Laparotomy Closure and Incisional Hernia Prevention - What are the Surgical Requirements?

In the light of an incisional hernia incidence of between 10 and 20% that remains constantly high in spite of modifications of suture materials and suture techniques, intensified scientific efforts aiming at incisional hernia prevention are required. This article reviews the scientific results dealing with incisional hernia incidence, time of manifestation, risk factors and the influence of suture material and suture technique. A lack of evidence-based data and no current consensus concerning the ideal material and technique to close laparotomies has to be mentioned. To encourage a novel approach to incisional hernia prevention, the results of experimental studies which demonstrate the negative effects of conventional laparotomy closure on the abdominal wall are discussed. Histology and additionally laser-fluorescence angiography reveal the weakening of abdominal wall structures and abdominal wall perfusion after directly suturing the incisional edges. Additionally, inadequate suture tension has an influence on collagen quantity and quality in the healing incision. Further investigations with a suture simulator have made clear that surgical sutures vary widely in precision and reproducibility of suture tension when completed only under visual and tactile control. As suture tension dynamics cannot be measured due to the lack of adequate devices, an implantable sensor has been developed that reveals a loss of suture tension of up to 60% of the initial tension in the first 2 hours after completion of laparotomy closure. These results have led to the development and experimental use of a bridging closure with a tension-banding technique. This technique has almost no influence on abdominal wall perfusion, leaves the architecture and dynamics of the abdominal wall intact, and results in a favourable ultra-structural composition of collagen and a mechanically stable laparotomy healing after 15 months. Measures to prevent incisional hernia formation - which is in fact the post-operative complication in surgery most frequently leading to re-operation - require intensified research activities. Success will only be achieved if the development of unconventional closure techniques is encouraged and the beaten path of suturing the incisional edges is discarded.