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Biomedical subjects

L A Israelsson

Publications and source records attributed to L A Israelsson.

At least 19 recordsLinked to original sources
PubMed2006

Incisional hernia repair in Sweden 2002.

Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.

Adult↗
PubMed2005

Randomized trial of traditional dissection with electrocautery versus ultrasonic fundus-first dissection in patients undergoing laparoscopic cholecystectomy.

BACKGROUND: In laparoscopic cholecystectomy dissection can be with monopolar electrocautery or with ultrasonic shears, and can start at the triangle of Calot or at the fundus of the gallbladder. METHODS: Thirty-seven patients undergoing laparoscopic cholecystectomy were randomized to electrocautery dissection from the triangle of Calot and 43 to fundus-first dissection with ultrasonic shears. All procedures were strictly standardized, and patients and their postoperative carers were blinded to the operation performed. RESULTS: Ultrasonic fundus-first dissection was associated with a shorter duration of operation (mean 46 versus 61 min), fewer overnight hospital stays (two versus eight), lower pain scores 4 and 24 h after surgery, less nausea at 2, 4 and 24 h, and a shorter period of sick leave (mean 5.5 versus 9.3 days) compared with electrocautery from the triangle of Calot. CONCLUSION: Ultrasonic fundus-first dissection during laparoscopic cholecystectomy was quicker and associated with less nausea and pain than electrocautery dissection from the triangle of Calot.

Adult↗
PubMed2004

Randomized clinical trial of the use of a prosthetic mesh to prevent parastomal hernia.

BACKGROUND: Parastomal hernia is a common complication following colostomy, and repair with a prosthetic mesh is associated with the lowest recurrence rate. The aim of this study was to determine the effect on stoma complications of using a mesh at the primary operation. METHODS: Patients undergoing permanent colostomy were randomized to have either a conventional stoma or the addition of a mesh placed in a sublay position. A large-pore lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material was used. RESULTS: Twenty-seven patients were randomized to have a conventional stoma and 27 to have the mesh. No infection, fistula formation or pain occurred (observation time 2-28 months). At the 12-month follow-up, parastomal hernia was present in eight of 18 patients without a mesh and in none of 16 patients in whom the mesh was used. CONCLUSION: A lightweight prosthetic mesh in a sublay position at the stoma site was not associated with infection or other early complications. Preliminary results indicate that the mesh prevented the development of parastomal hernia.

Aged↗
PubMed2003

Wound complications and stitch length.

The effect of suturing with a very short stitch on the development of wound complications in midline incisions was investigated. Three hundred sixty-eight patients were analysed. The suture length to wound length ratio and mean stitch length were calculated. Wound infection occurred in 4% (four of 103) of patients sutured with a mean stitch length of less than 4 cm, in 8% (nine of 117) with stitch length 4-4.9 cm, and in 16% (24 of 148) with a longer stitch ( P=0.004). At 12-month follow up, incisional hernia was present in 3% (two of 76) of patients sutured with a mean stitch length of less than 4 cm and in 12% (25 of 215) sutured with a longer stitch ( P=0.043). In midline incisions closed with a suture length to wound length ratio of at least 4, a short stitch is associated with a lower rate of both wound infection and incisional hernia.

Aged↗
PubMed2003

Cost analysis of incisional hernia repair by suture or mesh.

The objective was to make a cost analysis of incisional hernia repair by suture repair or prosthetic mesh repair. The study included 44 patients who underwent hernia repair between 1991 and 2000. The rate of recurrent incisional hernia after more than 1 year with associated costs was registered. In 1996, the technique of incisional hernia repair was changed from suture repair to mesh repair. With a mesh repair, zero out of 19 patients presented with a recurrence at follow-up, and with suture repair, five out of 13 had a recurrence (P<0.01). The duration of anaesthetic and operation was longer, but stay in the surgical ward, and sick leave was shorter for patients with a mesh repair than for those with a suture repair. For working patients, costs in the operating theatre were 4,095 Swedish kronor (SEK) higher with a mesh repair, and the costs for surgical ward, sick leave, and examination were 10,129 SEK lower than with a suture repair. Thus, with a mesh repair, the total costs were 6,034 SEK lower than with a suture repair. For retired patients, the total costs with a mesh repair were 1,898 SEK lower than with a suture repair. We conclude that in this setting, mesh repair of incisional hernias produced lower costs than suture repair.

Adult↗
PubMed2001

Small tissue bites and wound strength: an experimental study.

HYPOTHESIS: Placing stitches close to the cut wound edge does not produce low wound bursting strength in midline laparotomy incisions closed with a suture length:wound length ratio of 4. DESIGN: Experimental study in rats. METHODS: Midline incisions were closed with a running suture in 51 Sprague-Dawley rats. A suture length:wound length ratio of 4 was used and stitches were placed at a distance of 3, 6, or 10 mm from the wound edge. Wound bursting strength was studied immediately after and 4 days after wound closure. RESULTS: Immediately after wound closure, bursting pressure was higher with stitches placed 10 mm from the wound edge than those at a distance of 3 mm. After 4 days, bursting pressure and bursting volume were lower with stitches placed 10 mm from the wound edge than those at a distance of 3 or 6 mm. The abdominal wall ruptured outside the suture line in 14 of 17 wounds closed with 21 stitches, in 11 of 17 wounds closed with 16 stitches, and in 6 of 17 wounds closed with 11 stitches (P=.02). CONCLUSIONS: Four days after closure of midline laparotomy incisions using a suture length-wound length ratio of 4, wound bursting strength is higher with stitches placed 3 to 6 mm from the wound edge than those at a distance of 10 mm. Wound bursting strength increases with the number of stitches used.

Abdominal Muscles↗
PubMed2001

Mass closure technique: an experimental study on separation of wound edge.

OBJECTIVE: To study separation of wound edges in midline laparotomy incisions closed with either a mass stitch or a stitch incorporating only aponeurosis. DESIGN: Experimental study in pig. SETTING: University hospital, Norway. ANIMALS: 8 domestic pigs. METHODS: Steel sutures were used and metallic clips were placed in the aponeurosis. After increasing the intra-abdominal pressure the distance between the lateral edge of stitches and between pairs of clips was measured on sequential radiographs. RESULTS: After three hours with raised intra-abdominal pressure the lateral edge of stitches became separated by a mean (SD) of 5.6 (1.3) mm with a mass stitch and by 0.5 (0.6) mm with stitches placed only in the aponeurosis (p < 0.001). Corresponding figures for separation of clips was 3.6 (1.5) mm and 0.1 (0.3) mm (p < 0.001). The suture cut through the muscle by more than 3mm in 25 out of 36 mass stitches. Muscle and peritoneum included in the mass stitch was compressed, darkly discoloured, and there were signs of haemorrhage. CONCLUSIONS: Wound edges become separated with a mass stitch but not with stitches placed only in the aponeurosis when the intra-abdominal pressure is raised after closure of midline laparotomy incisions. This results from sutures compressing or cutting through subcuticular fat, muscle, and peritoneum enclosed in a mass stitch.

Abdomen↗
PubMed2000

Cost minimisation analysis of change in closure technique of midline incisions.

OBJECTIVES: To make a cost minimisation analysis of incisional hernia repair at a county hospital and extrapolate the results nationally. SETTING: County hospital, Sweden. SUBJECTS: 861 patients who underwent midline laparotomy between August 1989 and November 1992. INTERVENTIONS: In April 1991 surgeons were urged to change their suture technique towards wound closure with a suture length: wound length ratio of at least 4. MAIN OUTCOME MEASURES: Rate of incisional hernia at 12 months and the number of hernia repairs required with associated costs. RESULTS: The average cost of one hernia repair was SEK 42643. After the intervention the risk of requiring a hernia repair was reduced by 0.016 for each patient operated on through a midline incision. The cost was reduced by SEK 686 and the cost of an operation 5 minutes longer was SEK 570, so the intervention generated savings of SEK 116 for each patient operated on. A similar reduction on a national level would yield annual savings of SEK 2107140, which may be regarded as the annual opportunity cost of an inadequate surgical technique in Sweden. CONCLUSIONS: An alteration to the suture technique that reduces the rate of incisional hernia and the number of hernia repairs required is cost effective and generates savings.

Cost Savings↗
PubMed2000

Conventional running suture and continuous double loop closure: an experimental study of wound strength.

OBJECTIVE: To study the strength of laparotomy wounds closed by a continuous double loop technique or a conventional running suture, taking into account the ratio of suture length: wound length. DESIGN: Experimental study. ANIMALS: 60 Sprague-Dawley rats. INTERVENTIONS: Midline laparotomy incisions were closed with either a conventional running suture or a continuous double loop. Wounds were allocated to closure with a suture length: wound length ratio of 3, 4 and 7. MAIN OUTCOME MEASURES: Bursting pressure, bursting volume and the way the suture cut through the tissues. RESULTS: With a suture length: wound length ratio of 3 or 4 bursting pressure and bursting volume were lower with a continuous double loop closure. A conventional running suture and a continuous double loop produced similar bursting pressure and bursting volume only if closure was with a ratio of 7. CONCLUSIONS: Wound bursting strength is higher with a conventional running suture than with a continuous double loop closure when the effect of the suture length: wound length ratio is accounted for.

Animals↗
PubMed1999

Incisional hernias in patients with aortic aneurysmal disease: the importance of suture technique.

OBJECTIVE: To study the rate of incisional hernia at 12 months in patients undergoing abdominal aortic aneurysm repair compared with others undergoing other surgery through midline incisions. METHODS: A prospective study of 1023 patients, 85 of these with aneurysmal disease. Wounds were continuously closed and the suture technique was monitored by the suture length to wound length ratio. RESULTS: Wound incisions were longer and operations lasted longer in aneurysm patients than in others. Incisional hernia was less common if closure was with a suture length to wound length ratio of at least four. Wounds were closed with a ratio of four or more in 39% (33 of 85) of aneurysm patients and in 59% (546 of 923) of others (p < 0.01). In aneurysm patients no wound dehiscence was recorded, the rate of wound infection was low and incisional hernia occurred in the same amount as in others. CONCLUSIONS: It is concluded that the rate of incisional hernia is similar in patients with abdominal aortic aneurysmal disease and others. Wounds are closed with a less meticulous suture technique in aneurysm patients.

Aged↗
PubMed1999

Bias in clinical trials: the importance of suture technique.

OBJECTIVE: To study the effect on suture technique of introducing a new suture material. DESIGN: Prospective clinical study. SETTING: County hospital, Sweden. SUBJECTS: 224 patients included during the first 10 months of a clinical study that had been designed to compare two suture materials. INTERVENTIONS: Wounds were sutured by a continuous technique. The suture length: wound length ratio was recorded together with details of patients and operations. MAIN OUTCOME MEASURES: The incidence of incisional hernia after 12 months. RESULTS: The mean suture length: wound length ratio was 3.6 (95% confidence interval (CI) 3.4 to 3.9) in wounds closed with the introduced new material and 3.2 (2.9 to 3.4) with the familiar material (p<0.01). With the new material a higher proportion of wounds were sutured at a ratio of 4 or more. Incisional hernias developed in 6% (3 of 50) of wounds sutured with a suture length : wound length ratio of 4 or more and in 22% (26 of 119) if it was less (p = 0.01). The rate of incisional hernia was lower in wounds sutured with the new suture material. CONCLUSION: During the first 10 months of a clinical trial the introduction of a new suture material caused a potential systematic error. The suture technique was more meticulous with the new material and this may have affected the rate of incisional hernia. The suture technique should therefore be monitored in such studies in the future.

Aged↗
PubMed1998

The surgeon as a risk factor for complications of midline incisions.

OBJECTIVE: To compare among surgeons the risk-adjusted rates of wound infection and incisional hernia after midline incisions. DESIGN: Prospective clinical study. SETTING: County hospital, Sweden. SUBJECTS: 1013 patients who underwent midline laparotomy between August 1989 and June 1993. INTERVENTIONS: Wounds were sutured by a continuous technique and details of patients and operations were recorded. The suture technique was monitored by the suture length:wound length ratio. MAIN OUTCOME MEASURES: . Postoperative wound infection, and incidence of incisional hernia at 12 months. RESULTS: The details of patients and operations varied significantly among surgeons. Senior surgeons sutured with a lower suture length:wound length ratio than juniors (mean (SD) 4.1 (1.4) compared with 5.3 (2.1), p < 0.01). The individual rates of wound infection varied from 0 to 27% (mean 10%) and that of incisional hernia from 5% to 26% (mean 15%). After correction for patient selection three surgeons had significantly higher rates of wound infection and one significantly lower than the others, two surgeons had significantly higher rates of incisional hernia and two significantly lower. Only one surgeon differed significantly in the rate of incisional herniation after also adjusting for the suture technique. The length of surgical experience did not affect the rate of wound complications. CONCLUSION: The suture technique, monitored by the SL:WL ratio, is the most important factor for variability in the incidence of incisional hernia among surgeons in continuously sutured midline incisions. The suture technique may also help to explain the variability in rates of wound infection.

Clinical Competence↗
PubMed1997

Overweight and healing of midline incisions: the importance of suture technique.

OBJECTIVE: To study the effect of body mass index on the healing of midline laparotomy wounds closed with a continuous technique. DESIGN: Prospective clinical study. SETTING: County hospital, Sweden. SUBJECTS: 1023 patients who underwent midline laparotomy between September 1991 and June 1993. INTERVENTIONS: Body mass index was recorded and overweight was defined as an index above 25. MAIN OUTCOME MEASURES: Postoperative wound infection, and incidence of incisional hernia at 12 months. RESULTS: Overweight patients were sutured with a higher suture length:wound length ratio than others (p < 0.01). Wound infection developed postoperatively in 97 of 1023 patients (10%) and overweight, youth, wound contamination, and reoperation were independent risk factors. However, overweight was not associated with a higher rate of infection if the suture length:wound length ratio was 4.0-4.9. Incisional hernias developed in 118 of 808 patients (15%) and overweight, old age, wound infection, and suture length:wound length ratio less than 4 were independent risk factors. However, overweight was not associated with a higher hernia rate if the suture length:wound length ratio was 4.0-4.9. CONCLUSION: Overweight is a risk factor for wound infection and incisional hernia after midline abdominal surgery but these effects may be eliminated if patients are sutured with a suture length to wound length ratio of 4.0-4.9.

Adult↗
PubMed1996

Incisional hernia after midline laparotomy: a prospective study.

OBJECTIVE: To study the healing of midline laparotomy wounds. DESIGN: Prospective clinical study. SETTING: County hospitals, Sweden and Iceland. SUBJECTS: 861 patients who underwent midline laparotomy between August 1989 and November 1992. 453 of whom were operated on during the first 20 months, and 408 of whom were operated on during the second 20 months after surgeons had been asked to adjust their technique to achieve a suture length: wound length ratio of more than 4. MAIN OUTCOME MEASURES: Wound dehiscence, wound infection, and incidence of incisional hernia at 12 months. RESULTS: 78/861 patients (9%) developed wound infection. This incidence correlated with previous midline laparotomy and degree of wound contamination. Mean (SD) suture length: wound length ratio increased from 3.6 (1.3) in the first period to 4.9 (1.6) during the second period (p < 0.01), as a result of a reduction in the stitch interval from 1.2 (0.2)-0.9 (0.2) cm (p < 0.01). All other recorded variables were comparable in both study periods. The rate of incisional hernia decreased from 19% (68 of 363) during the first period to 11% (35 of 320) during the second period (p < 0.01). Suture length: wound length ratio < 4, wound infection and age 60 years or more were significantly and independently associated with an increased incidence of incisional hernia. CONCLUSION: Suture technique is a major determinant of incisional hernia in continuously sutured midline laparotomies. Simple adjustments in technique can considerably improve late operative results.

Female↗
PubMed1996

Suture technique and wound healing in midline laparotomy incisions.

OBJECTIVE: To study the influence of suture technique on healing of midline laparotomy wounds. DESIGN: Prospective clinical study. SETTING: County hospital, Sweden. SUBJECTS: 467 patients who underwent midline laparotomy between September 1991 and June 1993. INTERVENTIONS: Wounds were sutured by a continuous technique. The suture length: wound length ratio, the stitch length, and the interval between stitches were recorded together with the body mass index and operative variables. MAIN OUTCOME MEASURES: Incidence of postoperative wound infection and of incisional hernia at 12 months. RESULTS: Wound infection developed in 25 of 150 (17%) wounds if the stitch length was 5 cm or more and in 21 of 307 (7%) if it was shorter than 5 cm (p < 0.01). Overweight patients were sutured with a longer stitch and there was a high rate of infection among these patients: 20/253 (14%) compared with 30/211 (8%) (p < 0.05). In a multivariate analysis stitch length 5 cm or more and degree of wound contamination were independent risk factors for wound infection. Incisional hernias developed in 42 of 368 patients (11%). In a multivariate analysis suture length: wound length ratio less than 4, overweight, and wound infection were independent risk factors. CONCLUSION: Suture technique affects both early and late wound complications. The rate of incisional hernia is lower if the suture length: wound length ratio is 4 or more. However, a high ratio should not be achieved by suturing with a stitch length of 5 cm or more as this is associated with an increase in the rate of wound infection.

Body Mass Index↗