Discussion
hernias, hernia, fascial dehiscence
POSTOPERATIVE COMPLICATIONS
CONTINT is the first multicenter RCT comparing continuous and interrupted abdominal wall closure with the composite primary endpoint incidence of incisional hernia and burst abdomen after emergency midline laparotomy. No significant difference between continuous and interrupted closure was found regarding the primary endpoint and any other postoperative complications. Length of hospital, length of intensive care unit stay and quality of life 1 and 12 months after surgery were comparable between groups. However, time needed for abdominal wall closure was significantly longer in the interrupted suture group than in the continuous group.The rate of incisional hernia or burst abdomen in our trial is considerably higher than the rates reported in elective surgery trials [An analogous US trial comparing slowly absorbable interrupted polydioxanone sutures to a continuous suture in the emergency setting showed far lower rate of early fascial dehiscence (not reporting reoperations due to burst abdomen), but similar rates of incisional hernias after 1 year (13.5% for interrupted and 22.0% for continuous). Such high rates remain commonplace after emergency midline incisions, contrary to the findings of large RCTs in elective surgeries (e.g., 12.6% in the INSECT and 21% in the STITCH trial) [In our analysis BMI was a risk factor for the presence of incisional hernia or burst abdomen thus confirming findings of previous retrospective studies [Abdominal wall closure happens at the end of the operation, and in the emergency setting this can mean that patients need to be transferred to intensive care expeditiously to stabilize the cardiac, respiratory and metabolic situation. Thus, the time needed for the abdominal wall suture is of importance. Considering both approaches, continuous suturing exhibited significantly faster speed compared to interrupted sutures. This aspect could hold particular significance during emergency laparotomy closure, where timing plays a critical role.We reported a 16.9% mortality in both groups, a finding comparable to those of a retrospective cohort study of the ACS-NSQIP database during the same time [Our study has some considerable strengths. Primarily, the use of the composite endpoint deems our findings clinically relevant. Further, the rigorous evaluation of hernia minimizes the risk of reporting bias. Several limitations must also be considered. The most important shortcoming of this trial is the high number of patients lost to follow-up mainly due to high postoperative mortality (16.9%) which along with patients’ consent withdrawal during follow-up (10.3% in the current study) have been highlighted by similar studies [These challenges should be considered when planning for an RCT in a similar setting. Heterogeneous definitions of emergency surgery and the complexity of cases in tertiary centers might induce survivorship bias to a trial but adding regional or rural centers with solid clinical trial organization can balance those. With regard to enrollment, trials can use a stratified design to minimize selection bias. Finally, adding patients’ groups and other stakeholders into clinical trial design could reduce the rate of lost to follow-up due to withdrawal of consent.