Abdominal wall closure:
Clinical Challenge

30 million global open surgery procedures annually1

1 in 3 patientsexperience abdominal wall complications after laparotomy2‍

Open surgery performed at large scale

Despite the rise in minimally invasive surgery, a large proportion of operations, such as colorectal surgery, are performed using open techniques.

In many cases, a laparotomy is unavoidable for the precise assessment of lesions, removal of large specimens, and global and speedy access to the operative field.1

Indications for laparotomy include:

  • Advanced abdominal cancer debulking
  • Caesarean sections
  • Transplantations
  • Severe trauma
  • Conversion from minimally invasive techniques

Significant clinical challenges arise with abdominal wall closure, particularly linked to the abdominal fascia.

Abdominal fascia heals slowly

The abdominal wall fascia has low vascularization, resulting in a slow healing process.1 During the first 14-28 days post-surgery, wound support relies entirely on the suture line.2 This period is critical for abdominal wall wound healing and complications, even severe, can develop.

Challenges in surgical tissue healing: Risks and complications

Tissue healing depends on various patient and intraoperative factors. Multiple factors can increase the risk of impaired wound healing. Some factors can be modified pre- or intraoperatively, while others cannot.

The most common wound-related complication is surgical site infection.

Wound dehiscence can involve the skin or fascia, potentially leading to aburst abdomen with protrusion of abdominal contents (typically omentum or bowel).

Incisional hernia may develop months to years after surgery.

Surgical site infection and wound dehiscence increase the risk of incisional hernia, stressing the need to prevent these early complications.

Risk factors

Preoperative
factors
Intraoperative
factors

Risk factors

Preoperative
factors
Intraoperative
factors

Challenges in surgical tissue healing: Most frequent controllable risk factors

High Body Mass Index (BMI)

7.5-fold increase in the risk of surgical site infection1

Nearly 2.5-fold increase in the risk of incisional hernia3

Cigarette Smoking

Two-fold increase in the risk of surgical site infection2

Three-fold increase in the risk of incisional hernia4

Diabetes

More than 1.5-fold increase in the risk of surgical site infection1

More than 1.5-fold increase in the risk of incisional hernia5

Closure technique impacts complications and costs

Surgical site infection

Surgical site infections after laparotomies occur in 10-18% of patients1,2
  • Surgical site infections double the risk of incisional hernia3
  • 1,6 x more likely to end up in an intensive care unit4
  • 2x more likely to die4
  • Prolonged hospitalization by 7-12 days4
  • Increased direct costs by $3,000-$5,0004

Burst abdomen

Up to 7% incidence of burst abdomen following laparotomy5,6
  • Incidence of 4% on elective surgeries7
  • Up to 25% increased mortality risk8
  • Patients with burst abdomen less likely to receive planned adjuvant chemotherapy9
  • 80% increase of subsequent incisional hernia repair7

Incisional Hernia

21-32% risk of incisional hernia after laparotomy10,11
  • The burden of incisional hernias includes pain, limitations of activity and reduced QoL12
  • 22% recurrence after incisional hernia repair13
  • 7.5% mortality in emergency incisional hernia repair14
  • Average increased healthcare cost
  • 10 000 USD/procedure15
  • €9 Billion incisional hernia repair costs/ year in Europe15

Impact of complications on patient treatment plans

  • Patients who develop a post-operative surgical site infection have a 1.6-fold increased risk of being admitted to the Intensive Care Unit (ICU).1
  • Surgical site infection is associated to a 2- to 11-fold increase in the risk of mortality with 75% of surgical site infection-associated death directly attributable to the surgical site infection.2,3
  • Hospital stays are 92% longer for patients with surgical site infections.4
  • Patients undergoing emergency laparotomy who develop burst abdomen have a 2-fold increase in mortality at 30 days and have a median hospital stay of 22 days compared to 7 for patients without burst abdomen.5
  • Post-operative complications are strong predictors of delaying adjuvant chemotherapy.6
  • Complications lead to delayed recovery.7
  • In some cases, re-operations are necessary, adding to the patient's physical and emotional burden.

Preventing these complications is crucial for ensuring optimal patient outcomes and efficient use of healthcare resources.

Factors driving costs in open abdominal surgery1

Complications from open abdominal surgery significantly increase healthcare costs and strain hospital resources. Here are some key factors contributing to these increased costs:

  • Reoperation
  • Prolonged hospitalization
  • Follow-up visits at primary care
  • Sick leave
  • Wound care nurse and wound dressings
  • Antibiotics
  • Other hospital costs

Reducing these complications is essential for managing resources effectively and improving patient outcomes.

Healthcare costs double for patients requiring Incisional Hernia repair

The graph illustrates the cost impact of incisional hernia based on a study by Dr. John P. Fischer, which analyzed data from 12,373 patients who underwent gastrointestinal or gynecologic procedures at the University of Pennsylvania Health System January 1, 2005 - June 1, 2013.

Financial data included direct variable costs (operating room, labs, radiology, pharmacy, blood products, surgical implants, and perioperative services) and total costs for each admission and related readmissions due to any complications.