Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision
To determine whether a transverse incision is an alternative to a midline incision in terms of incisional hernia incidence, surgical site infection, postoperative pain, hospital stay and cosmetics in cholecystectomy.
Summary background data
Incisional hernias after midline incision are commonly underestimated but probably complicate between 2 and 20% of all abdominal wall closures. The midline incision is the preferred incision for surgery of the upper abdomen despite evidence that alternatives, such as the lateral paramedian and transverse incision, exist and might reduce the rate of incisional hernia. A RCT was preformed in the pre-laparoscopic cholecystectomy era the data of which were never published.
One hundred and fifty female patients were randomly allocated to cholecystectomy through midline or transverse incision. Early complications, the duration to discharge and the in-hospital use of analgesics was noted. Patients returned to the surgical outpatient clinic for evaluation of the cosmetic results of the scar and to evaluate possible complications such as fistula, wound dehiscence and incisional hernia after a minimum of 12 months follow-up.
Two percent (1/60) of patients that had undergone the procedure through a transverse incision presented with an incisional hernia as opposed to 14% (9/63) of patients from the midline incision group (P = 0.017). Transverse incisions were found to be significantly shorter than midline incisions and associated with more pleasing appearance. More patients having undergone a midline incision, reported pain on day one, two and three postoperatively than patients from the transverse group. The use of analgesics did not differ between the two groups.
In light of our results a transverse incision should, if possible, be considered as the preferred incision in acute and elective surgery of the upper abdomen when laparoscopic surgery is not an option.
- Mudge M, Hughes LE (1985) Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 72(1):70–71 CrossRef
- Lewis RT, Wiegand FM (1989) Natural history of vertical abdominal parietal closure: Prolene versus Dexon. Can J Surg 32(3):196–200
- Sugerman HJ, Kellum JM Jr, Reines HD, DeMaria EJ, Newsome HH, Lowry JW (1996) Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg 171(1):80–84 CrossRef
- Hodgson NC, Malthaner RA, Ostbye T (2000) The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 231(3):436–442 CrossRef
- Höer J, Lawong G, Klinge U, Schumpelick V (2002) Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years. Chirurg 73(5):474–480 CrossRef
- Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J (2004) Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240(4):578–583; discussion 583–585
- Burger JW, van ‘t Riet M, Jeekel J (2002) Abdominal incisions: techniques and postoperative complications. Scand J Surg 91(4):315–321
- Inaba T, Okinaga K, Fukushima R, Iinuma H, Ogihara T, Ogawa F, Iwasaki K, Tanaka M, Yamada H (2004) Prospective randomized study of two laparotomy incisions for gastrectomy: midline incision versus transverse incision. Gastric Cancer 7(3):167–171 CrossRef
- Guillou PJ, Hall TJ, Donaldson DR, Broughton AC, Brennan TG (1980) Vertical abdominal incisions—a choice? Br J Surg 67(6):395–399 CrossRef
- Nahai F, Brown RG, Vasconez LO (1976) Blood supply to the abdominal wall as related to planning abdominal incisions. Am Surg 42(9):691–695
- Greenall MJ, Evans M, Pollock AV (1980) Midline or transverse laparotomy? A random controlled clinical trial. Part I: influence on healing. Br J Surg 67(3):188–190 CrossRef
- Thompson JB, Maclean KF, Coller FA (1949) Role of the transverse abdominal incision and early ambulation in the reduction of postoperative complications. Arch Surg 59(6):1267–1277
- Lord RS, Crozier JA, Snell J, Meek AC (1994) Transverse abdominal incisions compared with midline incisions for elective infrarenal aortic reconstruction: predisposition to incisional hernia in patients with increased intraoperative blood loss. J Vasc Surg 20(1):27–33
- Johnson B, Sharp R, Thursby P (1995) Incisional hernias: incidence following abdominal aortic aneurysm repair. J Cardiovasc Surg (Torino) 36(5):487–490
- Luijendijk RW, Jeekel J, Storm RK, Schutte PJ, Hop WC, Drogendijk AC, Huikeshoven FJ (1997) The low transverse Pfannenstiel incision and the prevalence of incisional hernia and nerve entrapment. Ann Surg 225(4):365–369 CrossRef
- Armstrong PJ, Burgess RW (1990) Choice of incision and pain following gallbladder surgery. Br J Surg 77(7):746–748 CrossRef
- Lindgren PG, Nordgren SR, Oresland T, Hultén L (2001) Midline or transverse abdominal incision for right-sided colon cancer—a randomized trial. Colorectal Dis 3(1):46–50 CrossRef
- Greenall MJ, Evans M, Pollock AV (1980) Midline or transverse laparotomy? A random controlled clinical trial. Part II: influence on postoperative pulmonary complications. Br J Surg 67(3):191–194 CrossRef
- Donati D, Brown SR, Eu KW, Ho YH, Seow-Choen F (2002) Comparison between midline incision and limited right skin crease incision for right-sided colonic cancers. Tech Coloproctol 6(1):1–4 CrossRef
- Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision
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Volume 13, Issue 3 , pp 275-280
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- 1. Department of General Surgery, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- 4. Department of Surgery, Ikazia Hospital, Montessoriweg 1, 3083 AN, Rotterdam, The Netherlands
- 2. Department of Anesthesiology, Sophia Hospital, Zwolle, The Netherlands
- 3. Department of Trials and Statistics, Erasmus MC, University Medical Center Rotterdam, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands