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Closure of midline abdominal incisions with small stitches: studies on wound complications and health economy
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background A midline incision inflicts minimal damage to muscles, nerves and blood supply. Postoperative complications cause patients suffering and costs for society. Midline incisions should be closed with a continuous single-layer technique and a suture length (SL) to wound length (WL) ratio over 4. It has been recommended to place stitches at least 10 mm from the wound edge. Recent studies, taking the SL to WL ratio into account, have shown that a stronger wound is produced with small stitches placed closer to the wound edge.

Aims The aims were to study the rate of surgical site infection (SSI) and incisional hernia in relation to the use of small or large stitches; to study the effect of the SL to WL ratio and other risk factors for SSI and incisional hernia in relation to the size of stitches; and to study if the use of small stitches generates cost savings.

Materials and methods In a non-randomised study, 1991 to 1993, the patients having their midline incisions closed with an SL to WL ratio over 4 were selected. The rate of SSI and incisional hernia was analysed in relation stitch length (SL/number of stitches). In a randomised trial, 2001 to 2006, patients were randomised to closure of midline incisions with small stitches, placed 5 to 8 mm from the wound edge, or large stitches placed at a distance of at least 10 mm. Patient and operative characteristics were recorded. The rate of SSI and incisional hernia was studied and risk factors were analysed. The proportion of patients subjected to an incisional hernia repair was identified. The mean cost for a hernia repair during 2010 was calculated. A cost analysis was performed.

Results In the non-randomised study 368 patients were analysed. The lowest rate of SSI and incisional hernia was with a short stitch length. In the randomised trial, 356 patients were closed with small stitches and 381 with large. With small stitches SSI occurred in 17 of 326 patients (5.2%) and with large stitches in 35 of 343 (10.2%) (p=0.02). With small stitches incisional hernia was present in 14 of 250 patients (5.6%) and with large stitches in 49 of 272 (18.0%) (p<0.001). With small stitches, no risk factors could be identified. The rate of incisional hernia was lower with an SL to WL ratio over 4. A very high ratio did not affect the complication rates. With small stitches there was a cost for a longer suturing time, but a cost reduction of 1339 SEK was generated from the societal perspective for each closure compared with large stitches.

Conclusions In midline abdominal incisions closed with a continuous single-layer technique the rate of SSI and incisional hernia is lower with small stitches than with large. The rate of incisional hernia is lower with an SL to WL ratio over 4 and increasing the ratio very much above 4 does not increase the rate of complications. With small stitches no risk factors for the development of SSI and incisional hernia can be identified and cost savings are generated. The previous recommendation to use large stitches should be changed to recommend small stitches.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2012. , 44 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1496
Keyword [en]
Wound closure techniques, Postoperative complications, Surgical wound infection, Surgical wound dehiscence, Hernia, Costs, Cost analysis
National Category
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-55179ISBN: 978-91-7459-419-5 (print)OAI: oai:DiVA.org:umu-55179DiVA: diva2:526137
Public defence
2012-06-05, Aulan, hiss 8, plan 1, Länssjukhuset Sundsvall-Härnösand, 851 86 Sundsvall, Sundsvall, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2012-05-15 Created: 2012-05-10 Last updated: 2012-05-25Bibliographically approved
List of papers
1. Wound complications and stitch length
Open this publication in new window or tab >>Wound complications and stitch length
2004 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 8, no 1, 39-41 p.Article in journal (Refereed) Published
Abstract [en]

The effect of suturing with a very short stitch on the development of wound complications in midline incisions was investigated. Three hundred sixty-eight patients were analysed. The suture length to wound length ratio and mean stitch length were calculated. Wound infection occurred in 4% (four of 103) of patients sutured with a mean stitch length of less than 4 cm, in 8% (nine of 117) with stitch length 4-4.9 cm, and in 16% (24 of 148) with a longer stitch ( P=0.004). At 12-month follow up, incisional hernia was present in 3% (two of 76) of patients sutured with a mean stitch length of less than 4 cm and in 12% (25 of 215) sutured with a longer stitch ( P=0.043). In midline incisions closed with a suture length to wound length ratio of at least 4, a short stitch is associated with a lower rate of both wound infection and incisional hernia.

Keyword
Incisional hernia, Wound healing, Wound infection, Suture technique
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-22676 (URN)10.1007/s10029-003-0159-4 (DOI)13680306 (PubMedID)
Available from: 2009-05-15 Created: 2009-05-15 Last updated: 2017-12-13Bibliographically approved
2. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial
Open this publication in new window or tab >>Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial
2009 (English)In: Archives of surgery (Chicago. 1960), ISSN 0004-0010, E-ISSN 1538-3644, Vol. 144, no 11, 1056-1059 p.Article in journal (Refereed) Published
Abstract [en]

HYPOTHESIS: In midline incisions closed with a single-layer running suture, the rate of wound complications is lower when a suture length to wound length ratio of at least 4 is accomplished with a short stitch length rather than with a long one.

DESIGN: Prospective randomized controlled trial.

SETTING: Surgical department.

PATIENTS: Patients operated on through a midline incision.

INTERVENTION: Wound closure with a short stitch length (ie, placing stitches <10 mm from the wound edge) or a long stitch length.

MAIN OUTCOME MEASURES: Wound dehiscence, surgical site infection, and incisional hernia.

RESULTS: In all, 737 patients were randomized: 381 were allocated to a long stitch length and 356, to a short stitch length. Wound dehiscence occurred in 1 patient whose wound was closed with a long stitch length. Surgical site infection occurred in 35 of 343 patients (10.2%) in the long stitch group and in 17 of 326 (5.2%) in the short stitch group (P = .02). Incisional hernia was present in 49 of 272 patients (18.0%) in the long stitch group and in 14 of 250 (5.6%) in the short stitch group (P < .001). In multivariate analysis, a long stitch length was an independent risk factor for both surgical site infection and incisional hernia.

CONCLUSION: In midline incisions closed with a running suture and having a suture length to wound length ratio of at least 4, current recommendations of placing stitches at least 10 mm from the wound edge should be changed to avoid patient suffering and costly wound complications.

Place, publisher, year, edition, pages
American Medical Association, 2009
Keyword
Suture technique, Postoperative complications, Surgical wound infection, Surgical site infection, Incisional hernia, Surgical wound dehiscence
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-35753 (URN)10.1001/archsurg.2009.189 (DOI)19917943 (PubMedID)
Available from: 2010-09-02 Created: 2010-09-02 Last updated: 2017-12-12Bibliographically approved
3. Risk factors for wound complications in midline abdominal incisions related to the size of stitches
Open this publication in new window or tab >>Risk factors for wound complications in midline abdominal incisions related to the size of stitches
2011 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 15, no 3, 261-266 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Midline abdominal incisions should be closed continuously with a suture length (SL) to wound length (WL) ratio above 4 using small stitches. The effect on the rate of wound complications of a very high ratio and other potential risk factors when closure is performed with small stitches is unknown.

METHODS: Patients operated on through a midline incision were randomised to closure with small stitches, placed 5-8 mm from the wound edge and less than 5 mm apart, or with large stitches, placed more than 1 cm from the wound edge. Patient and operative variables were registered. Surgical site infection and incisional hernia were recorded.

RESULTS: Three hundred and twenty-one patients were randomised to closure with small stitches and 370 with large stitches. Infection and herniation were less common with small stitches. With small stitches, no risk factors for infection or herniation were identified. With large stitches, wound contamination and the patient being diabetic were independent risk factors for infection, and long operation time and surgical site infection were risk factors for herniation. A very high SL to WL ratio did not affect the complication rates.

CONCLUSIONS: In midline abdominal incisions closed with small stitches, no risk factors for surgical site infection or incisional hernia were identified. Increasing the ratio very much above 4 had no adverse effects on the rate of wound complications. The higher rates of infection and herniation with an SL to WL ratio over 5 and in overweight patients in previous reports were probably related to wounds being closed with large stitches.

Keyword
Suture technique, Postoperative complications, Surgical wound infection, Surgical site infection, Incisional hernia
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-55171 (URN)10.1007/s10029-010-0775-8 (DOI)21279664 (PubMedID)
Available from: 2012-05-10 Created: 2012-05-10 Last updated: 2017-12-07Bibliographically approved
4. Cost analysis of the use of small stitches when closing midline abdominal incisions
Open this publication in new window or tab >>Cost analysis of the use of small stitches when closing midline abdominal incisions
2014 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 18, no 6, 775-780 p.Article in journal (Refereed) Published
Keyword
Cost analysis, Costs, Hernia, Postoperative complications, Surgical wound infection, Wound closure techniques
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-55174 (URN)10.1007/s10029-013-1135-2 (DOI)000345702100001 ()
Note

Originally included in thesis in manuscript form.

Available from: 2012-05-10 Created: 2012-05-10 Last updated: 2017-05-29Bibliographically approved

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