Variable use of modern abdominal wall closure techniques at emergency laparotomy - an international, cross-sectional survey of surgical practice.

Purpose: Incisional hernias (IH) occur after 20-30% of laparotomies. Modern closure techniques including small bite closure and prophylactic mesh augmentation (PMA) demonstrate significant reduction in IH rates. European and American Hernia Society guidelines suggest use of small bite closure and consideration of PMA at elective laparotomy closure but do not make a recommendation for emergency surgery. International surveys demonstrate poor uptake of small bite closure and PMA. This survey aims to assess the uptake of these techniques specifically in emergency abdominal surgery.

Methods: An online, cross-sectional survey was circulated through emergency general surgery (EGS) and abdominal closure networks between June and August 2024. This interrogated surgeons' technical approach to all elements of emergency laparotomy closure including use of wound bundles, small bite, suture-to-wound ratio, suture choice, and PMA.

Results: The survey was completed by 234 general surgeons from 32 countries. Wound bundle components varied between surgeons. Small bite closure was used by 85.8% during midline laparotomy closure but only 42.2% of surgeons used 5 mm wide tissue bites placed every 5 mm. Suture-to-wound ratio was rarely measured (7.7%). A looped PDS (size 0 or 1) was used preferentially (42.7%). Self-locking (15.8%) and antiseptic coated sutures (20.2%) were used infrequently. One in ten surgeons used PMA and most often placed the mesh in the retrorectus space (39.6%).

Conclusion: Uptake of new techniques in emergency laparotomy has been variable and with limited penetrance amongst emergency general surgeons. Many surgeons are using adapted versions of the original descriptions of these approaches.