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Page 2 of 8 Lesch et al. Mini-invasive Surg 2023;7:20 https://dx.doi.org/10.20517/2574-1225.2023.24

Results: We found that regardless of technique and material thickness, secure closure of median abdominal wall
®
incisions is feasible by suturing. In larger defects, the small bites technique using Monomax sutures achieves a
®
safer closure compared to PDS sutures.
Conclusion: Based on the results of this experimental study, a tailored standardized closure technique after midline
incision of the abdominal wall, including an optional mesh augmentation, is recommended.

Keywords: Incisional hernia, suture technique, abdominal wall reconstruction, biomechanical repair, multiaxial
tissue assessment

INTRODUCTION
In daily life, the abdominal wall gets stressed by repetitive peaks of intraabdominal pressure while moving,
defecating, or coughing. Therefore, an existing abdominal wall reconstruction needs to withstand these
[1]
[2]
repetitive loads . However, currently, up to 20% of the sutured incisions reopen results in hernias . A
[3,4]
reconstructed abdominal wall behaves as a coherent compound and must, therefore, be assessed as such .
To improve clinical care, abdominal wall closure should be examined closely and need to be tested under
lifelike conditions to obtain a realistic estimation of their behavior and durability.

For this purpose, we built a bench test that delivers repetitive cyclic pressure impacts, simulating coughs .
[5,6]
Increasing the amount of the pressure impacts and their height leads to the development and enlargement
of a hernia. This process of reconstruction failure starts early after closure .
[7,8]

The formation of an incisional hernia reveals an insufficiency of the compound, specifically the sutured
abdominal wall. The long-term success of a repair is determined by the creation of a successful synergy
among the individual components. The suture technique determines the load distribution of the
intraabdominal pressure on the abdominal wall. Additionally, the combination of the chosen material, the
individual tissue qualities, the type of defect, and the load determines the durability of the reconstruction .
[3,9]

In a randomized controlled study (ESTOIH study), the best results to date were achieved by means of the
short stitch technique compared to the long stitch technique (4.23% vs. 8.24%) in the 1-year follow-up, with
[10]
both groups using Monomax® . The current EHS guidelines recommend a continuous small-stitch-small-
bite technique with a suture to wound length (SWL) of at least 4:1. It is recommended to use a slowly
resorbable suture. No specific recommendation is suggested regarding the suture material and size [11,12] .
Previous studies showed that the careful execution and standardization of surgical sutures enhance the
outcome significantly [13,14] .

[2]
Despite active research to continually improve hernia reconstruction, recurrence rates remain high . The
performed experiments contribute to the active discussion about the optimal suturing techniques for
median abdominal wall closure.

MATERIAL AND METHODS
The bench test for generating cyclic pulse loads
We used stiff porcine and elastic bovine tissues as models for the abdominal wall. German pigs and cattle
were butchered at one to two years of age and delivered to the lab cooled on the same day. The porcine
tissues consist of the entire abdominal wall with similar properties to the human abdominal wall . The
[15]
bovine tissues include the oblique abdominal muscles, simulating thin and soft abdominal walls. The two