在接受急诊剖腹手术的患者中实施标准化筋膜闭合技术后，切口裂开率降低。

Reduced Rate of Dehiscence After Implementation of a Standardized Fascial Closure Technique in Patients Undergoing Emergency Laparotomy.

作者信息

Tolstrup Mai-Britt, Watt Sara Kehlet, Gögenur Ismail

机构信息

*Department of Gastrointestinal Surgery, Copenhagen University Hospital, Herlev, Denmark†Zealand University Hospital. Dept. Surgery, Center for Surgical Science, Copenhagen University, Koege, Denmark.

出版信息

Ann Surg. 2017 Apr;265(4):821-826. doi: 10.1097/SLA.0000000000001762.

DOI:10.1097/SLA.0000000000001762

PMID:28267697

Abstract

OBJECTIVE

In elective surgery, it is well documented that a midline laparotomy should be closed with a slowly absorbable monofilament suture material in a continuous technique, in a ratio of at least 4 : 1. The evidence concerning the suture material or suturing technique in the emergency setting is lacking. We aimed to investigate whether this technique would reduce the rate of dehiscence.

METHODS

A standardized procedure of closing the midline laparotomy by using a "small steps" technique of continuous suturing with a slowly absorbable (polydioxanone) suture material in a wound-suture ratio of minimum 1 : 4 was introduced in June 2014. All patients scheduled for any gastrointestinal emergency midline laparotomy were included until October 2015. Pre-, intra-, and postoperative data were registered. All emergency laparotomies performed from 2009 to 2013 served as reference. Chi-squared tests and multivariate Cox regression analysis were performed.

RESULTS

We included 494 patients from 2014 to 2015 and 1079 patients from our historical cohort for comparison. All patients had a midline laparotomy in an emergency setting. The rate of dehiscence was reduced from 6.6% to 3.8%, P = 0.03 comparing year 2009 to 2013 with 2014 to 2015. Factors associated with dehiscence were male gender [hazard ratio (HR) 2.8, 95% confidence interval (95% CI) (1.8-4.4), P < 0.001], performance status ≥3 [HR 2.1, 95% CI (1.2-3.7), P = 0.006], cirrhosis [HR 3.8, 95% CI (1.5-9.5), P = 0.004], and retention sutures [HR 2.8, 95% CI (1.6-4.9), P < 0.000]. The 30-day mortality rate was 18.4% in the standardized group vs 22.4% in 2009 to 2013, P = 0.057 and 90-day mortality 24.2% vs 30.4%, P = 0.008.

CONCLUSION

The standardized procedure of closing the midline laparotomy by using a "small steps" technique of continuous suturing with a slowly absorbable (polydioxanone) suture material reduces the rate of fascial dehiscence.

摘要

目的

在择期手术中，有充分文献记载，中线剖腹手术应以连续技术使用可缓慢吸收的单丝缝合材料进行缝合，比例至少为4∶1。但在急诊情况下，关于缝合材料或缝合技术的证据尚不充分。我们旨在研究该技术是否会降低切口裂开率。

方法

2014年6月引入了一种标准化程序，即采用“小步骤”连续缝合技术，使用可缓慢吸收（聚二氧六环酮）的缝合材料，伤口与缝线比例至少为1∶4来关闭中线剖腹手术切口。纳入2015年10月前所有计划进行任何胃肠道急诊中线剖腹手术的患者。记录术前、术中和术后数据。将2009年至2013年进行的所有急诊剖腹手术作为对照。进行卡方检验和多变量Cox回归分析。

结果

我们纳入了2014年至2015年的494例患者以及来自历史队列的1079例患者进行比较。所有患者均在急诊情况下接受了中线剖腹手术。切口裂开率从6.6%降至3.8%，2009年至2013年与2014年至2015年相比，P = 0.03。与切口裂开相关的因素有男性[风险比（HR）2.8，95%置信区间（95%CI）（1.8 - 4.4），P < 0.001]、体能状态≥3[HR 2.1，95%CI（1.2 - 3.7），P = 0.006]、肝硬化[HR 3.8，95%CI（1.5 - 9.5），P = 0.004]以及留置缝线[HR 2.8，95%CI（1.6 - 4.9），P < 0.000]。标准化组的30天死亡率为18.4%，2009年至2013年为22.4%，P = 0.057；90天死亡率分别为24.2%和30.4%，P = 0.008。