Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies
Executive Summary
This document synthesizes the 2022 updated guidelines from the European and American Hernia Societies (EHS and AHS) regarding the closure of abdominal wall incisions. Incisional hernia (IH) remains a significant surgical complication, occurring in approximately 12.8% of midline incisions within two years and leading to substantial healthcare costs and high recurrence rates (23–50% after repair).
The core takeaways from this analysis emphasize a shift toward minimally invasive approaches, the avoidance of midline incisions where feasible, and the adoption of the "small-bites" continuous suturing technique using slowly absorbable sutures. Furthermore, the guidelines highlight prophylactic mesh augmentation as a cost-effective and clinically beneficial strategy for high-risk patients. While the quality of evidence across many areas remains low or very low, these recommendations provide a standardized framework intended to reduce IH incidence and improve surgical outcomes.
1. Surgical Approach and Incision Selection
The choice of surgical approach and the specific location of the incision are primary determinants of postoperative complications, specifically incisional hernias and surgical-site occurrences (SSO).
Minimally Invasive vs. Open Surgery
Recommendation: Laparoscopic surgery is suggested whenever safe and feasible.
Evidence: Meta-analysis indicates a significant decrease in IH incidence for laparoscopic surgery (4.3%) compared to open surgery (10.1%). Total laparoscopy—excluding specimen extraction sites—further reduces this rate to 0.8%.
Infection Rates: Wound infection rates are lower in laparoscopic procedures (5.0%) compared to open surgery (11.4%).
Incision Location
Recommendation: Avoid midline incisions for both laparotomies and specimen extraction sites.
Clinical Findings: Midline incisions have the highest reported rates of IH. Transverse and Pfannenstiel incisions for specimen extraction are associated with a significantly lower risk (OR 4.1 for midline vs. non-midline).
Gallbladder Extraction: Comparing umbilical vs. epigastric extraction sites during cholecystectomy showed no significant difference in SSO or postoperative pain.
2. Closure of Minimally Invasive Surgery Ports
Trocar-site hernias are often under-reported, with incidences ranging from 0.1–0.5% in general, but reaching as high as 21.5% when diagnosed via CT imaging in specific procedures like bariatric surgery.
Closure Requirements: Fascial defects should be sutured for trocar sites of 10 mm or larger.
High-Risk Sites: Particular care should be taken at the umbilical port site and following Single-Incision Laparoscopic Surgery (SILS). SILS carries a significantly higher IH risk (OR >2.5) due to the larger fascial incision required.
Trocar Size: 12-mm ports show higher hernia rates than 5-mm trocars.
3. Laparotomy Closure Strategies
The method of closing a laparotomy is critical to the long-term integrity of the abdominal wall. The guidelines advocate for a specific technical approach known as the "small-bites" technique.
Technical Recommendations
Technique: A continuous "small-bites" suturing technique is suggested for elective midline incisions.
Parameters: Tissue bites should be 5–9 mm from the wound edge, incorporating the aponeurosis only, with stitches placed 5 mm apart.
Suture-to-Wound Ratio: A ratio of at least 4:1 is required to ensure adequate tension distribution and reduce the risk of IH.
Continuous vs. Interrupted: Continuous suturing is preferred over interrupted as it distributes tension more evenly, is faster, and leaves less foreign material in the wound.
Materials
Suture Type: Slowly absorbable monofilament sutures (e.g., USP 2/0) are recommended.
Absorption Logic: Fascial healing takes over a year. Slowly absorbable sutures maintain more than 50% of their tensile strength at six weeks, whereas fast-absorbing sutures lose 75% of their strength within four weeks, increasing the risk of mechanical failure before the fascia has sufficiently healed.
Antimicrobial Coating: While triclosan-coated sutures may reduce SSI in some contexts, they have not been proven to prevent incisional hernia.
4. Identifying and Managing High-Risk Patients
Incisional hernias are fundamentally the result of impaired wound healing. Identifying patients with high-risk profiles is essential for applying preventative measures like prophylactic mesh.
Known Risk Factors
Surgical Site Infection (SSI): OR 8.55
Diabetes: OR 6.68
Smoking: OR 3.93
Obesity: HR 1.74
Other factors: Age, COPD, aneurysmal disease, and immunosuppression.
Risk Stratification Tools
Surgeons are encouraged to use validated tools such as the HERNIAscore (utilizing BMI, COPD, incision length, and prior surgery) or dedicated risk calculator applications to identify candidates for mesh augmentation.
5. Prophylactic Mesh Augmentation
Prophylactic mesh augmentation (PMA) involves reinforcing the suture line with a prosthetic at the time of initial closure.
6. Postoperative Care and Activity
Current evidence regarding postoperative management is sparse, leading to a lack of formal recommendations for several common practices.
Abdominal Binders: These may reduce postoperative pain and do not compromise pulmonary function, but there is no evidence that they prevent burst abdomen or IH.
Activity Restriction: There is a lack of comparative trials regarding physical activity restrictions. However, expert surveys suggest that four weeks of no physical strain is a standard clinical expectation following laparotomy.
7. Implementation Barriers and Knowledge Gaps
Challenges to Implementation
Costs and Time: PMA adds to the initial procedure cost and operating time. However, cost-utility analyses suggest PMA is more cost-effective long-term by avoiding the expenses associated with IH repair.
Training: Techniques like the "small-bites" method and retromuscular mesh placement require specific surgical education and monitoring.
