Articulo 9

Review
A systematic review on the effectiveness of slowly-absorbable versus

non-absorbable sutures for abdominal fascial closure following laparotomy
M.S. Sajid
*
, U. Parampalli, M.K. Baig, M.R. McFall
Department of General & Colorectal Surgery, Worthing Hospital, Worthing, West Sussex BN11 2DH, UK
a r t i c l e i n f o
Article history:
Received 15 June 2011
Received in revised form
6 September 2011
Accepted 24 September 2011
Available online 30 October 2011
Keywords:
Laparotomy closure
Fascial defects
Dehiscence
Incisional hernia
Suture sinus
a b s t r a c t
Objective: To systematically analyse the effectiveness of delayed-absorbable (Polydioxanone; PDS) versus
non-absorbable (Polypropylene; Prolene, and Nylon) for abdominal fascial closure in patients undergoing
laparotomy.
Methods: Randomised trials evaluating PDS versus Prolene/Nylon for abdominal fascial closure were
selected and analysed by using the statistical tool RevMan
where summative data was expressed as

odds ratio (OR).
Results: Eight randomised trials encompassing 4261 patients undergoing laparotomy closure with either
PDS or Prolene/Nylon were retrieved. There was no statistically signicant heterogeneity among trials. In
the xed effect model PDS was comparable to Prolene/Nylon in terms of risk of incisional hernia (OR,
1.10; 95% CI, 0.87, 1.37; z 0.79; p 0.43), wound dehiscence (OR, 1.04; 95% CI, 0.67, 1.62; z 0.19;
p 0.85), peri-operative complications (OR, 0.94; 95% CI, 0.66, 1.33; z 0.37; p 0.71), suture sinus
formation (OR, 0.58; 95% CI, 0.33, 1.04; z 1.84; p 0.07) and surgical site infection (OR, 0.98; 95% CI,
0.68, 1.39; z 0.14; p 0.89). Subgroup analysis separately comparing Prolene and Nylon with PDS
supported same outcome.
Conclusion: PDS and Prolene/Nylon are equally effective for the closure of abdominal fascia following
laparotomy. Given that there are no signicant differences between two suture materials, further studies
may be conducted to evaluate their cost-effectiveness and measurement of health-related quality of life
instead of analysing their effectiveness in laparotomy closure.
2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Introduction
Incisional hernia is a frequent complication of abdominal surgery,
with a reported incidence of 3e13% of patients following lapa-
rotomy.
1e4
In the United States of America, approximately 4e5
million laparotomies are performed annually,
4
leading to at least
400,000e500,000 incisional hernias, of which approximately
200,000 repairs are performed.
4,5
In the Netherlands, 100,000 lapa-
rotomies and 3900 incisional hernia repairs are performedannually.
6
In the United Kingdom, more than 124,000 laparotomies and 7000
incisional hernia repairs were performed in 2005e2006 with both
open and laparoscopic techniques.
7
Thus about 4% of patients
undergoing a laparotomy require additional surgery to repair an
incisional hernia. When morbidity is added to the vast numbers and
the tremendous costs associated with incisional hernia repair,
8e12
it
becomes quite clear that effective preventive strategies may play
a vital role to save healthcare resources by reducing the incidence of
incisional hernia. Development of incisional hernia following lapa-
rotomy is multifactorial. These factors may be classied into patient
related, biological factors and surgical technique related.
13e16
Patient
related factors include age, higher body mass index, synchronous
presence of abdominal aortic aneurysm and multiple co-morbid-
ities.
17e20
Biological factors include the capacity for normal collagen
synthesis and organization to affect sound biological repair. Abno-
rmal biological healing of fascial sheathresults inthe development of
incisional hernia.
21e24
Therefore, biological factors are less amenable
to modications. Operative and technical factors may be considered
the weakest link in the development of incisional hernia which
should form the highest priority in preventive strategies.
Several systematic reviews
25e30
have examined the type of
suture used for abdominal fascial closure but none have success-
fully recommended an agreed suture technique and suture type.
The objective of this review is to systematically analyse only those
randomised controlled trials which have evaluated the efcacy of
the most commonly used suture material (in the United Kingdom)
* Corresponding author. Washington Suite, North Wing, Worthing Hospital, West
Sussex BN11 2DH, UK. Tel.: 44 (0) 1903 205 111x4030, 07891667608 (Mobile);
fax: 44 (0) 1903 285 010.
E-mail address: surgeon1wrh@hotmail.com (M.S. Sajid).
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery
j ournal homepage: www. t hei j s. com
1743-9191/$ e see front matter 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijsu.2011.09.006
International Journal of Surgery 9 (2011) 615e625
REVIEW
for abdominal fascial closure, that is monolamentous slowly-
absorbable Polydioxanone (PDS) versus monolamentous non-
absorbable Polypropylene (Prolene) and Nylon.
2. Methods
Relevant prospective randomized controlled trials on the use of PDS versus
Prolene/Nylon for abdominal fascial closure following laparotomy until April 2011
were included in this review. The Cochrane Colorectal Cancer Group (CCCG)
Controlled Trial Register, the Cochrane Central Register of Controlled Trials
(CENTRAL) in The Cochrane Library, Medline, Embase and Science Citation Index
Expanded were searched until April 2011 using the medical subject headings
(MeSH) terms laparotomy closure, and fascial sheath closure. These headings
were used in combination with slowly-absorbable suture, non-absorbable
suture, polydioxanone, PDS,polypropylene, and prolene. A lter for
identifying relevant studies recommended by The Cochrane Collaboration
31
was
used to lter out irrelevant studies in Medline and Embase. The references of the
included studies were searched to identify further trials. The software package
RevMan 5.0.1
32
provided by The Cochrane Collaboration was used for analysis. The
odds ratio (OR) with 95 per cent condence interval (CI) was calculated for binary
data variables. The random effects model
33
and the xed effect model
34
were used
to calculate the combined outcome in both binary and continuous variables. In
case of heterogeneity, only the results of the random effects model were reported.
Heterogeneity was explored using the c
2
test, with signicance set at p <0$05, and
quantied
35
using I
2
with a maximum value of 30% identifying low heteroge-
neity.
31
The Mantel-Haenszel method was used for the calculation of OR under the
xed effect model, and the DerSimonian/Laired method was used for the calcu-
lation of OR under the random effect model.
36
In a sensitivity analysis, 0.5 was
added to each cell frequency for trials in which no event occurred in either the
treatment or control group, according to the method recommended by Deeks
et al.
37
The estimate of the difference between both techniques was pooled
depending upon the effect weights in results determined by each trial estimate
variance. A forest plot (Figs. 3e17) was used for the graphical display of results
from the meta-analysis. The square around the estimate stands for the accuracy of
the estimation (sample size) and the horizontal line represents the 95% CI. We also
performed subgroup analysis on trials where comparison between PDS versus
Prolene and PDS versus Nylon was made separately to evaluate the inuence of
individual suture material.
3. Results
Eight studies
38e45
encompassing 4261 patients undergoing
laparotomyclosure witheither PDS or Prolene/Nylonwere retrieved
from the electronic databases (Fig. 1). There were 2195 patients in
PDS group and 2066 patients in Prolene/Nylon group. The charac-
teristics of these trials are given inTable 1. Variables used to achieve
a combined outcome are given in Table 2. On subgroup analysis,
combined outcome was achieved by a separate meta-analysis of 4
trials
38,39,42,44
comparing the effectiveness of PDS (863 patients)
versus Prolene (865 patients). Furthermore, combined outcome was
also achieved after a separate meta-analysis of 4 trials
40,41,43,45
comparing the effectiveness of PDS (1332 patients) versus Nylon
(1201 patients) and difference between outcomes of these two
groups was critically assessed to quantify bias based on these two
suture materials.
Potentially relevant trials identified for
the electronic databases and screened for
retrieval
n = 79
Printed copies of published trials
retrieved from the electronic databases
were evaluated in detail
n = 51
Trials excluded n =28
Reasons: Trials on the use of other types of sutures used for
laparotomy closure
Potentially appropriate randomized trials
to be included in the review
n = 20
Trials with usable information by
outcome,
n = 8 on 4261 patients
Trials excluded n = 31
Reasons: Duplicate publications of same trials (11),
extended abstracts of same trials (8) and commentaries
on same trials (5).
Trials excluded = 12
Reasons: Clinical controlled trials (4), literature
reviews (3) and meta-analysis (5)
Fig. 1. Quorum diagram showing trial selection methodology.
M.S. Sajid et al. / International Journal of Surgery 9 (2011) 615e625 616
REVIEW
Table 1
Characteristics of included trials.
Trial Type
of trial
Country Surgical procedures Suture comparison Follow-up
duration
Reported outcomes
Bloemen 2011 RCT Netherlands Both elective
and emergency
laparotomy
Polydioxanone 1/0 versus
Polypropylene 1/0 Mass closure
Polydioxanone:
34.5(31.6e37.3)
Polypropylene:
33.3(30.5e36.0)
Wound infection
Peri-operative complications
Wound dehiscence
Suture sinus
Incisional hernia
Cameron 1987 RCT UK Midline laparotomy
for various abdominal
procedures
Polydiaxanone 1 versus
Polypropylene 1 Mass closure
14.70 months Wound infection
Per-ioperative complications
Wound dehiscence
Suture sinus
Incisional hernia
Docobo-Durantez
2006
RCT Spain Laparotomy for
Hepatobiliopancreatic diseases
and liver transplantation
Polydioxanone 1 versus
Nylon 1 Mass closure
18 months Wound infection
Wound dehiscence
Suture sinus
Incisional hernia
Israelsson 1994 RCT Iceland
Sweden
Midline laparotomy for various
abdominal procedures
Wound dehiscence
Suture sinus
Incisional hernia
Krukowski 1987 RCT UK Midline laparotomy for various
abdominal procedures
Polypropylene 1
Wound dehiscence
Suture sinus
Incisional hernia
Leaper 1985 RCT UK Midline and transverse laparotomy
for various abdominal procedures
Wound dehiscence
Suture sinus
Incisional hernia
Mirza 2003 RCT UAE Midline and transverse laparotomy
for various abdominal procedures
Polypropylene 1 Mass closure
Wound dehiscence
Suture sinus
Incisional hernia
Wissing 1987 RCT Netherlands All midline laparotomies:
emergency and elective
Wound dehiscence
Suture sinus
Incisional hernia
Table 2
Outcome variables.
Trial Number
of patients
Incisional
hernia
Surgical site
infection
Suture
sinus
Peri-operative
complications
30-day wound
dehiscence
Bloemen 2011
Polydiaxanone 267 58/267 18/267 5/267 41/267 18/267
Polypropylene 256 45/256 14/256 3/256 26/256 9/256
Cameron 1987
Polydiaxanone 143 10/143 12/143 0/143 44/143 1/143
Polypropylene 141 11/141 21/141 1/141 47/141 9/141
Docobo-Durantez 2006
Polydiaxanone 451 5/65 21/451 Not 25/451 4/451
Nylon 319 2/42 20/319 reported 23/319 2/319
Israelsson 1994
Polydiaxanone 405 49/325 38/405 1/405 8/405 2/405
Nylon 408 50/318 35/408 1/408 11/408 3/408
Krukowski 1987
Polydiaxanone 374 22/285 13/374 0/374 16/374 3/343
Polypropylene 383 28/295 27/383 1/383 35/383 7/362
Leaper 1985
Polydiaxanone 107 1/107 18/106 0/107 19/107 1/106
Nylon 97 0/97 9/97 0/97 9/97 0/97
Mirza 2003
Polydiaxanone 79 5/79 8/79 2/79 11/79 1/79
Polypropylene 85 4/85 10/85 11/85 23/85 2/85
Wissing 1987
Polydiaxanone 370 37/281 43/370 11/281 67/281 13/370
Nylon 377 31/299 27/377 23/299 58/299 8/377
REVIEW
3.1. Methodological quality of included studies
The methodological quality of included trials was initially
assessed by the published guideline of SIGN(Scottish Intercollegiate
Guidelines Network) andRangel et al.
46,47
All trials scoredfrom11 to
15a maximumof 19moderates togoodstrengthof eachrandomized
controlled trial. Based on the quality of included randomised
controlled trials,
38e45
the strength and summary of evidence was
further evaluated by GradePro
,
48
a statistical tool provided by
Cochrane Collaboration (Fig. 2). The Mantel-Haenszel xed effect
model was used to compute robustness and susceptibility to an
outlier among these trials. The allocation concealment and blinding
of investigator or assessor were not clearly reported as is often the
case in trial evaluating surgical procedures. Qualitatively the results
of this review may be considered relatively weaker. There was no
statistically signicant heterogeneity (clinical or methodological
diversity) amongst trials except in case of peri-operative compli-
cations including surgical site infection.
3.2. Incidence of incisional hernia (PDS versus Prolene/Nylon)
There was no heterogeneity [chi
2
4.31, df 7, (p 0.74);
I
2
0%] among trials. Therefore, in the xed effects model (OR, 1.11;
95% CI, 0.89, 1.39; z 0.92; p 0.36; Fig. 3), there was no statistical
Fig. 2. Summary and strength of the evidence from trials analysed on GradePro
.
REVIEW
difference in the incidence of incisional hernia following the use of
both types of sutures for abdominal fascial closure.
3.3. Surgical site infection rate (PDS versus Prolene/Nylon)
There was a signicant heterogeneity [Tau
2
0.14, chi
2
15.92,
df 7, (p < 0.03); I
2
56%] among trials. Therefore, in the random
effects model (OR, 0.97; 95% CI, 0.68, 1.39; z 0.16; p 0.88; Fig. 4),
there was no statistical difference in surgical site infection rate
following the use of both types of sutures.
3.4. Suture sinus development rate (PDS versus Prolene/Nylon)
2
4.70, df 5, (p 0.45);
I
2
0%] among trials. Therefore, in the xed effects model (OR,
0.49; 95% CI, 0.29, 0.85; z 2.54; p 0.01; Fig. 5), there was
statistically signicant higher risk of suture sinus development
following the use of Prolene/Nylon compared to PDS.
3.5. Peri-operative complications (PDS versus Prolene/Nylon)
2
0.19, chi
2
21.66,
df 7, (p <0.003); I
2
there was no statistical difference in the incidence of peri-operative
complications following the use of both types of sutures.
3.6. Peri-operative wound dehiscence (PDS versus Prolene/Nylon)
2
10.70, df 7,
(p 0.15); I
2
35%] among trials. Therefore, in the xed
effects model (OR, 1.05; 95% CI, 0.68, 1.62; z 0.20; p 0.84;
Fig. 7), there was no statistical difference in the incidence of
peri-operative wound dehiscence following the use of both
types of sutures.
3.7. Incidence of incisional hernia (PDS versus Prolene)
2
2.05, df 3, (p 0.56);
I
2
0%] among trials. Therefore, in the xed effects model
(OR, 1.08; 95% CI, 0.79, 1.48; z 0.47; p 0.64; Fig. 8), there
was no statistical difference in the incidence of incisional
hernia the use of both types of sutures for abdominal fascial
closure.
3.8. Surgical site infection rate (PDS versus Prolene)
2
4.46, df 3, (p 0.22);
I
2
0.69; 95% CI, 0.48, 1.00; z 1.94; p 0.05; Fig. 9), there was no
statistical difference in surgical site infection rate following the use
of both types of sutures.
Fig. 3. Incisional hernia (PDS versus Prolene/Nylon).
Fig. 4. Surgical site infection (PDS versus Prolene/Nylon).
REVIEW
Fig. 6. Peri-operative complications (PDS versus Prolene/Nylon).
Fig. 7. Wound dehiscence (PDS versus Prolene/Nylon).
Fig. 5. Suture sinus formation (PDS versus Prolene/Nylon).
REVIEW
3.9. Suture sinus development rate (PDS versus Prolene)
2
4.48, df 3, (p 0.21);
I
2
statistical difference in the incidence of suture sinus development
following the use of both types of sutures materials.
3.10. Peri-operative complications (PDS versus Prolene)
2
0.29, chi
2
12.69,
df 3, (p <0.005); I
2
complications following the use of both types of sutures.
3.11. Peri-operative wound dehiscence (PDS versus Prolene)
2
1.40, chi
2
9.87,
df 3, (p < 0.02); I
2
wound dehiscence following the use of both types of sutures.
3.12. Incidence of incisional hernia (PDS versus nylon)
2
1.44, df 3, (p 0.70);
I
2
difference in the incidence of incisional hernia following the use of
both types of sutures.
Fig. 9. Surgical site infection (PDS versus Prolene).
Fig. 10. Suture sinus formation (PDS versus Prolene).
Fig. 8. Incisional hernia (PDS versus Prolene).
REVIEW
3.13. Surgical site infection rate (PDS versus nylon)
2
5.68, df 3, (p 0.13);
I
2
statistical difference in the incidence of developing surgical site
infection following the use of both types of sutures.
3.14. Suture sinus development rate (PDS versus Nylon)
2
0.24, df 1, (p 0.62);
I
2
statistical difference in the incidence of suture sinus development
following the use of both types of sutures for abdominal fascial
closure in laparotomy.
3.15. Peri-operative complications (PDS versus Nylon)
2
5.28, df 3, (p 0.15);
I
2
statistical difference in the incidence of peri-operative complica-
tions following the use of both types of sutures for abdominal
fascial closure.
3.16. Peri-operative wound dehiscence (PDS versus Nylon)
2
1.73, df 3, (p 0.63);
I
2
difference in the incidence of peri-operative wound dehiscence
following the use of both types of sutures.
Fig. 12. Wound dehiscence (PDS versus Prolene).
Fig. 13. Incisional hernia (PDS versus Nylon).
Fig. 11. Peri-operative complications (PDS versus Prolene).
REVIEW
3.17. Subgroup analysis
A subgroup analysis was performed on trials with follow-up of
more than 1 year because a number of incisional hernias develop
later than one year after laparotomy. There was no heterogeneity
[chi
2
4, df 6, (p 0.68); I
2
0%] among trials. Therefore, in the
xed effects model (OR, 1.10; 95% CI, 0.88 1.38; z 0.87; p 0.38),
there was no statistical difference in the incidence of incisional
hernia following the use of both types of sutures for abdominal
fascial closure.
3.18. Other relevant variables
Although the authors of this review intended to analyse data of
other relevant and important variables such as cost-effectiveness,
health-related quality of life measurement, length of hospital
stay, operative time, long-term follow-up and re-admission rate
due intra-abdominal adhesions. These calculations were virtually
impossible to perform because of insufcient data reporting.
4. Discussion
This meta-analysis has demonstrated that PDS, Prolene and
Nylon all are equally effective for abdominal fascial closure. Risk of
incisional hernia, wound dehiscence, peri-operative complications,
suture sinus formation, and surgical site infection do not differ
signicantly for different suture materials. Subgroup analysis
comparing PDS with both Prolene and Nylon also suggest equiva-
lence. There is a lack of agreement within the surgical fraternity
about the ideal abdominal fascial closure technique. Several meta-
analyses of variable quality
25e30
have reported confusing and
conicting recommendations. Studies have compared the use of
Fig. 15. Suture sinus formation (PDS versus Nylon).
Fig. 16. Peri-operative complications (PDS versus Nylon).
Fig. 14. Surgical site infection (PDS versus Nylon).
REVIEW
absorbable versus non-absorbable, delayed-absorbable versus non-
absorbable, monolament versus multilament and the use of steel
wires for laparotomy closure but without any solid conclusion. The
ndings of our review correlate well with one meta-analysis
27
published in 2002 supporting the use of slowly-absorbable suture
material. This is further supported by Diener et al
25
favouring the
use of delayed-absorbable suture material like PDS. In contrast,
Hodgson et al
28
favour the use of non-absorbable Prolene and
Nylon. We consider this meta-analysis a valuable guide in current
surgical practice for the surgical community because the most
commonly used suture materials were compared and a conclusive
outcome could be reached to attain valid recommendations. A
recently published high quality randomised controlled
38
trial
favours our conclusion considerably but the incidence of incisional
hernia was reported higher between both groups because of
difference in baseline characteristics referring towards higher
number of recruited patients with chronic obstructive pulmonary
disease.
No further trials are required for the evaluation of suture material
in abdominal fascial closure according to the results of summative
outcomes of this review. Future randomised trials may be aimed to
evaluate variables like cost-effectiveness, health-related quality of
life measurement, length of hospital stay, operative time, long-term
follow-up and re-admission rate due to intra-abdominal adhesions.
Furthermore, research may be directed towards closure strategy in
emergency versus elective laparotomy closure, new suture material,
and the use of prophylactic biosynthetic meshes in a group of high
risk population like patients with obesity, chronic obstructive
pulmonary disease, metabolic syndromes, abdominal aortic aneu-
rysm and patients with previous laparotomy.
13e25
Conict of interest
None.
Funding
None.
Ethical approval
Not applicable.
Trial
Not applicable.
Author contribution
Study idea: Sajid
Study design: Sajid, Parampalli, McFall
Data collections: Sajid, Parampalli
Data conrmation: Baig
Data analysis: Sajid, Parampalli
Draft writing: Sajid, McFall
Critical review of the article: Baig
Final approval: Sajid, Parampalli, Baig, McFall
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Review

A systematic review on the effectiveness of slowly-absorbable versus

where summative data was expressed as

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