The edition · General Surgery
Small-bite fascial closure roughly halved incisional hernia after midline laparotomy
A meta-analysis of ten trials found the small-bite technique cut hernia, wound infection and complications, at the cost of about five minutes. Also: CT misses about three in ten diaphragm injuries after left thoracoabdominal stab wounds, five-year COLRAR results, and days at home as a recovery measure.
The edition in brief
A meta-analysis of ten randomised trials (2617 patients) found small-bite closure of midline laparotomy (5 mm bites and spacing) reduced incisional hernia compared with large-bite closure: RR 0.48 (95% CI 0.33 to 0.70) with more than 12 months' follow-up, and RR 0.56 (0.36 to 0.89) beyond 24 months. Surgical site infection and total complications were also lower, with closure taking about five minutes longer. A diagnostic meta-analysis of four studies (222 patients) found CT had pooled sensitivity of 0.70 and specificity of 0.94 for diaphragmatic injury after left thoracoabdominal penetrating trauma, too low to rule injury out, so diagnostic laparoscopy remains the reference standard. Five-year results of the Korean COLRAR trial (295 patients) showed robotic and laparoscopic total mesorectal excision had similar overall survival (92.4% vs 92.6%) and relapse-free survival; a post hoc signal of better local control after chemoradiotherapy needs confirmation. An Ontario cohort of 91,270 operations validated days at home at 90 days after GI cancer surgery: median 82 days, with frailty linked to 2.6 fewer days. The pearl covers the 4:1 suture length to wound length ratio.
CT misses about three in ten diaphragm injuries after left thoracoabdominal stab wounds
After a left thoracoabdominal stab wound, a negative CT does not exclude diaphragm injury; diagnostic laparoscopy remains the standard in stable patients.
Robotic and laparoscopic TME gave similar five-year survival in COLRAR
Robotic TME did not improve five-year survival over laparoscopic TME, so platform choice can rest on expertise, access and cost.
Days at home at 90 days validated as a recovery measure after GI cancer surgery
Days at home at 90 days is a valid, patient-centred measure worth using in counselling and audit after GI cancer surgery.
The 4:1 rule for closing the midline
Aim for at least four times as much suture as wound length when closing the midline, and measure it.
Small-bite closure of the midline cut incisional hernia by about half
Use small-bite closure for midline laparotomy; it reduced incisional hernia and wound complications for about five extra minutes.
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