Editorial
Evidence-based midline laparotomy closure and evidence of its use
El cierre de laparotomía media basado en la evidencia y la evidencia de su uso
a Departamento de Cirugía General y Digestiva, Hospital Universitario del Mar, Parc de Salut Mar, Barcelona, Spain
b Secretario de la Sección de Pared Abdominal de la Asociación Española de Cirujanos
c Departamento de Ciencias Experimentales y de la Salud, Universitat Pompeu Fabra, Barcelona, Spain
d Departamento de Cirugía, Universitat Autónoma de Barcelona, Barcelona, Spain
e Unidad de Cirugía de la Pared Abdominal, Hospital Vall d’Hebron, Barcelona, Spain
f Coordinador de la Sección de Pared Abdominal de la Asociación Española de Cirujanos
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"idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Evidence-based midline laparotomy closure and evidence of its use" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "2" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "José Antonio Pereira Rodríguez, Manuel López Cano" "autores" => array:2 [ 0 => array:4 [ "nombre" => "José Antonio" "apellidos" => "Pereira Rodríguez" "email" => array:1 [ 0 => "jpereira@parcdesalutmar.cat" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Manuel" "apellidos" => "López Cano" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Departamento de Cirugía General y Digestiva, Hospital Universitario del Mar, Parc de Salut Mar, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Secretario de la Sección de Pared Abdominal de la Asociación Española de Cirujanos" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Ciencias Experimentales y de la Salud, Universitat Pompeu Fabra, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Cirugía, Universitat Autónoma de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad de Cirugía de la Pared Abdominal, Hospital Vall d’Hebron, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Coordinador de la Sección de Pared Abdominal de la Asociación Española de Cirujanos" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El cierre de laparotomía media basado en la evidencia y la evidencia de su uso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">«Cuiusvis hominis est errare: nullius nisi insipientis, perseverare in errore.»</p><span class="elsevierStyleSmallCaps">Cicerón</span> (Filípicas XII)</span></p><p id="par0010" class="elsevierStylePara elsevierViewall">Science is advancing rapidly, and it is sometimes difficult to separate “the wheat from the chaff”. On other occasions, the difficulty lies in the technical or technological training necessary to implement changes. This is not the case with midline laparotomy closure, as there is currently scientific evidence of sufficient quality<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> to justify switching to a preferential closure technique, as recommended by the EHS guidelines.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Its implementation requires ‘tools’ as simple as: a ruler to measure the length of the incision wound and the length of thread used; continuous suture with 2/0 slow-absorbing material on a small needle; and a calculator to check that the suture length:wound length (SL:WL) ratio is greater than 4:1.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Surgeons use laparotomies to be able to directly treat disease. It is not justifiable that a patient may have complications related to a technique that the surgeon should have 100% under control if the recommendations of quality studies are followed. It is even less justifiable when the management of these complications (e.g., incisional hernia [IH]) requires another surgical intervention, which is sometimes more complex than the initial procedure. In the past, when saving the life of the patient was paramount despite possible complications, the appearance of IH may have been considered a ‘lesser evil’. Today, however, this is insufficient. It is not reasonable to ‘trade’ an illness for an alternate condition of IH.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although the implementation of the evidence is slow and may depend on various factors,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> it is striking that the use of this technique has not become generalized,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> even despite the publication of two randomized studies<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> that included almost 1300 patients and demonstrated that the ‘short stitch’ or ‘small bites’ technique is effective for the prevention of IH and even surgical site infection (SSI).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Even when learning systems and monitoring measures are established,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> a large number of surgeons do not comply with the recommendations (only 31% performed the closure by correctly following the protocol), despite acknowledging sufficient knowledge of the technique and the associated scientific evidence (95% knew the short-stitch technique and 98% knew the importance of the SL:WL ratio, 82% claimed to use the short-stitch technique, but only 53% systematically measured the SL:WL ratio). Interestingly, fewer IH and eviscerations occurred in this study when the recommendations were followed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In fact, when we compared the results of the patients included in these three studies,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,8</span></a>, totaling 1401 patients (719 vs 682), the short-stitch technique was significantly more effective for the prevention of both IH (OR: 2184; 95% CI: 1.530-3.115; <span class="elsevierStyleItalic">P</span> = .0001) as well as SSI (OR: 1516; 95% CI: 1109-2072; <span class="elsevierStyleItalic">P</span> = .009).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Social networks can be a barometer of opinion amongst the surgical community in this regard. Thus, one can read unexpected comments, such as “When I use 0 or 0 loop I sleep much better,”<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> or in surveys like the one by the journal <span class="elsevierStyleItalic">Diseases of Colon and Rectum</span>,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> in which 63% of a total of 254 surgeons reported using polydioxanone suture (no 1) with a large needle for closure of a midline laparotomies. Furthermore, it is unbelievable that some surgeons continue to use loop sutures, or have started using barbed sutures for abdominal wall closure, despite the fact that the evidence is at the very least controversial, low-quality or inferior, as shown by comparative studies.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Opening and closing the abdomen is probably the most frequently performed maneuver throughout the professional career of a surgeon treating intra-abdominal pathology (whatever the specialization). Therefore, we can assume that the technique used is the one supported by the greatest scientific evidence, regardless of other parameters like speed or ease of execution. Due to the importance of the associated complications and their repercussions on patients, we do not believe that anyone will be surprised if we state that the closure of a laparotomy should have an equivalent relevance to that of an intestinal suture or that of any system used for hemostasis. Surgeons must be aware that they not only have to cure the patient’s disease, but they must also ensure that it occurs with minimal complications related to their actions.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Aware of all this, the Abdominal Wall Division of the Spanish Association of Surgeons (<span class="elsevierStyleItalic">Sección de Pared Abdominal</span>, <span class="elsevierStyleItalic">Asociación Española de Cirujanos</span>) has launched theoretical and practical courses for residents for the last six years. Surgeons-in-training are very sensitive to these initiatives, but surveys conducted during these courses have shown that only 35% knew and systematically checked the SL/WL ratio, 12% knew it but were not allowed to use it, 54% stated that the short-stitch technique was used routinely in their hospital, 31% did not know what it was, and 15% knew it but did not use it.</p><p id="par0050" class="elsevierStylePara elsevierViewall">This does not affect digestive surgery alone, so this information should be disseminated and applied in any specialty that uses laparotomy for therapeutic purposes. In our opinion, it is the duty of department heads, scientific societies and healthcare administrators to ensure that surgeons are trained and properly perform laparotomy closure. The technical circumstances should be appropriately recorded on the operating sheets, and even in a national registry in order to audit proper compliance. Surgeons should monitor their results and be willing to change. In the face of solid scientific evidence, it is clear that we must renew our ideas and modify our practice.<span class="elsevierStyleDisplayedQuote" id="dsq0010"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">«To change is difficult; not to change is fatal.»</p>William G. Pollard (1911–1989)</span></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pereira Rodríguez JA, López Cano M. El cierre de laparotomía media basado en la evidencia y la evidencia de su uso. Cir Esp. 2022;100:1–2.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Small stitches with small suture distances increase laparotomy closure strength" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.J. Harlaar" 1 => "G.H. van Ramshorst" 2 => "J. Nieuwenhuizen" 3 => "J.G. Ten Brinke" 4 => "W.C. Hop" 5 => "G.J. 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Calvo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-2482-14-70" "Revista" => array:5 [ "tituloSerie" => "BMC Surg" "fecha" => "2014" "volumen" => "14" "paginaInicial" => "70" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25231161" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735077/0000010000000001/v1_202201040741/S2173507721002805/v1_202201040741/en/main.assets" "Apartado" => array:4 [ "identificador" => "7420" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735077/0000010000000001/v1_202201040741/S2173507721002805/v1_202201040741/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507721002805?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 2 | 5 |
| 2024 October | 19 | 6 | 25 |
| 2024 September | 30 | 1 | 31 |
| 2024 August | 23 | 4 | 27 |
| 2024 July | 16 | 3 | 19 |
| 2024 June | 17 | 5 | 22 |
| 2024 May | 10 | 3 | 13 |
| 2024 April | 11 | 6 | 17 |
| 2024 March | 20 | 0 | 20 |
| 2024 February | 23 | 2 | 25 |
| 2024 January | 14 | 1 | 15 |
| 2023 December | 21 | 2 | 23 |
| 2023 November | 32 | 4 | 36 |
| 2023 October | 48 | 4 | 52 |
| 2023 September | 23 | 8 | 31 |
| 2023 August | 10 | 1 | 11 |
| 2023 July | 21 | 1 | 22 |
| 2023 June | 12 | 7 | 19 |
| 2023 May | 16 | 0 | 16 |
| 2023 April | 5 | 3 | 8 |
| 2023 March | 13 | 4 | 17 |
| 2023 February | 9 | 17 | 26 |
| 2023 January | 7 | 3 | 10 |
| 2022 February | 1 | 0 | 1 |
| 2022 January | 3 | 2 | 5 |
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