several years and have, as alternatives to merely suturing, been implemented in the treatment of WD. The patients included in the three WD treatment groups (suture, VAWCM or mesh repair) in this study were found comparable in most demographic characteristics. The only significant difference was a higher rate of complete ruptures in mesh repair and VAWCM-treated patients compared to the sutured group. This illustrates the surgeons’ choice and preference for suturing when the rupture was small and to utilize mesh repair or VAWCM for larger or total ruptures. The selection between mesh repair and VAWCM was based on the presence of complicating factors or difficulties to close the fascia. From these aspects, there was a difference between the groups that might influence the results. The primary endpoint, incisional hernia, was seen in 53 % of patients finally closed with suture technique. Only one patient repaired with mesh (5 %) developed an incisional hernia as a result of late partial extirpation of an infected mesh. Scholtes et al. [16] also found a significant difference between suture and mesh repair groups (22 vs. 3 %). An explanation for the higher hernia incidence in our study may be a methodological effect since follow-up differed between the studies and information on how the clinical examination was performed in Scholtes study is lacking. A 13 % in-hospital mortality rate and a recurrent WD rate of 22 % are within the range of other reports. As in other studies [10, 13–15, 28], a recurrence of the WD was associated with poor outcome, in this study a mortality rate of 60 %. A recurrent WD is thus a serious complication and the techniques used for treatment of a WD should provide a good chance of avoiding a recurrence. It seems clear that suturing is not an adequate technique for all WD patients. Patients finally closed with mesh had significantly more wound complications, many with prolonged healing. Four mesh patients were treated more than 100 days for their wound problems and one patient was still not healed at the time of the follow-up (treatment [432 days). This particular patient had a skin necrosis leaving the mesh visible in the wound and, due to poor general condition, he has not been considered fit for additional surgery and treatment is now conservative. Most patients only had a small part of their wound engaged in a prolonged healing process which might explain why not many were treated with negative pressure wound therapy or surgical revision
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and secondary closure. Otherwise, Berrevoet et al. [29] recently showed that early initiation of NPWT in case of wound infection after mesh repair, followed by secondary suture, was successful in promoting wound healing and thereby possibly shorten the treatment times. To prevent wound complications several measures might be considered, as the use of wound drains, NPWT subcutaneously or NPWT on closed incisions. The use of drains was not shown beneficial in this aspect in a novel meta-analysis [30]. In this study, no patient was treated with subcutaneous NPWT at the time of wound closure. NPWT seems favorable, compared to standard wound care, when secondary healing is intended [31] and there are indications for decreased wound infection rates when NPWT is used on closed incisions [32]. Long-term patient perceived results of WD treatment are sparsely reported. Quality of life and perception of body image in patients treated for WD has recently been evaluated by van Ramshorst et al. [18]. In mostly conservatively treated patients, with 83 % incisional hernia frequency, significantly lower body image scores, as well as lower scores for physical and mental quality of life components, were seen when compared to controls consisting of patients who had undergone laparotomy without subsequent WD. We used a questionnaire designed to reflect how the patient experiences his/her wound/scar in regard to complete wound healing, pain, cosmetics and social limitations and if he/she feels content with the final results. We found no significant difference in long-term abdominal wall complaints between the suture and mesh repair groups. The majority of patients were satisfied with their treatment results. One patient from each group had experienced pain over the last week and approximately one-third of patients in both groups found their abdominal scar cosmetically disturbing or socially inhibiting. Whether these complaints were due to the specific WD treatment, or a result of the preceding index operation, cannot be revealed. The present study is, like almost all other reports on the subject, a retrospective evaluation and thereby suffers from weaknesses and disadvantages associated with this design. In the absence of a prospective protocol regulating the treatment, a selection bias determined by the choice of treatment technique, and differences in operation methods and pre- or postoperative care are likely to occur. In this study, the surgical techniques were evaluated from the operation records and were found to have been fairly uniform, but variations in selection of patients for the different techniques as well as care and handling of complications were seen. A prospective trial is warranted for further evaluation of the different techniques used in this study, with definitions of the conditions controlling the technique to be used.
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Furthermore, an optimized suturing technique needs to be defined in the study protocol. Hollinsky et al. [33] presented a ‘‘reinforced tension line’’ (RTL) suture technique in 2007 with good results when applied for incisional hernia repair. This technique aims at re-distributing the horizontally directed peak load forces from the punctuate areas where the sutures penetrate the fascia, to the entire length of the fascia, by placing a longitudinal suture between the anterior and posterior rectus muscle sheets. The RTL suture technique is so far not evaluated for WD treatment, but is an interesting alternative for patients considered suitable for suturing. It is obvious, from the results of this study, that there also is a need for improvement in prevention and treatment of wound complications, especially in case a mesh repair has been applied. In conclusion, patients with partial WD were more often managed with suturing, while patients with complete WD were treated with either direct mesh repair or, if complicating factors were present, VAWCM treatment before definite closure. Recurrence of WD was only seen in sutured patients, with a 60 % mortality rate. The mesh group had significantly more wound complications. More than half of the sutured patients developed an incisional hernia compared to 5 % in the mesh repair group. Serious long-term abdominal wall complaints were uncommon in both groups. Scientifically based treatment guidelines and prospective studies are requested for WD treatment. Conflict of interest PP declares no conflict of interest. AM declares no conflict of interest. UP declares conflict of interest not directly related to the submitted work (honorarium for lectures arranged by KCI).
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Hernia 8. Garg PK, Jain SK, Kaza RCM et al (2010) Staged closure after complete wound dehiscence: novel technique. Surgeon 8:177–178. doi:10.1016/j.surge.2009.10.012 9. Muckart DJ, Luvuno FM (1985) Abdominal wound disruption. A conservative approach. J R Coll Surg Edinb 30:47–49 10. van’t Riet M, De Vos Van Steenwijk PJ, Bonjer HJ et al (2004) Incisional hernia after repair of wound dehiscence: incidence and risk factors. Am Surg 70:281–286 11. van’t Riet M, de Vos van Steenwijk PJ, Bonjer HJ et al (2007) Mesh repair for postoperative wound dehiscence in the presence of infection: is absorbable mesh safer than non-absorbable mesh? Hernia 11:409–413. doi:10.1007/s10029-007-0240-5 12. White H, Cook J, Ward M (1977) Abdominal wound dehiscence. A 10-year survey from a district general hospital. Ann R Coll Surg Engl 59:337–341 13. Madsen G, Fischer L, Wara P (1992) Burst abdomen—clinical features and factors influencing mortality. Dan Med Bull 39:183–185 14. Ma¨kela¨ JT, Kiviniemi H, Juvonen T, Laitinen S (1995) Factors influencing wound dehiscence after midline laparotomy. Am J Surg 170:387–390 15. Abbott DE, Dumanian GA, Halverson AL (2007) Management of laparotomy wound dehiscence. Am Surg 73:1224–1227 16. Scholtes M, Kurmann A, Seiler CA et al (2012) Intraperitoneal mesh implantation for fascial dehiscence and open abdomen. World J Surg 36:1557–1561. doi:10.1007/s00268-012-1534-z 17. Greenburg AG, Saik RP, Peskin GW (1979) Wound dehiscence. Pathophysiology and prevention. Arch Surg 114:143–146 18. van Ramshorst GH, Eker HH, van der Voet JA et al (2013) Longterm outcome study in patients with abdominal wound dehiscence: a comparative study on quality of life, body image, and incisional hernia. J Gastrointest Surg 17:1477–1484. doi:10.1007/ s11605-013-2233-2 19. Rogmark P, Petersson U, Bringman S et al (2013) Short-term outcomes for open and laparoscopic midline incisional hernia repair: a randomized multicenter controlled trial: The ProLOVE (prospective randomized trial on open versus laparoscopic operation of ventral eventrations) trial. Ann Surg. doi:10.1097/SLA. 0b013e31828fe1b2 20. Petersson U, Acosta S, Bjorck M (2007) Vacuum-assisted wound closure and mesh-mediated fascial traction—a novel technique for late closure of the open abdomen. World J Surg 31:2133–2137. doi:10.1007/s00268-007-9222-0 21. Bjarnason T, Montgomery A, Hlebowicz J et al (2011) Pressure at the bowel surface during topical negative pressure therapy of
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the open abdomen: an experimental study in a porcine model. World J Surg 35:917–923. doi:10.1007/s00268-010-0937-y Acosta S, Bjarnason T, Petersson U et al (2011) Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction. Br J Surg 98:735–743. doi:10.1002/bjs.7383 Israelsson LA, Jonsson T (1993) Suture length to wound length ratio and healing of midline laparotomy incisions. Br J Surg 80:1284–1286 Millbourn D, Cengiz Y, Israelsson LA (2009) Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg 144:1056–1059. doi:10. 1001/archsurg.2009.189 Muysoms FE, Miserez M, Berrevoet F et al (2009) Classification of primary and incisional abdominal wall hernias. Hernia 13:407–414. doi:10.1007/s10029-009-0518-x Korenkov M, Paul A, Sauerland S et al (2001) Classification and surgical treatment of incisional hernia. Results of an experts’ meeting. Langenbecks Arch Surg 386:65–73 Clay L, Franneby U, Sandblom G et al (2012) Validation of a questionnaire for the assessment of pain following ventral hernia repair—the VHPQ. Langenbecks Arch Surg 397:1219–1224. doi:10.1007/s00423-012-0932-x Pavlidis TE, Galatianos IN, Papaziogas BT et al (2001) Complete dehiscence of the abdominal wound and incriminating factors. Eur J Surg 167:351–354. doi:10.1080/110241501750215221 (discussion 355) Berrevoet F, Vanlander A, Sainz-Barriga M et al (2013) Infected large pore meshes may be salvaged by topical negative pressure therapy. Hernia 17:67–73. doi:10.1007/s10029-012-0969-3 Kosins AM, Scholz T, Cetinkaya M, Evans GRD (2013) Evidence-based value of subcutaneous surgical wound drainage: the largest systematic review and meta-analysis. Plast Reconstr Surg 132:443–450. doi:10.1097/PRS.0b013e3182958945 Suissa D, Danino A, Nikolis A (2011) Negative-pressure therapy versus standard wound care: a meta-analysis of randomized trials. Plast Reconstr Surg 128:498e–503e Ingargiola MJ, Daniali LN, Lee ES (2013) Does the application of incisional negative pressure therapy to high-risk wounds prevent surgical site complications? A systematic review. Eplasty 13:e49 Hollinsky C, Sandberg S, Kocijan R (2007) Preliminary results with the reinforced tension line: a new technique for patients with ventral abdominal wall hernias. Am J Surg 194:234–239. doi:10. 1016/j.amjsurg.2006.09.045
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ORIGINAL ARTICLE
Wound dehiscence: outcome comparison for sutured and mesh reconstructed patients P. Petersson • A. Montgomery • U. Petersson
Received: 28 October 2013 / Accepted: 23 May 2014 Ó Springer-Verlag France 2014
Abstract Purpose Treatment guidelines for abdominal wound dehiscence (WD) are lacking. The primary aim of the study was to compare suture to mesh repair in WD patients concerning incisional hernia incidence. Secondary aims were to compare recurrent WD, morbidity, mortality and long-term abdominal wall complaints. Methods A retrospective chart review of 46 consecutive patients operated for WD between January 2010 and August 2012 was conducted. Physical examination and a questionnaire enquiry were performed in January 2013. Results Six patients were treated by vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) before definitive closure. Three patients died early resulting in 23 patients closed by suture and 20 by mesh repair. Five sutured, but no mesh repair patients had recurrent WD (p = 0.051) with a mortality of 60 %. Finally, 18 sutured and 21 mesh repair patients were eligible for follow-up. The incidence of incisional hernia was higher for the sutured patients (53 vs. 5 %, p = 0.002), while mesh repair patients had a higher short-term morbidity rate (76 vs. 28 %, p = 0.004). Abdominal wall complaints were rare in both groups.
P. Petersson Department of Clinical Medicine, Aarhus University, Aarhus, Denmark A. Montgomery U. Petersson Department of Clinical Sciences, Malmo¨, Faculty of Medicine, Lund University, Lund, Sweden A. Montgomery U. Petersson (&) Department of Surgery, Ska˚ne University Hospital Malmo¨, 205 02 Malmo¨, Sweden e-mail: [email protected]
Conclusions Suture of WD was afflicted with a high incidence of recurrent WD and incisional hernia formation. Mesh repair overcomes these problems at the cost of more wound complications. VAWCM seems to be an alternative for treating contaminated patients until definitive closure is possible. Long-term abdominal wall complaints are uncommon after WD treatment. Keywords Abdominal wound dehiscence Burst abdomen Vacuum-assisted wound closure and meshmediated fascial traction Mesh Suture Incisional hernia
Introduction Abdominal wound dehiscence (WD), or burst abdomen, is defined as a rupture of the wound and a separation of the abdominal wall layers including the fascia, and occurs in up to 5 % of patients after laparotomy [1–4]. In case of emergency operations for peritonitis, even higher incidences may be anticipated [5]. A WD can be partial or complete and sometimes leads to evisceration [2, 6]. Surgical re-closure of the abdominal wall, by suturing, mesh repair or temporary closure with later definite closure, is often necessary. A non-surgical, conservative treatment strategy may be an option in some cases but will invariably result in incisional hernia development [7–9]. Abdominal wound dehiscence has far-reaching consequences and is a potentially life-threatening complication. Mortality rates vary between 0 and 56 %, with the highest incidence reported in WD patients treated with mesh in infected surgical fields [7, 10–14]. Recurrent WD has been described in 4–44 % of sutured patients while mesh repair seems to prevent this complication [14–16]. Incisional hernia incidences for sutured patients have been reported to
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be between 14 and 67 % [7, 17] and 3 % for non-absorbable mesh repairs, provided no mesh infection occurs [16]. If absorbable meshes are used or the patients are treated conservatively without surgical re-closure, the incisional hernia incidence will be close to 100 % [8, 9, 15]. In a recent study, quality of life and perception of body image in patients treated for WD was evaluated [18]. Most patients were treated conservatively in this study. An incisional hernia rate of 83 % was reported and significantly lower body image scores as well as lower scores for physical and mental function were seen when compared to patients who had undergone laparotomy without complicating WD. In 2010, van Ramshorst et al. [4] presented a review on therapeutic alternatives for WD treatment where they concluded that the large variety of treatment options and divergent outcome variables presented make it difficult to evaluate the results. Clinical treatment guidelines are largely lacking. At the Department of Surgery, Ska˚ne University Hospital Malmo¨, the retromuscular mesh technique has been the standard operation for abdominal wall hernia for many years and the advantages as well as pitfalls of the technique are well-known [19]. A novel temporary open abdomen closure technique, with high definite closure rates has been described and evaluated [20–22]. Both these techniques have, over the last years, been implemented into the treatment of WD at the department. Besides conservative treatment for patients not suitable for surgical re-closure, the following three surgical treatment methods have been used in a fairly concurrent way: (1) suturing, (2) open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) followed by either suturing or retromuscular mesh repair or (3) direct reconstruction with retromuscular mesh repair. The primary aim of this study was to evaluate late incisional hernia development after WD treatment using either suture or retromuscular mesh repair as final closure treatment. Secondary objectives were to evaluate incidence of WD recurrence, short-term morbidity (especially wound complications), mortality and long-term abdominal wall complaints.
groups’’. After closure of the VAWCM-treated patients, either by suture or mesh repair, the two ‘‘primary closure groups’’ were defined as the sutured and the mesh repair groups. Finally, the two ‘‘final closure groups’’ were formed consisting of surviving patients that were finally closed with suture or mesh repair and eligible for long-term follow-up according to Fig. 2. Surgical techniques Suture Suture with either a slowly absorbable or a non-absorbable suture (0–0 or 2–0, polydioxanone or polypropylene) was used in patients when the fascia quality was judged sufficient to hold the suture. The studies and results of Israelsson and Millbourn et al. [23, 24], showing benefits of using a suture length to wound length ratio (SL/WL) of at least 4:1, are well-known but wound or suture length was not routinely measured. VAWCM When intra-abdominal swelling prohibited closure of the fascia or other circumstances (e.g., deep wound infection) made it inappropriate to complete a primary closure, open abdomen treatment with VAWCM was used. The technique is described in detail elsewhere [20], summarized below and in Fig. 1. A 30 9 30 cm polypropylene mesh (ProleneÒ; Ethicon, Johnson & Johnson, Somerville, NJ, USA) was cut to fit the curvature of the fascial edges and divided into two halves. The mesh was sutured to the
7 6 5 4 3 2
Material and method All consecutive patients treated for WD after midline laparotomy at the department, between January 2010 and August 2012, were identified by searching the diagnoseand operation-code registries. Exclusion criteria were WD after non-midline incisions and non-surgical treatment. Patients were treated with either suturing, VAWCM or mesh repair and the groups were named ‘‘WD treatment
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1
Fig. 1 Schematic figure over the vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) treatment technique; 1 bowel, 2 visceral protective layer, 3 the rectus muscle fascia, 4 mesh sutured to the fascial edge and in the midline, 5 polyurethane sponges placed over the sutured mesh, 6 occlusive self-adhesive polyethylene sheet, 7 connector for negative pressure application
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fascial edges on each side in an inlay position to bridge the gap. The visceral protective layer of the negative pressure therapy system (V.A.C.Ò abdominal dressing system; KCI, San Antonio, TX, USA) was applied intra-abdominally. The mesh halves were sutured in the midline, superficially to the visceral protective layer, with some traction. After minimizing the wound gap, by pushing the skin edges towards the midline, two polyurethane sponges were placed over the sutured mesh and the wound was covered with occlusive self-adhesive sheets. Finally, a continuous topical negative pressure was applied. The negative pressure therapy system was changed and the mesh tightened every second to fourth day depending on conditions. When fascial edges could be brought together the mesh was removed and the fascia was closed by either suturing (as described above) or with a retromuscular mesh, depending on the quality of the fascia. Mesh repair Patients with fascia evaluated not suitable for suturing and with no indication for VAWCM treatment were reconstructed with a retromuscular non-absorbable mesh repair. The anterior rectus sheets were bilaterally incised medially along the ruptured fascial edges and the retromuscular spaces were dissected. In case of heavily torn or ischemic fascia, debridement was performed. The abdomen was closed by suturing the retromuscular rectus sheets in the midline. A heavy-weight polypropylene (ProLiteÒ Mesh, Atrium Medical, Hudson, NH, USA) or polyvinylidene fluoride mesh (Dynamesh-CICATÒ FEG Textiltechnik mbH, Aachen, Germany) was positioned behind the rectus muscles. The mesh was sutured to the closed retromuscular rectus sheets in the midline. The anterior rectus sheets were closed to cover the mesh, or if this was not possible, sutured to the mesh. All suturing, besides closure of the skin, were done with a non-absorbable running 2–0 polypropylene suture. Chart review A chart review was performed and data retrieved in accordance with Tables 1, 2, 3 and 4. In case a CT scan had been performed, it was examined for possible abdominal wall hernias.
position during relaxation, straining and coughing. Incisional hernia was defined and measured according to the European Hernia Society definitions [25, 26]. If there was a discrepancy in findings of an incisional hernia between chart notation, physical examination and CT, the latter was considered the most sensitive. Follow-up time was defined as the time between hospital discharge and the latest physical examination, CT scan or the date for the last chart notation revealing presence or absence of an incisional hernia. The examining physician was not blinded regarding the operation method. Pain Questionnaire The validated Ventral Hernia Pain Questionnaire was used in a modified version (modified VHPQ) after approval of the inventors [27]. The questionnaire consists of 21 questions designed to reflect how the patient experiences his/her wound/scar with regard to complete wound healing, pain, cosmetics, social limitations and if he/she felt content with the present result. If the patient suffered from pain, further questions for characterizing the pain in terms of frequency, duration, use of pain medication and impact on the patient’s ability to perform certain activities, were asked. At the visit, the patients were asked to fill out the modified VHPQ. Exclusion criteria for participation in the modified VHPQ were dementia, mental functional disorder or non-Swedish speaking. Patients not able to attend the physical examination were contacted by telephone and the questionnaire answers were obtained. Ethical approval and statistics The study was approved by the Regional Ethics Committee at Lund University, Sweden. Quantitative variables were expressed as median (range) and comparison between groups analyzed by Mann–Whitney U test or Kruskal– Wallis test, as appropriate. Qualitative data was analyzed by Pearson’s v2 test or Fisher’s exact test, as appropriate. p \ 0.05 was considered significant. All statistic analyses were performed using Statistical Package for Social Sciences (SPSSÒ) version 20 (SPSS, Chicago, IL, USA).
Physical examination
Results
Patients alive in January 2013 were invited to visit the outpatient clinic. A physical examination of the abdominal wall was performed according to a protocol where incisional hernia and related symptoms were evaluated. The abdominal wall was palpated in the upright and supine
WD treatment groups A total of 48 patients were treated for WD and 46 were included according to inclusion criteria (Fig. 2). Twenty-two patients were treated with suture, six with
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Hernia Table 1 Patient characteristics for the three WD treatment groups Suture (n = 22) Age
76.5 (60–90)
Male gender
17/22 (77 %)
a
BMI
26.0 (18.1–32.7)
VAWCM (n = 6) 76.5 (63–87) 3/6 (50 %) 19.5 (18.4–29.5)
Mesh repair (n = 18) 73 (38–88) 12/18 (67 %)
p value 0.4021 0.4042
26.4 (15.2–33.5)
0.1851
Comorbidity Diabetes mellitus COPD/Asthma Malignancy
b
c
Immunosuppression
3/22 (14 %)
0/6 (0 %)
2/18 (11 %)
1.02
2/22 (9 %)
1/6 (17 %)
3/17 (18 %)
0.5952
10/22 (45 %)
1/6 (17 %)
8/18 (44 %)
0.5422
3/22 (14 %)
1/6 (17 %)
3/18 (17 %)
1.02
20 (19–26)
21.5 (15–31)
0.8001
1.5 (0–4)
0.8991
Serum albumin levelsd
24 (16–27)
Sum of comorbidities per patient
e
2 (0–4)
Index operation Colorectal surgery
1.5 (0–4)
14/22 (64 %)
3/6 (50 %)
14/18 (78 %)
0.3802
12/22 (55 %)
4/6 (67 %)
10/18 (56 %)
0.9222
5/22 (23 %)
2/6 (33 %)
3/18 (17 %)
0.6172
8/22 (36 %)
5/6 (83 %)
15/18 (83 %)
0.0062
20/22 (91 %)
6/6 (100 %)
17/18 (94 %)
1.02
3/22 (14 %)
3/6 (50 %)
1/18 (6 %)
Median days (range) between index-OP and rupture diagnose
8 (2–17)
7 (5–20)
7 (4–14)
0.7071
Median days (range) between WD diagnose and operation
0 (0–9)
0 (0–2)
1 (0–4)
0.3731
Emergency surgery Contaminated wound at index OP (perforation or gangrene) WD operation Complete rupturef WD due to fascial tear
g
Patients with complicating factor(s)
1
h
Kruskal–Wallis test
2
Fisher’s exact test
a
BMI: Body Mass Index. Suture: n = 19, VAWCM: n = 5, mesh: n = 17 Suture: n = 22, VAWCM: n = 6, mesh: n = 17
b
0.0552
c
Malignancy = present disease, indication for operation
d
At the time of rupture diagnose. Suture: n = 11, VAWCM: n = 5, mesh: n = 16
e
Comorbidities: dementia, Parkinson’s disease, cardiovascular disease, stroke, asthma/COPD, cortisone or other immune-modulating treatment, connective tissue disease, hypertension, warfarin treatment, prostate cancer epilepsy, cancer in the own medical history, diabetes mellitus, aortic aneurysm, liver cirrhosis, Crohn’s disease drug addiction, renal failure
f
Complete rupture defined as rupture of more than half of the wound
g
Other aetiologies for WD were fracture of the suture or a slipped knot
h
Complicating factors: bowel perforation, intra-abdominal infection, abscess in the wound/rupture area, small intestine fistula, distended bowel
VAWCM and 18 with mesh repair. Demographic characteristics for the three ‘‘WD treatment groups’’ are shown in Table 1. The only significant difference between the groups was the extent of the WD. Complete rupture was more frequent in the VAWCM and mesh repair groups compared to the sutured group (p = 0.006). Among the sutured patients, 14 had a partial rupture. Six had only the ruptured part sutured and eight had the entire length of the wound sutured. Neither hospital stay nor mortality was significantly different between the WD treatment groups (Table 2). After WD treatment with VAWCM, the five surviving patients were closed with either suture (n = 2) or mesh repair (n = 3). Average duration of the open abdomen treatment for the VAWCM patients was 7 days (3–20 days).
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Primary closure groups After closure of the VAWCM-treated patients, the two ‘‘primary closure groups’’ were formed: suture (n = 23) and mesh repair (n = 20), as shown in Fig. 2. Five patients (22 %) in the sutured group had a recurrent WD compared to none in the mesh group (p = 0.051). Of the five patients with a recurrent WD, three had initially a partial rupture. Of those, two had only the ruptured part sutured and one was sutured in the entire length of the wound. Three of five patients (60 %) with a recurrent WD died. Cause of death was cardiac failure in all three patients. Of the two surviving patients, one was treated with VAWCM and thereafter closed with mesh, and the other was unfit for additional surgery and conservatively treated until discharge.
Hernia Table 2 Short-term outcome and long-term follow-up results Wound dehiscence treatment groups
Suture (n = 22)
VAWCM (n = 6)
Mesh repair (n = 18)
p value
Hospital stay after index-OP, median days (range)
22 (9–74)
26 (18–64)
21 (12–54)
0.3383
Hospital stay after WD operation, median days (range)
10 (4–64)
15.5 (5–56)
11 (5–43)
0.5413
Mortality
1/22 (5 %)
1/6 (17 %)
1/18 (6 %)
0.5041
Outcome
Primary closure groups
Suture (n = 23) (%)
Mesh repair (n = 20) (%)
p value
5/23 (22) 3/5 (60)
0/20 (0) –
0.0511 –
Outcome WD recurrence Mortality after recurrence Final closure groups
Suture (n = 18) (%)
Mesh repair (n = 21) (%)
p value
Wound complications
5/18 (28)
15/21 (71)
0.0102
Over-all morbidity
5/18 (28)
16/21 (76)
0.0042
Outcome
Long-term follow-up
Suture (n = 15) (%)
Mesh repair (n = 20) (%)
p value
8/15 (53)
1/20 (5)
0.0021
1/9 (11)
1/14 (7)
0.641
Outcome Incisional hernia a
Postoperative abdominal wall pain 1 2
Fisher’s exact test Pearson’s v2 test
3
Kruskal–Wallis test
a
Suture: n = 9, mesh: n = 14
Table 3 Postoperative complications for the final closure groups
1
Fisher’s exact test
2
Pearson’s v2 test
3
Mann–Whitney U test
a
Postoperative wound disruption of skin and subcutaneous tissue
b
Calculated only for patients with complication
c
Four patients exceeding 100 days of treatment
Suture (n = 18)
Mesh repair (n = 21)
p value
Aspiration pneumonia
0/18 (0 %)
3/21 (14 %)
0.2351
Suspected anastomotic insufficiency
0/18 (0 %)
1/21 (5 %)
1.01
Intra-abdominal infection
1/18 (6 %)
2/21 (10 %)
1.01
Seroma/serous leakage
2/18 (11 %)
10/21 (48 %)
0.0142
Hematoma
1/18 (6 %)
1/21 (5 %)
1.01
Positive wound or intra-abdominal cultures
2/18 (11 %)
11/21 (52 %)
0.0062
Wound infection
1/18 (6 %)
8/21 (38 %)
0.0231
Treatment with antibiotics
2/18 (11 %)
9/21 (43 %)
0.0282
Postoperative NPWT
0/18 (0 %)
4/21 (19 %)
0.1101
Partial mesh-extirpation
–
1/21 (5 %)
–
Prolonged healinga
1/18 (6 %)
7/21 (33 %)
0.0491
Days until wound healing, median days (range)b
21 (7–76)
77 (30 to [432)c
0.0113
Any complication
5/18 (28 %)
16/21 (76 %)
0.0041
Complication
Final closure groups After treatment of the WD recurrences the patients were divided into the two ‘‘final closure groups’’ resulting in 18 sutured and 21 mesh repair patients, as shown in Fig. 2. None of the patients in either group were treated with planned NPWT at the time of wound closure. Short-term
morbidity and wound complication rates were significantly higher in the mesh group (Tables 2, 3). There was no difference in wound complication rates between the different types of mesh (polypropylene 9/11, polyvinylidene fluoride 6/10, p = 0.361). Of the 39 patients in the final closure groups, six had been treated with VAWCM at some point. Two of
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Hernia Table 4 Selected questions from the abdominal wall complaints questionnaire Suture (n = 9) (%)
Mesh repair (n = 14) (%)
p value
Do you feel any abdominal wall pain right now?
0/9 (0)
1/14 (7)
1.01
Have you felt any abdominal wall pain during the last week?
1/9 (11)
1/14 (7)
0.641
Do you find your abdominal scar cosmetically disturbing?
3/9 (33)
3/14 (21)
0.6431
Du you consider your abdominal scar socially inhibitory?
1/9 (11)
2/14 (14)
1.01
Do you experience stiffness or rigidity from the abdominal wall?
0/9 (0)
2/14 (14)
0.5021
Are you satisfied with the final result of the treatment?
6/9 (67)
12/14 (86)
0.3431
1
Fisher’s exact test
Fig. 2 Study flow diagram. Total in-hospital mortality was 13 % (6 of 46 pt.). NPWT negative pressure wound therapy, VAWCM vacuumassisted wound closure with mesh-mediated fascial traction. aTreated conservatively
these were finally closed with suture, whereof one had a wound complication. The corresponding figures for those finally closed with mesh were four and three, respectively. When the patients who, at some point, had been treated with VAWCM were excluded from the wound complication calculation, 4 of the remaining 16 patients in the suture group had a wound complication compared to 12 of the remaining 17 patients in
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the mesh repair group. This difference was significant (p = 0.009). Follow-up After discharge, a total of 39 patients were eligible for follow-up. The follow-up rate was 90 % (35/39 patients discharged from hospital) without difference between
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groups. Four patients were lost to follow-up due to dementia or poor physical condition (n = 2) and declining visit (n = 2). The median follow-up times for incisional hernia observation in sutured and mesh repair patients were 619 days (205–1,042) and 405 days (40–953), respectively (p = 0.046). Incisional hernia rates were 53 % for the sutured, compared to 5 % for mesh repair patients (p = 0.002). Of the 39 discharged patients, 29 were identified as possible for follow-up with the modified VHPQ. Patients were excluded due to dementia (n = 5), mental functional disorder (n = 1), non-Swedish speaking (n = 1), and death after discharge (n = 3). Six patients were lost to follow-up due to declining visit and interview (n = 5), and missing contact information (n = 1), resulting in a questionnaire follow-up rate of 79 % (23/29). Answers were obtained either at the physical examination (n = 17) or by telephone interview (n = 6). There were no significant differences in reported postoperative abdominal wall complaints between the groups (Tables 2, 4).
Discussion Wound dehiscence is as old a phenomenon as laparotomies. Despite this, scientifically based treatment guidelines are largely lacking [4]. Suturing has traditionally been the most common treatment option for WD, but may not be the optimal technique due to high recurrent WD rates with corresponding high mortality and high incisional hernia rates. As van Ramshorst et al. [4] concludes, suture could be a valid treatment method for a young population with few complicating factors, and in patients were the cause of the WD is a technical problem (e.g., a slipped knot). In patients with gross contamination or infection, however, suturing might be associated with a higher risk of recurrent WD since an inflamed and weakened fascia is less likely to hold the suture. Alternatives to suturing should be considered in these situations. Some authors present conservative treatment as a good and safe option for these patients. The end result will of cause be a large ventral hernia that would need later reconstruction [7–9]. The use of mesh for WD closure in the contaminated or infected wound is not without risk. van’t Riet et al. [11] concludes that the use of mesh (absorbable or nonabsorbable) in WD patients with intra-abdominal infections is associated with a high mortality rate (up to 83 %) and high frequency of mesh removal. They reported on patients operated for WD between 1988 and 1998, when knowledge of new methods for open abdomen treatment, as well as today’s mesh technology were lacking. The complicated WD patients might benefit from a period of open abdomen treatment with VAWCM before definite closure. Acosta
et al. [22] have demonstrated the effectiveness of VAWCM, also in contaminated patients, which partly could be explained by the ability of the abdominal dressing to drain intra-abdominal pro-inflammatory fluid [21]. At the Department of Surgery, Ska˚ne University Hospital Malmo¨, a standardized retromuscular mesh technique for incisional hernia repair and the VAWCM technique for open abdomen treatment have been used for several years and have, as alternatives to merely suturing, been implemented in the treatment of WD. The patients included in the three WD treatment groups (suture, VAWCM or mesh repair) in this study were found comparable in most demographic characteristics. The only significant difference was a higher rate of complete ruptures in mesh repair and VAWCM-treated patients compared to the sutured group. This illustrates the surgeons’ choice and preference for suturing when the rupture was small and to utilize mesh repair or VAWCM for larger or total ruptures. The selection between mesh repair and VAWCM was based on the presence of complicating factors or difficulties to close the fascia. From these aspects, there was a difference between the groups that might influence the results. The primary endpoint, incisional hernia, was seen in 53 % of patients finally closed with suture technique. Only one patient repaired with mesh (5 %) developed an incisional hernia as a result of late partial extirpation of an infected mesh. Scholtes et al. [16] also found a significant difference between suture and mesh repair groups (22 vs. 3 %). An explanation for the higher hernia incidence in our study may be a methodological effect since follow-up differed between the studies and information on how the clinical examination was performed in Scholtes study is lacking. A 13 % in-hospital mortality rate and a recurrent WD rate of 22 % are within the range of other reports. As in other studies [10, 13–15, 28], a recurrence of the WD was associated with poor outcome, in this study a mortality rate of 60 %. A recurrent WD is thus a serious complication and the techniques used for treatment of a WD should provide a good chance of avoiding a recurrence. It seems clear that suturing is not an adequate technique for all WD patients. Patients finally closed with mesh had significantly more wound complications, many with prolonged healing. Four mesh patients were treated more than 100 days for their wound problems and one patient was still not healed at the time of the follow-up (treatment [432 days). This particular patient had a skin necrosis leaving the mesh visible in the wound and, due to poor general condition, he has not been considered fit for additional surgery and treatment is now conservative. Most patients only had a small part of their wound engaged in a prolonged healing process which might explain why not many were treated with negative pressure wound therapy or surgical revision
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and secondary closure. Otherwise, Berrevoet et al. [29] recently showed that early initiation of NPWT in case of wound infection after mesh repair, followed by secondary suture, was successful in promoting wound healing and thereby possibly shorten the treatment times. To prevent wound complications several measures might be considered, as the use of wound drains, NPWT subcutaneously or NPWT on closed incisions. The use of drains was not shown beneficial in this aspect in a novel meta-analysis [30]. In this study, no patient was treated with subcutaneous NPWT at the time of wound closure. NPWT seems favorable, compared to standard wound care, when secondary healing is intended [31] and there are indications for decreased wound infection rates when NPWT is used on closed incisions [32]. Long-term patient perceived results of WD treatment are sparsely reported. Quality of life and perception of body image in patients treated for WD has recently been evaluated by van Ramshorst et al. [18]. In mostly conservatively treated patients, with 83 % incisional hernia frequency, significantly lower body image scores, as well as lower scores for physical and mental quality of life components, were seen when compared to controls consisting of patients who had undergone laparotomy without subsequent WD. We used a questionnaire designed to reflect how the patient experiences his/her wound/scar in regard to complete wound healing, pain, cosmetics and social limitations and if he/she feels content with the final results. We found no significant difference in long-term abdominal wall complaints between the suture and mesh repair groups. The majority of patients were satisfied with their treatment results. One patient from each group had experienced pain over the last week and approximately one-third of patients in both groups found their abdominal scar cosmetically disturbing or socially inhibiting. Whether these complaints were due to the specific WD treatment, or a result of the preceding index operation, cannot be revealed. The present study is, like almost all other reports on the subject, a retrospective evaluation and thereby suffers from weaknesses and disadvantages associated with this design. In the absence of a prospective protocol regulating the treatment, a selection bias determined by the choice of treatment technique, and differences in operation methods and pre- or postoperative care are likely to occur. In this study, the surgical techniques were evaluated from the operation records and were found to have been fairly uniform, but variations in selection of patients for the different techniques as well as care and handling of complications were seen. A prospective trial is warranted for further evaluation of the different techniques used in this study, with definitions of the conditions controlling the technique to be used.
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Furthermore, an optimized suturing technique needs to be defined in the study protocol. Hollinsky et al. [33] presented a ‘‘reinforced tension line’’ (RTL) suture technique in 2007 with good results when applied for incisional hernia repair. This technique aims at re-distributing the horizontally directed peak load forces from the punctuate areas where the sutures penetrate the fascia, to the entire length of the fascia, by placing a longitudinal suture between the anterior and posterior rectus muscle sheets. The RTL suture technique is so far not evaluated for WD treatment, but is an interesting alternative for patients considered suitable for suturing. It is obvious, from the results of this study, that there also is a need for improvement in prevention and treatment of wound complications, especially in case a mesh repair has been applied. In conclusion, patients with partial WD were more often managed with suturing, while patients with complete WD were treated with either direct mesh repair or, if complicating factors were present, VAWCM treatment before definite closure. Recurrence of WD was only seen in sutured patients, with a 60 % mortality rate. The mesh group had significantly more wound complications. More than half of the sutured patients developed an incisional hernia compared to 5 % in the mesh repair group. Serious long-term abdominal wall complaints were uncommon in both groups. Scientifically based treatment guidelines and prospective studies are requested for WD treatment. Conflict of interest PP declares no conflict of interest. AM declares no conflict of interest. UP declares conflict of interest not directly related to the submitted work (honorarium for lectures arranged by KCI).
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