M. J. Minarich1, L. Y. Smucker1,2, R. E. Schwarz1,2 1Goshen Center for Cancer Care,Surgical Oncology,Goshen, INDIANA, USA 2Indiana University School of Medicine,South Bend, INDIANA, USA
Introduction: Long-term recovery after abdominal operations can be impaired by incisional healing complications. Incisional herniae are reported in between 5 to more than 20% of patients undergoing open celiotomy, and are often encountered after laparoscopic operations as well. Incisional hernia formation risk has been linked to closure techniques.
Methods: A continuous, single-layer, tension-free musculofascial mass closure with absorbable monofilament looped #1 PDS suture with greater than 2 cm bite size has been used for all open celiotomies, while 12 mm umbilical port sites are closed with 2 interrupted #0 PDS figure-of-eight sutures. Incisional hernia frequency and associated clinicopathologic factors were analyzed from prospective data in consecutive patients undergoing primary incision closure after visceral resections without simultaneous hernia repair or mesh placement.
Results: Out of 159 patients, 146 met study criteria and had at least 30 days of follow-up. There were 77 men and 69 women, with a median age of 64 years (range: 17-88) and a cancer diagnosis in 87%. There were 62 pancreatic (42%), 47 hepatobiliary (32%), 13 gastroesophageal (9%), 4 colorectal (3%) and 20 other procedures (14%), including 21 multivisceral resections (14%). Open operations (n=131, 90%) outweighed laparoscopic resections (n=15, 10%); a total of 69 patients had an umbilical port site, primarily from simultaneous diagnostic laparoscopy. The main incision was at the subcostal margin (n=117, 80%), midline (n=17, 12%) or elsewhere (n=12, 8%). At a median follow-up of 20.4 months (range 1-58, 22.5 for survivors), 6 patients had developed an incisional hernia (4.1%); 2 of these developed at a subcostal, 2 in an umbilical, 1 in both of these, and 1 at a transverse incision. Median time to hernia was 355 days (209-592). Hernia rates were 2.6% for subcostal margin, 0% for midline, and 8.3% for other incisions (including 10% of umbilical port sites)(p=0.006). Factors associated with incisional herniae included increased weight (p=0.007), abdominal depth and girth (p=0.02), spleen size (p=0.02), visceral fat (p=0.03), and platelet count (p=0.04), but not type of resection, prior operations, underlying diagnosis, weight loss or adjuvant treatment with chemotherapy or radiation.
Conclusion: The closure technique as utilized leads to a low, acceptable incisional hernia rate of <3% in subcostal or midline incisions, and can thus be recommended as routine approach. Based on the hernia rate in umbilical port site closures of 10%, we now prefer nonumbilical 5 mm port access for diagnostic laparoscopy procedures.