Signature of the Candidate

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“A PROSPECTIVE COMPARATIVE STUDY OF CONVENTIONAL ABDOMINAL CLOSURE WITH HUGHES ABDOMINAL REPAIR TO

PREVENT BURST ABDOMEN AND INCISIONAL HERNIA IN MIDLINE LAPORATOMY EMERGENCY ABDOMINAL

SURGERIES”

DISSERTATION SUBMITTED TO

THE TAMIL NADU DR.MGR MEDICAL UNIVERSITY, TAMILNADU IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

DEGREE OF

MASTER OF SURGERY IN

GENERAL SURGERY

DEPARTMENT OF GENERAL SURGERY

GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM

Year : 2018-2021

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GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE, SALEM

DECLARATION BY THE CANDIDATE

I solemnly declare that this dissertation“A PROSPECTIVE COMPARATIVE STUDY OF CONVENTIONAL ABDOMINAL CLOSURE WITH HUGHES ABDOMINAL REPAIR TO PREVENT BURST ABDOMEN AND INCISIONAL HERNIA IN MIDLINE LAPORATOMY EMERGENCY ABDOMINAL SURGERIES" was prepared by me at Government Mohan Kumaramangalam Medical College and Hospital , Salem-636030 under the guidance and supervision of Prof.Dr.K.VIJAYAKUMAR, M.S., Professor and HOD of General Surgery. Govt .Mohan Kumaramangalam Medical College and Hospital, Salem. This dissertation is submitted to the Tamilnadu Dr.M.G.R Medical University, Chennai-32 in fulfilment of the University regulations for the award of the degree of M.S. General Surgery ( Branch I ).

Date :

Place : Salem

Signature of the Candidate

Dr C. VIJAYALAKSHMI

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CERTIFICATE BY THE GUIDE

This is to certify that this dissertation entitled “A PROSPECTIVE COMPARATIVE STUDY OF CONVENTIONAL ABDOMINAL CLOSURE WITH HUGHES ABDOMINAL REPAIR TO PREVENT BURST ABDOMEN AND INCISIONAL HERNIA IN MIDLINE LAPORATOMY EMERGENCY ABDOMINAL SURGERIES" is a work done by Dr. C. VIJAYALAKSHMI under my guidance during the period of 2018-2021. This has been submitted to the partial fulfilment of the award of M.S Degree in General Surgery, (Branch I) examination to be held in May 2021 by Tamilnadu Dr.M.G.R Medical University , Chennai – 32.

Date :

Place : Salem

Signature and seal of the Guide

Prof.Dr. K.KESAVALINGAM, M.S., Professor of General Surgery GMKMCH, Salem, Tamil Nadu.

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ENDORSEMENT BY THE HEAD OF DEPARTMENT

This is to certify that this dissertation entitled “A PROSPECTIVE COMPARATIVE STUDY OF CONVENTIONAL ABDOMINAL CLOSURE WITH HUGHES ABDOMINAL REPAIR TO PREVENT BURST ABDOMEN AND INCISIONAL HERNIA IN MIDLINE LAPORATOMY EMERGENCY ABDOMINAL SURGERIES” IN GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM is a bonafide and genuine work done by Dr.C.VIJAYALAKSHMI under the overall guidance and supervision of Prof.Dr.K.VIJAYAKUMAR M.S., Professor, and Head, Department of General Surgery, Government Mohan Kumaramangalam Medical College Hospital, in partial fulfillment of the requirement for the degree of M.S in General Surgery, examination to be held in May 2021.

Date :

Place : Salem

Signature and Seal of the Prof & HOD

Prof.Dr. K.VIJAYAKUMAR, M.S., Professor and HOD of General Surgery

GMKMCH, Salem, Tamil Nadu.

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ENDORSEMENT BY THE DEAN OF THE INSTITUTION

This is to certify that this dissertation titled “A PROSPECTIVE COMPARATIVE STUDY OF CONVENTIONAL ABDOMINAL CLOSURE WITH HUGHES ABDOMINAL REPAIR TO PREVENT BURST ABDOMEN AND INCISIONAL HERNIA IN MIDLINE LAPORATOMY EMERGENCY ABDOMINAL SURGERIES” IN GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM is a bonafide work done by DrC.

VIJAYALAKSHMI under the guidance and supervision of Prof. Dr. K.

VIJAYAKUMAR M.S., Professor and Head, Department of General Surgery, Government Mohan Kumaramangalam Medical College Hospital, in partial fulfillment of the requirement for the degree of M.S in General Surgery, examination to be held in 2021.

Date :

Place : Salem

Signature and Seal of the Dean

DEAN

Government Mohan Kumaramangalam Medical College Hospital,

Salem,Tamilnadu, India.

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COPYRIGHT

I hereby declare that the Government Mohan Kumaramangalam Medical College Hospital, Salem, Tamilnadu,India, shall have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic format for academic / research purpose.

Place: Salem

Signature of the Candidate

Dr.C.VIJAYALAKSHMI

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ACKNOWLEDGEMENT

I am extremely thankful to Prof.Dr.R.BALAJINATHAN M.D., Dean, Govt. Mohan Kumaramangalam Medical College and Hospital, Salem for allowing me to utilize the hospital facilities for doing this work.

I am also thankful to Prof.Dr.P.V.DHANAPAL,M.S., Medical Superintendent,Govt.Mohan Kumaramangalam Medical College Hospital, Salem for his whole hearted support and encouragement for the completion of this dissertation.

I express my deep sense of gratitude and indebtedness to Prof.Dr.K.VIJAYAKUMAR,M.S., Head of the Department of General Surgery, for giving me inspiration, valuable guidance and his unstinting help in completing the thesis.

I express my deep sense of gratitude and indebtedness to

Prof.Dr.K.KESAVALINGAM ,M.S., Unit chief and Guide, Professor of Department of General Surgery, for giving me inspiration, valuable guidance and his unstinting help in completing the thesis.

I thank all surgical unit chiefs Prof.Dr.G.RAJASHOK,M.S., Prof.Dr.P.SUMATHI,M.S.,DGO., Prof.Dr.M.RAJASEKAR,.M.S., and

Associate Professors Dr.R.Ravi M.S., and

Dr.M.ARULKUMARAN,M.S.,DA., for their advice and kind help.

I also thank my registrar Dr.R.Swaminathan M.S.,who guided me to success this study.

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It is my privileged duty to profusely thank my assistant professors DrS.S.MEERA ,M.S.,Dr.T.KARTHIKEYAN ,M.S., DR.A.VIJAY ANAND ,M.S., Dr.D.VINOTHKMAR ,M.S., who helped and guided me in many aspects of this study.

I take this opportunity to thank my senior PG’s DR. TAMILSELVAN M.S., DR.VENKATESHWAR , DR. SRI

PRIYADARSHAN who despite of my shortcoming were eager to teach me. I thank my colleague

DR.PRASANNA VENKATESH and I thank my junior PG’s DR.SENTHILKUMAR, DR.THIRUMOORTHY, DR.RAJENDRAN, DR.ELANCHEZHIAN and my other post graduate colleagues and my house surgeons who shared majority of my duties so that I could complete this study with ease.

I cordially thank my parents, my family and friends who have always been there with me whenever I needed their help and cooperation.

I am deeply obliged to my patients, without whose help the present study would not have been possible.

DR. C. VIJAYALAKSHMI

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PLAGIARISM CERTIFICATE

rtify that this dissertation work titled “A PROSPECTIVE COMPARATIVE STUDY OF CONVENTIONAL ABDOMINAL CLOSURE WITH HUGHES ABDOMINAL REPAIR TO PREVENT BURST ABDOMEN AND INCISIONAL HERNIA IN MIDLINE LAPORATOMY EMERGENCY ABDOMINAL SURGERIES” of the candidate Dr. C.VIJAYALAKSHMI with registration Number 221811411 for the award of M.S DEGREE in the branch of GENERAL SURGERY - I personally verified the urkund.com

website for the purpose of plagiarism Check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 9% percentage of plagiarism in the dissertation.

Guide & Supervisor sign with Seal.

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INDEX

S.No Contents Page Number

1 Introduction 1

2 Aim of the study 6

3 Objectives of the study 8

4 Review of Literature 10

5 Material and Methods 21

6 Results 26

7 Discussion 63

8 Summary and Conclusion 76

9 Limitations 80

10 Future Recommendations 82

11 Annexures 84

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Abstract Background

The incidence of incisional hernias varies between open surgeries and laparoscopic surgeries. A number of studies have been done to ascertain the best method of closing the abdominal wall; however, it is still inconclusive. There are studies that suggest that non absorbable sutures reduce the risk of recurrence and incisional hernia incidence.

Aim and Objective

This study aimed to compare the efficacy of Hughes Abdominal repair with conventional abdominal closure in midline emergenc abdominal surgeries and to reduce the incidence of Incisional Hernias.

Material and Methods

A Prospective Comparative study was done among 100 patients planned for emergency Laparotomy each 50 divided non-randomly in to two groups from November 2018 to December 2020. The 50 cases of emergency laparotomy were chosen non randomly and allocated for Hughes Abdominal Repair. The 50 cases of emergency / elective laparotomy were chosen non randomly and allocated for conventional repair. All patients were discharged after suture removal on 10^th post- operative day and 15th post-operative day and monthly follow up to 1

(15)

year. Both groups are followed monthly for a period of one year and the after second year and incidence of incisional hernia in both groups documented and tabulated. CT abdomen taken at one year and at second year and any defect was documented. All data were recorded in structured questionnaires, coded and entered in Microsoft Excel. The data was analysed using SPSS v23. Student’s t-test was used for comparison.

Results and Conclusions

The mean age of the participants in Hughes repair group is 54.02 years with a standard deviation of 8.9 years. The mean age of the participants in conventional repair group is 56 years with a standard deviation of 12.1 years. Among all the cases, majority of them were males (n=77, 77%).

Rest of them were females (n=23, 23%). In the Hughes repair group, majority of them have hollow viscous perforation (n=10, 20%). In the conventional repair group, majority of them have hollow viscous perforation (n=10, 20%). The mean duration of hospital stay in Hughes repair is 10. 5 days (S.D=2.09 days). The mean duration of hospital stay in conventional repair is 11. 3 days (S.D=3.02 days). Chi-square analysis of wound complications shows that the incidence of complications are higher in the Conventional repair group that is statistically significant (p<0.05). Chi-square analysis of overall complications shows that the incidence of complications are higher in the Conventional repair group

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that is statistically significant (p<0.05). Hughes Repair (n=1): Only one incisional hernia was noted first in 11^th month. Conventional Repair (n=4): Incisional hernias were noted in 6^th, 8^th, 9^th and 12^th month CT scan. In the first year; Hughes Repair (n=1): Only one defect was found but in Conventional Repair (n=3): three defects were found Chi-square analysis of wound defects shows that the incidence of defects are higher in the Conventional repair group that is statistically significant (p<0.05).

CT scan in 2^nd year showed no defects in both the groups

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1

INTRODUCTION

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2

Introduction

Incisional hernias are clinically defined as the gaps in the abdominal walls in places of postoperative scars. They are found during clinical examination or imaging^1,2. These are the most common postoperative complications after major abdominal surgery where a midline closure was done. It impairs quality of life³ and also leads to higher medical expenses⁴. The conventional method of abdominal closure is by closing all the layers of the abdominal wall, a technique of mass closure using nonabsorbable or slow-resorbing sutures⁵. The incidence of incisional hernias vary between open surgeries and laparoscopic surgeries.

In open surgeries, it varies from 8.6% to 33% whereas in laparoscopic surgeries, it ranges between 4.7% and 24.3%^6-9. The repair of incisional hernias is not 100% successful. The repair is done either through sutures or mesh repairs. The recurrence rate of suture repair is 12 to 54% whereas for mesh repair is 2 to 36%^10,11. Apart from recurrence, there are also serious complications of bowel obstruction, chronic pain and enterocutaneous fistula.

There are a number of factors leading to the development of incisional hernias;

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a) Diabetes Mellitus¹² b) Obesity¹³

c) Cachexia¹⁴ d) Age >45 years e) Males¹⁵

f) COPD¹⁶

g) Post-menopausal women¹⁷ h) Anemia

i) History of abdominal aortic aneurysm¹⁸ j) Smoking

k) Corticosteroids¹⁹

Most of the aforementioned factors are non-modifiable, hence beyond the control of the surgeon. This explains why there is a need for developing a good surgical technique that offsets all technical weaknesses in repairing abdominal wall defects.

A number of studies have been done to ascertain the best method of closing the abdominal wall, however, it is still inconclusive. There are studies that suggest that non absorbable sutures reduce the risk of recurrence and incisional hernia incidence^20,21.On the other hand, there are studies that show that absorbable sutures are of lower risk²². These differences can be attributed to the methodological variations in various

(20)

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trials, patient selection, type of surgeries, expertise of the surgical team, etc. Lower sample sizes were also a major reason for incomplete reporting.

There are two noteworthy trials in this aspect;

The STITCH trial- a multicentric trial reported a lower incidence of incisional hernias in small-bite than large bite²³.

Another ongoing trial CONTINT is being done to compare interrupted sutures with continuous sutures while closing midline incisions in emergency laparotomy²⁴.

Hughes Repair

It is also called as ‘far-and-near’ repair or ‘Cardiff repair²⁵’. It was developed by Professor Leslie Hughes²⁶. This repair combines a standard mass closure (two loop 1-PDS sutures) with a series of horizontal and two vertical mattress sutures within a single suture (1 Nylon). This distributes the load along the width and length of the incision.

Following principles underlie this;

• Use only sound normal tissues for repair that is ascertained through palpation

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• For easy approximation, use graduated tension

• Create a pulley system through monofilament nylon suture that slips through the tissues²⁷

Studies show that Hughes repair is more effective than conventional repair²⁸. This technique is used for patients who are at a higher risk of developing incisional hernias post laparostomy and total abdominal wound dehiscence²⁹.

This study aimed to compare the efficacy of Hughes Abdominal repair with conventional Abdominal closure in midline emergency abdominal surgeries and to reduce the incidence of Incisional Hernias.

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6

AIM OF THE

STUDY

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7

Aim of the Study

• To compare the efficacy of Hughes Abdominal repair with conventional Abdominal closure in midline emergency abdominal surgeries

• To reduce the incidence of Incisional Hernias

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8

OBJECTIVES

OF THE STUDY

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Objectives of the study Primary Objective

• To compare the efficacy of Hughes Abdominal repair with

conventional Abdominal closure in midline emergency abdominal surgeries

Secondary Objective

• To study the incidence of incisional hernias

• To reduce the incidence of incisional hernias

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10

REVIEW OF

LITERATURE

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Review of literature

Overview of the anatomy of abdomen

The abdominal wall covers the abdominal cavity and protects the inner organs. It has the following boundaries;

a) Superior margins

Xiphoid process and costal cartilages b) Inferiorly

Pelvic bones and Inguinal Ligament c) Posteriorly

Vertebral column

Image 1: Abdominal cavity and its relations to other cavities

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Quadrants and regions of the abdomen

It is divided into nine regions and four quadrants;

Regions;

a) Epigastric region b) Umbilical region c) Hypogastric region d) Right lumbar region e) Left lumbar region f) Right iliac region g) Left iliac region

h) Right hypochondriac region i) Left hypochondriac region

Image 2: Quadrants and regions of the abdomen Quadrants;

a) Right upper quadrant b) Left upper quadrant c) Right lower quadrant d) Left lower quadrant

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Internal organs

Abdominal cavity has a large number of organs in situ

Image 3: Abdominal organs

Abdominal Wall

It is divided into two sections;

a) Posterior wall b) Anterolateral wall From superficial to deep;

1) Skin

2) Superficial fascia 3) Muscles

4) Transversalis fascia 5) Extra peritoneal fat 6) Peritoneum

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Image 4: Layers of the abdominal wall Muscles of the anterior abdominal wall

a) Transversus abdominis muscle b) Internal abdominal oblique c) Rectus abdominis

d) External abdominal oblique e) Pyramidalis

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Image 5: Muscles of the anterior abdominal wall

Muscles of the posterior abdominal wall a) Psoas major

b) Psoas minor c) Iliacus

d) Quadratus lumborum

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Image 6: Muscles of the posterior abdominal wall Neurovasculature of the abdominal wall

Superficial branches

- Musculophrenic arteries - Superficial Epigastric arteries Deep branches

- Superior Epigastric ateries - Inferior Epigastric arteries - Intercostal arteries

- Subcostal arteries

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Image 7: Vascular supply of the abdominal wall

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Common abdominal incisions

1) Midline 2) Paramedian 3) Kocher 4) Rooftop

5) Mercedes Benz

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A number of studies have been done to ascertain the best method of closing the abdominal wall, however, it is still inconclusive. There are studies that suggest that non absorbable sutures reduce the risk of recurrence and incisional hernia incidence^20,21.On the other hand, there are studies that show that absorbable sutures are of lower risk²². These

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20

differences can be attributed to the methodological variations in various trials, patient selection, type of surgeries, expertise of the surgical team, etc. Lower sample sizes were also a major reason for incomplete reporting.

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21

MATERIALS AND

METHODS

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MATERIALS AND METHODS STUDY DESIGN

A Prospective Comparative study STUDY POPULATION

The material for the study is taken from the cases admitted in all the surgical ward of the Department of General surgery, GMK Medical College & Hospital, who are planned for emergency Laparotomy

STUDY PERIOD

From NOVEMBER 2018 and DECEMBER 2020 SAMPLE SIZE

100

This study includes 100 patients planned for emergency laparotomy each 50 divided non-randomly in to two groups.

INCLUSION CRITERIA

1. Patients giving informed consent

2. Patients aged above 18 years

3. Midline emergency laporatomy incisions of more than 6 cms

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EXCLUSION CRITERIA

1. Patients below 18 years

2. Patients not willing and not in sound mind to give consent 3. Mesh repairs

METHODOLOGY

1) Patients were selected from the department of surgery

2) They were recruited after ascertaining their inclusion criteria

3) The 50 cases of emergency laparotomy were chosen non randomly and allocated for Hughes Abdominal Repair

4) The 50 cases of emergency laparotomy were chosen non randomly and allocated for conventional repair

Group A Abdomen closed by Hughes abdominal repair Group B conventional abdominal closure done

5) Both are already proven safe methods for subjects.

6) All patients were discharged after suture removal on 10^th post- operative day and 15th post-operative day and monthly follow up to 1 year

7) Both groups are followed monthly for a period of one year and the after second year and incidence of incisional hernia in both groups documented and tabulated.

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8) CT abdomen taken at one year and at second year and any defect, documented.

Diagram showing the Hughes closure method using a combination of conventional closure with series of horizontal and two vertical mattress sutures within a single suture

When the sutures are pulled to close the defect, the sutures lie both across and along the incision.

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PRIVACY/CONFIDENTIALITY OF STUDY SUBJECTS:

Privacy of the subjects shall be maintained.

STATISTICAL ANALYSIS

All data were recorded in structured questionnaires, coded and entered in Microsoft Excel. The data was then cleaned, checked for inconsistencies, missing values and prepared for analysis using SPSS v23. The data was then analyzed for descriptive statistics and inferential statistics. The tests for significance were run to statistically validate the data. Student’s t-test was used for comparison.

The results were then tabulated and visualized in Microsoft word.

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RESULTS

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Results

The 50 cases of emergency laparotomy were chosen non randomly and allocated for Hughes Abdominal Repair. The 50 cases of emergency laparotomy were chosen non randomly and allocated for conventional repair. All patients were discharged after suture removal on 10^th post- operative day and 15th post-operative day and monthly follow up to 1 year. Both groups are followed monthly for a period of one year and the after second year and incidence of incisional hernia in both groups documented and tabulated. CT abdomen taken at one year and at second year and any defect, documented.

The mean age of all the participants is 55 years with a standard deviation of 10.7 years. The median age is 56 years ranging between 29 and 74 years. The mean age of the participants in Hughes repair group is 54.02 years with a standard deviation of 8.9 years. The median age is 55 years ranging between 36 and 71 years. The mean age of the participants in conventional repair group is 56 years with a standard deviation of 12.1 years. The median age is 58.5 years ranging between 29 and 74 years.

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Among all the cases, majority of them were males (n=77, 77%).

Rest of them were females (n=23, 23%). In the Hughes repair, 38 of them are males and 12 are females. In the conventional repair, 39 of them are males and 11 are females. In the Hughes repair group, majority of them have hollow viscous perforation (n=10, 20%). In the conventional repair group, majority of them have hollow viscous perforation (n=10, 20%).

In all the cases, emergency laparotomy was done. The mean duration of hospital stay in Hughes repair is 10. 5 days (S.D=2.09 days).

The median duration is 10 days. The range is between 10 and 21 days.

The mean duration of hospital stay in conventional repair is 11. 3 days (S.D=3.02 days). The median duration is 10 days. The range is between 10 and 22 days. Student t-test shows that the two groups do not differ significantly in the duration of hospital stay (p> 0.05).

Analysis shows that; in the Hughes repair group 47 of them (94%) did not have any complications. Out of the remaining three patients, two of them (4%) had wound dehiscence while one of them (2%) had wound discharge. Analysis shows that; in the conventional repair group 40 of them (80%) did not have any complications. Out of the remaining ten patients, two of them (4%) had wound gaping, wound dehiscence was present in 10% (n=5) of cases while three of them (6%) had wound

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discharge. Chi-square analysis of wound complications shows that the incidence of complications are higher in the Conventional repair group that is statistically significant (p<0.05). Chi-square analysis of overall complications shows that the incidence of complications are higher in the Conventional repair group that is statistically significant (p<0.05).

Hughes Repair (n=1): Only one incisional hernia was noted first in 11^th month. Conventional Repair (n=4): Incisional hernias were noted in 6^th, 8^th, 9^th and 12^th month CT scan. In the first year; Hughes Repair (n=1): Only one defect was found but in Conventional Repair (n=3): three defects were found Chi-square analysis of wound defects shows that the incidence of defects are higher in the Conventional repair group that is statistically significant (p<0.05).

CT scan in 2^nd year: No defects in both the groups

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Findings

Age Distribution

The mean age of all the participants is 55 years with a standard deviation of 10.7 years. The median age is 56 years ranging between 29 and 74 years. The following table and figure shows the age distribution of the participants.

S.No All Cases (N=100) Age (in years)

1 Mean 55.0100

2 Median 56.0000

3 Mode 52.00^a

4 Std. Deviation 10.65956

5 Minimum 29.00

6 Maximum 74.00

Table 1: Age Distribution of all the Participants

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Figure 1: Age Distribution of all the Participants

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The mean age of the participants in Hughes repair group is 54.02 years with a standard deviation of 8.9 years. The median age is 55 years ranging between 36 and 71 years.

S.No Hughes Repair (N=50) Age (in years)

1 Mean 54.02

2 Median 55.00

3 Mode 55

5 Minimum 36

6 Maximum 71

Table 2: Age Distribution of the Participants in the Hughes repair group

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Figure 2: Age Distribution of the Participants in the Hughes repair group

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The mean age of the participants in conventional repair group is 56 years with a standard deviation of 12.1 years. The median age is 58.5 years ranging between 29 and 74 years.

S.No Conventional repair (N=50) Age (in years)

1 Mean 56.00

2 Median 58.50

3 Mode 66

5 Minimum 29

6 Maximum 74

Table 3: Age Distribution of the Participants in the Conventional repair group

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Figure 3: Age Distribution of the Participants in the Conventional repair group

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Gender Distribution

Rest of them were females (n=23, 23%). In the Hughes repair, 38 of them are males and 12 are females. In the conventional repair, 39 of them are males and 11 are females.

S.No Gender (All cases) Frequency Percent

1 Male 77 77

2 Female 23 23

Total 100 100

Table 4: Gender Distribution among all cases

Figure 4: Gender Distribution among all cases

Male 77%

Female 23%

Gender (All cases)

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S.No Gender (Hughes Repair) Frequency Percent

1 Female 12 24

2 Male 38 76

Total 50 100

Table 5: Gender Distribution among Hughes repair

Figure 5: Gender Distribution among Hughes repair

Male 76%

Female 24%

Gender (Hughes Repair)

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S.No Gender (Conventional Repair)

Frequency Percent

1 Female 11 22

2 Male 39 78

Total 50 100

Table 6: Gender Distribution among conventional repair

Figure 6: Gender Distribution among conventional repair

Male 78%

Female 22%

Gender (Conventional Repair)

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Comparison of gender distribution among the two groups

In the Hughes repair, 38 of them are males and 12 are females.

In the conventional repair, 39 of them are males and 11 are females.

Female Male Total Chi-square

analysis Gender

(Hughes Repair)

12 38 50 3.53

p> 0.05

Not Significant Gender

(Conventional Repair)

11 39 50

Total 23 77 100

Table 7: Comparison of Gender Distribution among two groups

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Figure 7: Comparison of Gender Distribution among two groups

0 5 10 15 20 25 30 35 40 45

Gender (Hughes Repair) Gender (Conventional Repair)

Female Male

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Diagnosis

In the Hughes repair group, majority of them have hollow viscous perforation (n=10, 20%).

Hughes Repair Frequency Percent

Acute intestinal obstruction 5 10.0

Acute mesentric ischemia 2 4.0

Adhesive intestinal obstruction 1 2.0

Appendicular perforation 1 2.0

Blunt injury abdomen 5 10.0

Caecal perforation 2 4.0

Carcinoma stomach 1 2.0

Duodenal perforation 6 12.0

gastric perforation 6 12.0

Hepatic flexure growth 1 2.0

Hollow viscus perforation 10 20.0

Ileal perforation 1 2.0

Ileocaecal growth 4 8.0

Jejunal perforation 1 2.0

Rectosigmiod growth 3 6.0

Stab injury abdomen 1 2.0

Total 50 100.0

Table 8: Diagnosis of Hughes Repair Group

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Figure 8: Diagnosis of Hughes Repair Group

0 2 4 6 8 10 12

Hughes Repair

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In the conventional repair group, majority of them have hollow viscous perforation (n=10, 20%).

Conventional Repair Frequency Percent Acute intestinal obstruction 9 18.0

Acute mesentric ischemia 2 4.0

Blunt injury abdomen 8 16.0

Bullgore injury 1 2.0

caecal perforation 1 2.0

Caecal volvulus 1 2.0

Duodenal perforation 5 10.0

Gastric antral perforation 5 10.0 Hollow viscus perforation 10 20.0

Perforative peritonitis 2 4.0

Rectosigmoid growth 1 2.0

small bowel obstruction 1 2.0

Spleenic flexure growth 1 2.0

Stab injury abdomen 3 6.0

Total 50 100.0

Table 9: Diagnosis of Conventional Repair Group

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Figure 9: Diagnosis of Conventional Repair Group

0 2 4 6 8 10 12

Conventional Repair

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Procedure done

In all the cases, emergency laparotomy was done.

Emergency laparotomy Total Gender (Hughes

Repair)

50 50

Gender (Conventional Repair)

50 50

Total 100 100

Table 10: Procedure done

Figure10: Procedure done

0 10 20 30 40 50 60

Emergency Laparotomy

Hughes Repair Conventional Repair

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Duration of hospital stay

The mean duration of hospital stay in Hughes repair is 10. 5 days (S.D=2.09 days). The median duration is 10 days. The range is between 10 and 21 days.

S.No Hughes Repair (N=50) Duration of hospital stay (in days)

1 Mean

10.50

2 Median

10.00

3 Mode

10

4 Std. Deviation

2.092

5 Minimum

10

6 Maximum

21

Table 11: Duration of hospital stay (Hughes Repair Group)

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Figure 11: Duration of hospital stay (Hughes Repair Group)

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The mean duration of hospital stay in conventional repair is 11. 3 days (S.D=3.02 days). The median duration is 10 days. The range is between 10 and 22 days.

S.No Conventional repair (N=50) Duration of hospital stay (in days)

1 Mean 11.32

2 Median 10.00

3 Mode 10

5 Minimum 10

6 Maximum 22

Table 12: Duration of hospital stay (Conventional Repair Group)

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Figure 12: Duration of hospital stay (Conventional Repair Group)

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The mean duration of hospital stay in Hughes repair is 10. 5 days (S.D=2.09 days). The median duration is 10 days. The range is between 10 and 21 days.

The mean duration of hospital stay in conventional repair is 11. 3 days (S.D=3.02 days). The median duration is 10 days. The range is between 10 and 22 days.

S.No Duration of hospital stay (in days)

Hughes Repair (N=50)

Conventional repair (N=50)

1 Mean

10.50 11.32

2 Median

10.00 10.00

3 Mode

10 10

4 Std. Deviation

2.092 3.020

5 Minimum

10 10

6 Maximum

21 22

Table 13: Comparison of duration of hospital stay between the two groups

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Figure 13: Comparison of duration of hospital stay between the two groups

10 10.2 10.4 10.6 10.8 11 11.2 11.4

Mean Duration of hospital stay (in days)

Hughes Repair (N=50) Conventional repair (N=50)

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Comparison of duration of hospital stay

Student t-test shows that the two groups do not differ significantly in the duration of hospital stay (p> 0.05).

S.No Duration of hospital stay (in days)

Hughes Repair (N=50)

Conventional repair (N=50)

1 Mean

10.50 11.32

2 Std. Deviation

2.092 3.020

T-test p-value >0.05

Interpretation The two groups do not significantly differ in the duration of hospital stay

Table 14: Comparison of duration of hospital stay between the two groups using T-test

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Wound Complications

Analysis shows that;

In the Hughes repair group 47 of them (94%) did not have any complications.

Out of the remaining three patients, two of them (4%) had wound dehiscence while one of them (2%) had wound discharge.

S.No Hughes Repair Frequency Percent

1 No Complications 47 94

2 Wound Dehiscence 2 4

3 Wound Discharge 1 2

Total 50 100

Table 15: Wound Complications in the Hughes Repair group

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Figure 14: Wound Complications in the Hughes Repair group

0 5 10 15 20 25 30 35 40 45 50

No Complications Wound Dehiscence Wound Discharge

Hughes Repair

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Analysis shows that;

In the conventional repair group 40 of them (80%) did not have any complications.

Out of the remaining ten patients, two of them (4%) had wound gaping, wound dehiscence was present in 10% (n=5) of cases while three of them (6%) had wound discharge.

S.No Conventional Repair Frequency Percent

1 No Complications 40 80

2 Wound Dehiscence 5 10

3 Wound Discharge 3 6

4 Wound Gaping 2 4

Total 50 100

Table 16: Wound Complications in the Conventional Repair group

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Figure 15: Wound Complications in the Conventional Repair group

0 5 10 15 20 25 30 35 40 45

No Complications Wound

Dehiscence Wound Discharge Wound Gaping

Conventional Repair

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Comparison of wound complications

Chi-square analysis of wound complications shows that the incidence of complications are higher in the Conventional repair group that is statistically significant (p<0.05).

Wound Complications

Yes No Total Chi-square

analysis

Hughes Repair 3 47 50 4.76

P< 0.05

Statistically Significant Conventional

Repair

10 40 50

Total 13 87 100

Table 17: Comparison of wound complications

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Figure 16: Comparison of wound complications

0 5 10 15 20 25 30 35 40 45 50

Yes No

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Complications

Chi-square analysis of overall complications shows that the incidence of complications are higher in the Conventional repair group that is statistically significant (p<0.05).

Hughes Repair (n=1): Only one incisional hernia in 11^th month Conventional Repair (n=4): Incisional hernias in 6^th, 8^th, 9^th and 12^th

Overall Complications in 24 months

analysis

P< 0.05

Repair

4 46 50

Total 5 95 100

Table 18: Comparison of overall complications

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Figure17: Comparison of overall complications

0 10 20 30 40 50 60

Yes No

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CT Scan findings CT scan in 1^st year In the first year;

Hughes Repair (n=1): Only one defect was found Conventional Repair (n=3): three defects were found

Chi-square analysis of wound defects shows that the incidence of defects are higher in the Conventional repair group that is statistically significant (p<0.05).

CT Scan in 1^st year (Defects)

analysis

P< 0.05

Repair

3 47 50

Total 4 96 100

Table 19: CT scan in first year

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Figure 18: CT scan in first year

CT scan in 2^nd year: No defects in both the groups

0 10 20 30 40 50 60

Yes No

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DISCUSSION

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Discussion

There are a number of factors leading to the development of incisional hernias;

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• Diabetes Mellitus¹²

• Obesity¹³

• Cachexia¹⁴

• Age >45 years

• Males¹⁵

• COPD¹⁶

• Post-menopausal women¹⁷

• Anemia

• History of abdominal aortic aneurysm¹⁸

• Smoking

• Corticosteroids¹⁹

Most of the aforementioned factors are non-modifiable, hence beyond the control of the surgeon. This explains why there is a need for developing a good surgical technique that offsets all technical weaknesses in repairing abdominal wall defects.

A number of studies have been done to ascertain the best method of closing the abdominal wall, however, it is still inconclusive. There are studies that suggest that non absorbable sutures reduce the risk of recurrence and incisional hernia incidence^20,21.On the other hand, there are studies that show that absorbable sutures are of lower risk²². These

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differences can be attributed to the methodological variations in various trials, patient selection, type of surgeries, expertise of the surgical team, etc. Lower sample sizes were also a major reason for incomplete reporting.

There are two noteworthy trials in this aspect;

The STITCH trial- a multicentric trial reported a lower incidence of incisional hernias in small-bite than large bite²³. Another ongoing trial CONTINT is being done to compare interrupted sutures with continuous sutures while closing midline incisions in emergency laparotomy²⁴.

Hughes repair is also called as ‘far-and-near’ repair or ‘Cardiff repair²⁵’. It was developed by Professor Leslie Hughes²⁶. This repair combines a standard mass closure (two loop 1-PDS sutures) with a series of horizontal and two vertical mattress sutures within a single suture (1 Nylon). This distributes the load along the width and length of the incision.

Following principles underlie this;

• Use only sound normal tissues for repair that is ascertained through palpation

• For easy approximation, use graduated tension

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• Create a pulley system through monofilament nylon suture that slips through the tissues²⁷

The 50 cases of emergency laparotomy were chosen non randomly and allocated for Hughes Abdominal Repair. The 50 cases of emergency laparotomy were chosen non randomly and allocated for conventional repair. All patients were discharged after suture removal on 10^th post- operative day and 15th post-operative day and monthly follow up to 1 year. Both groups are followed monthly for a period of one year and the after second year and incidence of incisional hernia in both groups

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documented and tabulated. CT abdomen taken at one year and at second year and any defect, documented.

Among all the cases, majority of them were males (n=77, 77%). Rest of them were females (n=23, 23%). In the Hughes repair, 38 of them are males and 12 are females. In the conventional repair, 39 of them are males and 11 are females. In the Hughes repair group, majority of them have hollow viscous perforation (n=10, 20%). In the conventional repair group, majority of them have hollow viscous perforation (n=10, 20%).

In all the cases, emergency laparotomy was done. The mean duration of hospital stay in Hughes repair is 10. 5 days (S.D=2.09 days). The median duration is 10 days. The range is between 10 and 21 days. The mean duration of hospital stay in conventional repair is 11. 3 days (S.D=3.02 days). The median duration is 10 days. The range is between

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10 and 22 days. Student t-test shows that the two groups do not differ significantly in the duration of hospital stay (p> 0.05).

Analysis shows that; in the Hughes repair group 47 of them (94%) did not have any complications. Out of the remaining three patients, two of them (4%) had wound dehiscence while one of them (2%) had wound discharge. Analysis shows that; in the conventional repair group 40 of them (80%) did not have any complications. Out of the remaining ten patients, two of them (4%) had wound gaping, wound dehiscence was present in 10% (n=5) of cases while three of them (6%) had wound discharge. Chi-square analysis of wound complications shows that the incidence of complications are higher in the Conventional repair group that is statistically significant (p<0.05). Chi-square analysis of overall complications shows that the incidence of complications are higher in the Conventional repair group that is statistically significant (p<0.05).

Hughes Repair (n=1): Only one incisional hernia was noted first in 11^th month. Conventional Repair (n=4): Incisional hernias were noted in 6^th, 8^th, 9^th and 12^th month CT scan.

In the first year; Hughes Repair (n=1): Only one defect was found but in

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Conventional Repair (n=3): three defects were found Chi-square analysis of wound defects shows that the incidence of defects are higher in the Conventional repair group that is statistically significant (p<0.05).

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INTRAOPERATIVE PICTURES

Picture 1 Hughes Abdominal Repair

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Pocture 4 Hughes Abdominal Repair

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SUMMARY AND

CONCLUSION

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Summary and conclusions

The 50 cases of emergency laparotomy were chosen non randomly and allocated for Hughes Abdominal Repair. The 50 cases of emergency laparotomy were chosen non randomly and allocated for conventional repair. All patients were discharged after suture removal on 10^th post- operative day and 15th post-operative day and monthly follow up to 1 year. Both groups are followed monthly for a period of one year and the after second year and incidence of incisional hernia in both groups documented and tabulated. CT abdomen taken at one year and at second year and any defect, documented.

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Rest of them were females (n=23, 23%). In the Hughes repair, 38 of them are males and 12 are females. In the conventional repair, 39 of them are males and 11 are females. In the Hughes repair group, majority of them have hollow viscous perforation (n=10, 20%). In the conventional repair group, majority of them have hollow viscous perforation (n=10, 20%).

In all the cases, emergency laparotomy was done. The mean duration of hospital stay in Hughes repair is 10. 5 days (S.D=2.09 days).

The median duration is 10 days. The range is between 10 and 21 days.

The mean duration of hospital stay in conventional repair is 11. 3 days (S.D=3.02 days). The median duration is 10 days. The range is between 10 and 22 days. Student t-test shows that the two groups do not differ significantly in the duration of hospital stay (p> 0.05).

Analysis shows that; in the Hughes repair group 47 of them (94%) did not have any complications. Out of the remaining three patients, two of them (4%) had wound dehiscence while one of them (2%) had wound discharge. Analysis shows that; in the conventional repair group 40 of them (80%) did not have any complications. Out of the remaining ten patients, two of them (4%) had wound gaping, wound dehiscence was present in 10% (n=5) of cases while three of them (6%) had wound

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discharge. Chi-square analysis of wound complications shows that the incidence of complications are higher in the Conventional repair group that is statistically significant (p<0.05). Chi-square analysis of overall complications shows that the incidence of complications are higher in the Conventional repair group that is statistically significant (p<0.05).

Hughes Repair (n=1): Only one incisional hernia was noted first in 11^th month. Conventional Repair (n=4): Incisional hernias were noted in 6^th, 8^th, 9^th and 12^th month CT scan.

In the first year; Hughes Repair (n=1): Only one defect was found but in

Conventional Repair (n=3): three defects were found. Chi-square analysis of wound defects shows that the incidence of defects are higher in the Conventional repair group that is statistically significant (p<0.05).

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LIMITATIONS

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Limitations

Following are the limitations of the study;

a) The study is a single centric study

b) Smaller sample size affects the generalizability of the findings

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FUTURE

RECOMMENDATIONS

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Future recommendations

Following are the future directions;

a) Multicentric studies must be conducted to help get a better perspective

b) Larger sample size must be recruited to better generalizability of findings

c) Randomised control trial is best suited for studies like this

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ANNEXURES

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REFERENCES

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References

1. Korenkov M, Paul A, Sauerland S, et al. Classification and surgical treatment of incisional hernia. Results of an experts’ meeting.

Langenbecks Arch Surg. 2001;386(1):65–73.

2. Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias. Hernia.

2009;13(4):407–14.

3. van Ramshorst GH, Eker HH, Hop WC, et al. Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study. Am J Surg. 2012;204(2):144–50.

4. Burger JW, Luijendijk RW, Hop WC, et al. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004;240(4):578–83.

5. Sajid MS, Parampalli U, Baig MK, McFall MR. A systematic review on the effectiveness of slowly-absorbable versus nonabsorbable sutures for abdominal fascial closure following laparotomy. Int J Surg. 2011;9(8):615–25.

6. Braga M, Frasson M, Vignali A, et al. Laparoscopic vs. open colectomy in cancer patients: long-term complications, quality of life, and survival. Dis Colon Rectum. 2005;48(12):2217–23.

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7. Kuhry E, Schwenk W, Gaupset R, et al. Long-term outcome of laparoscopic surgery for colorectal cancer: a Cochrane systematic review of randomised controlled trials. Cancer Treat Rev.

2008;34(6):498–504.

8. Skipworth JR, Khan Y, Motson RW, et al. Incisional hernia rates following laparoscopic colorectal resection. Int J Surg.

2010;8(6):470–3.

9. Winslow ER, Fleshman JW, Birnbaum EH, Brunt LM. Wound complications of laparoscopic vs open colectomy. Surg Endosc.

2002;16(10):1420–5.

10. Diener MK, Voss S, Jensen K, et al. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg. 2010;251(5):843–56.

11. van’t Riet M, Steyerberg EW, Nellensteyn J, et al. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg.

2002;89(11):1350–6.

12. Franchi M, Ghezzi F, Buttarelli M, et al. Incisional hernia in gynecologic oncology patients: a 10-year study. Obstet Gynecol.

2001;97(5 pt 1):696–700.

13. Hoer J, Lawong G, Klinge U, Schumpelick V. Factors influencing the development of incisional hernia. A retrospective study of

(104)

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2,983 laparotomy patients over a period of 10 years. Chirurg.

2002;73(5):474–80.

14. Mäkelä JT, Kiviniemi H, Juvonen T, Laitinen S. Factors influencing wound dehiscence after midline laparotomy. Am J Surg. 1995;170(4):387–90.

15. Sørensen LT, Hemmingsen UB, Kirkeby LT, et al. Smoking is a risk factor for incisional hernia. Arch Surg. 2005;140(2):119–23.

16. Adell-Carceller R, Segarra-Soria MA, Pellicer-Castell V, et al.

Incisional hernia in colorectal cancer surgery. Associated risk factors. Cir Esp. 2006;79(1):42–5.

17. Colombo M, Maggioni A, Parma G, et al. A randomized comparison of continuous versus interrupted mass closure of midline incisions in patients with gynecologic cancer. Obstet Gynecol. 1997;89(5 pt 1):684–9.

18. Adye B, Luna G. Incidence of abdominal wall hernia in aortic surgery. Am J Surg. 1998;175(5):400–2.

19. Junge K, Klinge U, Klosterhalfen B, et al. Review of wound healing with reference to an unrepairable abdominal hernia. Eur J Surg. 2002;168(2):67–73.

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20. Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg.

2000;231(3):436–42.

21. Weiland DE, Bay RC, Del Sordi S. Choosing the best abdominal closure by meta-analysis. Am J Surg. 1998;176(6):666–70.

22. Diener MK, Voss S, Jensen K, et al. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg. 2010;251(5):843–56.

23. Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet. 2015.

24. Rahbari NN, Knebel P, Kieser M, et al. Design and current status of CONTINT: continuous versus interrupted abdominal wall closure after emergency midline laparotomy— a randomized controlled multicenter trial [NCT00544583]. Trials. 2012;13:72.

25. Shukla VK, Gupta A, Singh H, et al. Cardiff repair of incisional hernia: a university hospital experience. Eur J Surg.

1998;164(4):271–4.

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26. Hughes BR, Webster D. Leslie Ernest Hughes – Obituary. BMJ.

2011;343.

27. Mudge M, Harding KG, Hughes LE. Incisional hernia. Br J Surg.

1986;73(1):82.

28. Godara R, Garg P, Shankar G. Comparative evaluation of Cardiff repair and mesh plasty in incisional hernias. Internet J Surg [Internet]. 2007;9:about 8 p.

29. Malik R, Scott NA. Double near and far prolene suture closure: a technique for abdominal wall closure after laparostomy. Br J Surg.

2001;88(1):146–7.

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Signature of the Candidate

Signature of the Candidate

Signature and seal of the Guide

Signature and Seal of the Prof & HOD

Signature and Seal of the Dean

Signature of the Candidate

PLAGIARISM CERTIFICATE

INTRODUCTION

AIM OF THE

STUDY

OBJECTIVES

OF THE STUDY

REVIEW OF

LITERATURE

MATERIALS AND

METHODS

RESULTS

Gender (All cases)

Gender (Hughes Repair)

Gender (Conventional Repair)

Hughes Repair

Conventional Repair

Hughes Repair

Conventional Repair

DISCUSSION

INTRAOPERATIVE PICTURES

SUMMARY AND

CONCLUSION

LIMITATIONS

FUTURE

RECOMMENDATIONS

ANNEXURES

REFERENCES

PATIENT CONSENT

FORM