Skip to main content

ECLAPTE: Effective Closure of LAParoTomy in Emergency—2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings

A Correction to this article was published on 27 November 2023

This article has been updated


Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.


An appropriate incision is fundamental to performing any surgical procedure. The choice of incision in the case of laparotomy depends on the anatomical site of interest, the kind of setting, and the surgeon’s preference. In the case of emergency settings, laparotomy incisions allow rapid and easy access to the peritoneal cavity. However, incisional hernia (IH) represents a frequent complication of any abdominal wall incision.

IHs are defined as a late manifestation of failure of the abdominal fascia closure after surgical incisions [1]. The estimated incidence of IHs following major abdominal surgery ranges from 2 to 40% across studies considering both elective and emergency procedures [2]. Patient and wound factors contribute to the risk of developing an IH, but the setting—elective versus emergency—and the surgical technique seem to be an adjunctive factor for the development of these complications [2,3,4].

IHs can cause discomfort to the patients resulting in work and physical activities restriction, but their most redoubtable complications can include pain, deformity, bowel obstruction, incarceration, strangulation, and the necessity of both hospital readmission and reoperation marked with higher morbidity [5, 6]. Prevention of IHs is, therefore, crucial.

Several conditions contribute to the risk of developing an IH. Surgical aspects—such as the site of the incision, closure technique, suture material, and postoperative treatment—are well-described factors contributing to IHs occurring within the first two years after surgery [7,8,9]. Some other conditions not determined by surgeons and patients’ factors are relevant contributions to the risk of primary abdominal closure failure and hence incisional hernias [9, 10]. According to recent literature, a definition of high-risk patients for IH development has been described: patients with diabetes, chronic pulmonary disease, smoking, obesity, immunosuppression, surgical site infection (e.g., contaminated superficial fields), and previous abdominal surgery are at high risk of developing incisional hernias [11, 12].

In 2015, the European Hernia Society (EHS) published the first version of guideline statements with indications for the closure of abdominal wall incisions [13]. After that, systematic reviews and meta-analyses have been published trying to address these knowledge and evidence gaps [14]: an updated version of guidelines for the closure of midline incisions from EHS and American Hernia Society has been recently published. It aims to provide an up-to-date, complete point-of-view on this topic [15]. However, considering the heterogeneity of clinical scenarios in which a laparotomy could be performed, there are some concerns about these recent guidelines. The guidelines did not consider indications for laparotomy in emergency settings. Laparotomy is still particularly important in the emergency setting for trauma, intra-abdominal sepsis management, and other acute abdominal conditions. Therefore, evidence-based guidelines on emergency laparotomy were clearly necessary.

With this objective in mind, in 2022, the World Society of Emergency Surgery (WSES) proposed a project called ECLAPTE (Effective Closure of LAParotomy in Emergency) to develop guidelines on the closure of emergency laparotomies following a previous survey among the WSES members. After a preliminary identification of the key questions, the evidence-based recommendations were drafted and reviewed by representatives for each section. During the 9th International WSES Congress in Perth, Western Australia, a Consensus Conference reviewed the guidelines in-depth prior to a Delphi process involving the WSES Board of Directors (Fig. 1). This manuscript summarizes the evidence to date, as well as the results of the Delphi and expert opinion.

Fig. 1
figure 1

ECLAPTE project step-by-step process


A systematic informatic search of the English-language literature was conducted by the ‘Pavia Organizational group’ in Pubmed, Scopus, and EMBASE web databanks. The databases were screened without time restrictions up to 1 July 2022 using the keywords ‘laparotomy,’ ‘closure,’ ‘midline incision,’ ‘emergency,’ ‘abdominal wall incision,’ ‘laparotomic incision,’ ‘closure technique,’ ‘incisional hernia,’ ‘wound dehiscence,’ ‘fascial dehiscence,’ and ‘wound complications’: results were combined with words AND/OR. No search restrictions were imposed; comprehensive published manuscripts of clinical trials, consensus conferences, comparative studies, guidelines, multicenter studies, systematic reviews, meta-analyses, large case series, original articles, and randomized clinical trials were considered.

A survey of WSES members guided the scope of topics for this guideline. Subsequently, representatives responsible from the Organizational Group identified six relevant sections to be investigated in depth and created a draft version of the guideline statements. The certainty of evidence and strength of recommendations were determined using the ‘Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology’ [16,17,18]. Specifically, the GRADE system is an evidence-based tool that systematically evaluates the available literature and grades the Certainty of Evidence (CoE) as ‘High’/‘Moderate’/‘Low/‘Very low’ and the Strength of Recommendation (SoR) as either ‘Strong’ or ‘Weak’ (Table 1).

Table 1 GRADE system to evaluate the level of evidence and recommendation

During the 9th World Congress of the WSES held in Perth, Western Australia, in October 2022, each section and each question were discussed and voted upon by the audience—votes were either ‘YES/AGREE’ or ‘NO/DISAGREE.’ The poll was recorded using the Congress official mobile phone app, and the representatives of the Organizational group could immediately check the percentage of agreement. In case of disagreement or any comments, the statement was modified following the discussion. After the Congress poll, the Organizational group reviewed the guidelines according to the comments, and the revised version was voted online using a Delphi approach among the WSES Board of Directors and experts in the field. At the end of this step-by-step process, statements were approved with an agreement of ≥ 80%.

The method has already been employed in other guideline papers from WSES: this project was undertaken according to the usual methodology from the Society [19, 20].

The Organizational panel communicated via e-mail to prepare and revise the final guideline manuscript: valuable suggestion and comments from the Delphi process poll were integrated into the final document. The manuscript was successively reviewed by all contributors and ultimately revised as the present document. Statements are summarized in Table 2.

Table 2 Statements summary

These guidelines should be considered as an adjunctive tool for decision making in a field in which no evidence was clear until now. Still, they are not a substitute for the surgeon’s clinical consideration. The Organizational group will update the considerations in case of significant changes based on new evidence.


Introductory section

I. Does the abdominal wall incision in emergency surgery cases influence the incidence of incisional hernia, burst abdomen, or open abdomen?

I.1 When urgent access to the peritoneal cavity is required, we recommend midline laparotomy because it is faster and allows the best approach to the abdomen. When clinical circumstances allow, we suggest avoiding a midline incision for an alternative incision (2A).

$$\begin{aligned} & {\mathbf{\# }}\user2{CoE:A}{\mathbf{-}}{\varvec{High}}{\mathbf{/\# }}\user2{SoR:Weak} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{125}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{92}}\% } \right] \\ \end{aligned}$$

I.2 We recommend AGAINST midline incision as the extraction site when laparoscopic interventions are performed (1A).

$$\begin{aligned} & {\mathbf{\# }}\user2{CoE:A}{\mathbf{ - }}{\varvec{High}}{\mathbf{/\# }}\user2{SoR:Strong} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{125}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{87}}.{\mathbf{2}}\% } \right] \\ \end{aligned}$$

An appropriate incision is fundamental to performing any surgical operations, and the choice of incision in case of laparotomy depends on the anatomical site of interest, elective or emergency setting, and personal preference. Laparotomy incisions can be classified as follows:

  • Midline—a vertical incision through the skin, subcutaneous tissue, linea alba, and peritoneum.

  • Paramedian—the ‘conventional medial incision’ in which the rectus sheath and muscles are transected close to the linea alba and the ‘lateral incision’ in which rectus is transected near the lateral border.

  • Transverse—a possible supraumbilical transverse incision for access to the upper abdomen or a ‘Pfannenstiel’ infraumbilical transverse incision for access to the lower abdomen.

  • Oblique—a typical subcostal/Kocher incision or the McBurney incision.

In the literature, many randomized trials and systematic reviews with a high certainty evidence compared midline incisions to alternative incisions: the incisional hernia rate was significantly lower after non-midline incisions, for both transverse and oblique approaches [21,22,23,24]. In addition, a transverse incision appears to have less negative impact on pulmonary function, wound dehiscence, burst abdomen, and postoperative pain than a midline laparotomy [25, 26].

On the other hand, midline laparotomy is faster and allows the best access to all the organs of the peritoneal cavity: it is still the incision of choice in an emergency setting when a patient in a hemodynamically unstable condition needs to be explored [13, 15].

Therefore, our group recommends a different laparotomy incision from the classic midline approach when clinical circumstances allow: when preoperative imaging clearly identifies the site of pathology, a transverse incision can be used for emergency general surgery. For example, a transverse incision can be the best approach for advanced appendicitis and then could be extended medially to perform a right colectomy if necessary; similarly, a subcostal incision can be used for a complicated duodenal perforation. In addition, when emergency surgery is performed laparoscopically, we recommend avoiding midline incisions for the extraction site. However, the lack of evidence regarding the length and the location of these alternative incisions must be considered as a limitation.

Section 1

1. What is the optimal technique to close a laparotomy incision?

1.1 Continuous versus interrupted suture

The current evidence does not suggest any difference in the incidence of incisional hernia or dehiscence between continuous or interrupted sutures for fascial closure. However, the time taken for fascial closure is less with continuous closure. Therefore, we suggest a continuous suture technique of the midline abdominal wall incision in emergency settings (2A).

$$\begin{gathered} {\mathbf{\# }}\user2{CoE:A}{\mathbf{-}}{\varvec{High}}{\mathbf{/\# }}\user2{SoR:Weak} \hfill \\ \left[ {{\text{Panel}}\;{\text{participants}}:\;{126}/{\text{Vote}}\;{\text{percentage}}:{99}.{2}\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{92}}.{\mathbf{8}}\% } \right] \hfill \\ \end{gathered}$$

The literature search identified five large meta-analyses addressing the evidence on suture technique in terms of continuous versus interrupted methods [1, 14, 27,28,29]. Additionally, some well-designed randomized clinical trials were considered [30, 31]. Guidelines from the European Hernia Society—in the original 2015 version—recommended continuous closure of the midline abdominal wall, but the updated version in 2022 also considered more recent evidence and downgraded the certainty of evidence with a weak strength of recommendation due to the inconsistency of the results [13, 15]. Most of the evidence related to elective surgery, and clear data in the emergency setting are lacking. Therefore, in line with the evidence from Peponis et al. randomized clinical trial, we infer that there is no significant difference between continuous or interrupted sutures in the closure of abdominal wall incision, but the continuous technique might be preferred based on the elective surgery evidence because it is faster [1, 14, 27,28,29,30,31,32].

1.2 Closure versus non-closure of the peritoneum

We recommend AGAINST separate closure of the peritoneum during the abdominal wall closure of emergency laparotomy (1B).

$$\begin{aligned} & {\mathbf{\# }}\user2{CoE:B}{\mathbf{ - }}{\varvec{Moderate}}{\mathbf{/\# }}\user2{SoR:Strong} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{126}/{\text{Vote}}\;{\text{percentage}}:{98}.{4}\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{87}}.{\mathbf{1}}\% } \right] \\ \end{aligned}$$

Regarding the closure of the peritoneal layer in a midline laparotomy, the Cochrane Systematic review by Gurusamy et al. [33] concluded that there is no short-term or long-term benefit in peritoneal closure. This review included five randomized clinical trials (RCTs): inclusion criteria in the studies were heterogeneous—the type of incision, elective, or emergency setting—but the studies concluded that closure of the peritoneum is unnecessary [34,35,36,37,38]. There is considerable uncertainty in the benefits or harms of the single-layered closure of the peritoneum as a separate layer, but this procedure is likely to increase operating time in emergency surgery.

Closure of the peritoneum involves additional operating time and suture material, and no benefit is apparent from closure of peritoneum. Therefore, it does not seem necessary after a midline laparotomy, even in an emergency setting.

1.3 Mass closure versus layered closure

For closure of abdominal midline incision in emergency surgery, no difference between mass closure or layered closure was observed in terms of incisional hernia and wound complications: we suggest mass closure because it is faster than layered closure which might be highly important when emergency surgery is performed (2B).

$$\begin{aligned} & {\mathbf{\# }}\user2{CoE:B}{\mathbf{ - }}{\varvec{Moderate}}{\mathbf{/\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{125}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{86}}.{\mathbf{4}}\% } \right] \\ \end{aligned}$$

We used the EHS 2015 guidelines [13] definition of ‘mass closure’ versus ‘layered closure.’

Definitions proposed by Muysoms et al. (EHS 2015 guidelines) were:

  • Mass closure The midline incision is closed with a suture bite including all layers of the abdominal wall except the skin. With this approach, the suture includes the fascia layers, peritoneum (which may or may not be included), and superficial layers in a single bite. By definition, mass closure is a single-layer closure technique.

  • Layered closure The incision is closed with more than one separate layer of fascial closure. Specifically, if the incision is midline, there is only one layer of fascia. If the incision is paramedian, then there are two layers of rectus sheet above the arcuate line. With this approach, the peritoneal surface is normally closed separately as a different layer in the suture, and the same is done for the subcutaneous layer.

The following studies by Patel et al. and van Rooijen et al. in a systematic review and meta-analysis in 2018 analyzed the different impact of mass versus layered closure techniques in both elective and emergency settings. No difference was noted in terms of incisional hernia or wound complications, considering RCTs of moderate/low/very low certainty of evidence [1, 29, 39].

Therefore, we concluded that mass closure should be preferred because it is faster and no additional complications have been demonstrated, but the certainty of evidence is low due to the lack of specific data in emergency surgery and the low certainty of evidence from previous studies.

1.4 Suture Length-to-Wound Length ratio (SL/WL)

We recommend a suture-to-wound length ratio (SL/WL) of at least 4:1 for continuous closure of midline abdominal wall incisions in emergency surgery (1B).

$$\begin{aligned} & {\mathbf{\# }}\user2{CoE:B}{\mathbf{ - }}{\varvec{Moderate}}/{\mathbf{\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Strong}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{126}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{98}}.{\mathbf{4}}\% } \right] \\ \end{aligned}$$

The suture technique investigated through the suture length-to-wound length ratio is of crucial importance to avoid the development of incisional hernia and wound complications. The beneficial effect of a high suture length (SL)/wound length (WL) ratio has already been demonstrated, and previous guidelines consider a critical value a ratio of 4:1 or more (Jenkins Rule) [13, 15, 40,41,42,43].

Recently, data from RCTs were summarized in both elective and emergency surgeries after vascular operations: abdominal closure with a suture-to-wound length ratio of more than 4:1 compared with less than 4:1 significantly reduces the risk of incisional hernia and other wound complications [44,45,46].

Therefore, a SL/WL ratio of 4:1 or higher reduces the risk of incisional hernia and wound complications. It is recommended to document and ascertain this ratio at every wound closure.

1.5 ‘Small bite’ technique versus ‘large bite’ technique

We suggest the closure of the midline laparotomy with a ‘small bite’ technique to prevent incisional hernia and wound complications in emergency surgery cases although the evidence stems from elective surgery cases (2C).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{C}}{-}{\varvec{Low}}/{\mathbf{\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{126}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{88}}.{\mathbf{8}}\% } \right] \\ \end{aligned}$$

The ‘small bite’ technique in the closure of midline laparotomy consists of a tissue stitch of approximately 5 mm from the median wound edges and a distance of approximately 5 mm from the other stitch allowing surgeons to include only the aponeurosis and to ensure adequate distribution of tension on the edge of the incision [47]. The ‘large bite’ technique consists of a distance from the wound edge and between stitches of more than 10 mm.

The positive effects of small stitches on wound healing have been widely expressed: aponeurosis has limited possibilities for regeneration and cannot bridge over a large defect. With a large stitch, not only aponeurosis tissue is included, but also fat and muscle. In combination with increased intra-abdominal pressure, soft tissue can be compressed and damaged. This can result in slackening and separation of wound edges, tissue devitalization, and infection. A separation of wound edges of more than 10/12 mm during the first postoperative period has been strongly associated with the development of an incisional hernia.

Large RCTs of acceptable quality, systematic reviews, and previous guidelines have investigated outcomes from the closure techniques, showing that incisional hernias and wound complications are significantly lower with the ‘small bite’ suture technique [13, 15, 48, 49]. However, all the studies were in the elective setting. The only manuscript looking specifically at this comparison in the emergency setting was the one by Peponis et al. [31]. Therefore, we suggest using the ‘small bite’ technique with low certainty of evidence also in cases of midline emergency laparotomy, but future perspectives studies on this topic are necessary to prove the effectiveness of this technique.

Section 2

2. What is the optimal suture material to close a laparotomy incision?

2.1 Non-absorbable versus absorbable suture

There is currently no evidence to suggest that absorbable or non-absorbable sutures are better in terms of incisional hernia or surgical site infections. Absorbable sutures may decrease pain; therefore, we suggest slowly absorbable sutures for the closure of emergency laparotomy (2C).

$$\begin{aligned} & {\mathbf{\# }}\user2{CoE:C} - {\varvec{Low}}/{\mathbf{\# }}\user2{SoR:Weak} \\ & \left[ {{\text{Panel}}\;{\text{participants}}: {125}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{90}}.{\mathbf{4}}\% } \right] \\ \end{aligned}$$

There are many RCTs of high and moderate certainty evidence and even some previous systematic reviews and meta-analyses which investigated incisional hernia rates and other wound complications for different suture materials [14, 29, 32, 50,51,52]. A possible bias looking at these trials could be a combination of different suture techniques. Nevertheless, all high-level evidence considered a laparotomy incision closure through a continuous running suture. Taking into account these considerations, evidence failed to identify a significant superiority of one suture material over the other to reduce incisional hernia rate after a midline laparotomy [13, 15]. Van’t Riet et al. systematic review, Naz et al. RCT, and mainly Patel et al. Cochrane review highlighted less wound pain and surgical site infections in the absorbable suture group compared to the non-absorbable, but they agree that there is no clear evidence for all the other outcomes [1, 27, 53]. Most of the studies we considered include both elective and emergency settings.

Therefore, we conclude that there is no clear evidence for a recommendation about suture material, but some evidence about secondary outcomes suggest that non-absorbable suture may be avoided after emergency midline laparotomy.

2.2 Rapidly absorbable suture versus slowly absorbable suture

When using an absorbable suture for the closure of midline incisions in the emergency setting, we suggest choosing a slowly absorbable material (2A).

$$\begin{aligned} & {\mathbf{\# }}\user2{CoE:A}{\mathbf{ - }}{\varvec{High}}{\mathbf{/\# }}\user2{SoR:Weak} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{126}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\,{\mathbf{percentage}}:{\mathbf{99}}.{\mathbf{2}}\% } \right] \\ \end{aligned}$$

Randomized clinical trials and numerous systematic reviews reported a lower incisional hernia rate when closure of the midline incision is performed with a slowly absorbable suture, in both elective and emergency settings [27, 28, 30, 32, 52, 54,55,56]. Accordingly, Muysoms et al. (EHS 2015 guidelines) are not recommending the use of rapidly absorbable sutures—with a focus on the specific area of elective surgery—[13]. Most recent data do not confirm strong evidence supporting the implementation of slowly absorbable sutures: a trend of fewer incisional hernia and wound complications is confirmed but without statistical significance [14, 15, 29].

So, we recommend, based on the high and moderate certainty of evidence, a slowly absorbable suture for the closure of midline emergency laparotomy.

2.3 Monofilament suture versus multifilament suture

We recommend a monofilament suture material (slowly absorbable monofilament suture) in the closure of midline laparotomies in the emergency setting as they may decrease the incidence of incisional hernia (1A).

$$\begin{aligned} & {\mathbf{\# }}\user2{CoE:A}{\mathbf{-}}{\varvec{High}}{\mathbf{/\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Strong}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{126}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{96}}.{\mathbf{8}}\% } \right] \\ \end{aligned}$$

Our literature research found evidence, suggesting that monofilament sutures are associated with a significantly lower risk of incisional hernia than multifilament sutures in both elective and emergency settings [1, 13, 15, 29]. On the other hand, no evidence specifically about wound complications—wound infections, wound dehiscence, wound sinus, and fistula formation—emerged from previous high/moderate certainty of evidence.

Therefore, according to our previous statements, if a slowly absorbable suture is used, a monofilament material is the only possible choice.

Because of the significant amount of data supporting the lower incidence of incisional hernia in emergency surgical settings with monofilament sutures, we have made a strong recommendation.

2.4 Antimicrobial-coated sutures

We recommend an antimicrobial-coated suture for the fascial closure of abdominal laparotomy in cases of clean-, clean-contaminated, and contaminated fields when it is available in the emergency setting (1B).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{B}}{\mathbf{-}}{\varvec{Moderate}}/{\mathbf{\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Strong}} \\ & \left[ {{\text{Panelparticipants}}:{126}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{80}}.{\mathbf{1}}\% } \right] \\ \end{aligned}$$

Surgical site infections (SSIs) represent a common and serious complication of all surgical procedures, but it is even of greater concern in emergency surgery cases. Antimicrobial-coated sutures—typically triclosan-impregnated—have recently become a topic that generates considerable discussion, and is a well-known tool for preventing SSI, but they remain controversial due to elevated costs, worldwide availability, and the uncertainty in significant benefit for their use [55, 57,58,59,60,61,62,63,64,65,66,67].

Recently, high-quality RCTs in emergency settings and systematic reviews from Ahmed et al. and Uchino et al. have reported a significantly lower rate of surgical site infections when antibiotic-impregnated sutures are used in the closure of laparotomy in clean-, clean-contaminated, and contaminated fields [68,69,70].

Accordingly, our group is recommending antibiotic-coated suture in the emergency setting when it is available.

Section 3

3. Retention suture and suture needles

3.1 Is there a role for retention suture when closing a laparotomy in emergency setting?

There is currently no high-quality evidence literature to suggest that retention sutures decrease the incidence of wound dehiscence in patients undergoing emergency laparotomies. The panel did not reach consensus as to whether retention sutures should be used routinely in laparotomy closures in the emergency setting.

$$\begin{aligned} & \left[ {{\text{Panel}}\;{\text{participants}}:{125}/{\text{Vote}}\;{\text{percentage}}:{99}.{2}\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{68}}\% \;{\mathbf{on}}} \right. \\ & \left. {{\mathbf{avoiding}}\;{\mathbf{the}}\,{\mathbf{use}}\,{\mathbf{of}}\;{\mathbf{retention}}\;{\mathbf{sutures}}\;{\mathbf{routinely}}} \right] \\ \end{aligned}$$

The panel did not reach an agreement of at least 80%, and consequently, this statement cannot be considered as an indication in the current guidelines.

No systematic review was found regarding the implementation of retention sutures in the closure of laparotomy, in the elective or emergency surgery setting. Guidelines and indications for the prophylactic use of retention sutures are lacking and not clear. Nevertheless, some evidence supports the use of this technique in the case of [71, 72]:

  • Patients with increased tension in the incision;

  • Patients with preoperative severe malnutrition;

  • Patients who are immunocompromised;

  • Patients with previous fascial defects;

  • Patients with massive abdominal contamination.

‘Retention suture technique’ includes a suture outside from the primary incision site line through all layers of the abdominal wall, including the skin, with a large-bore non-absorbable suture material. Various tools are available to alleviate the tension of the retention suture on the skin for patients’ comfort. The effect is to reduce the tension on the primary suture line.

In the studies which were screened by our group, the target of the trials was always patients with an emergency indication for midline incisions or elective surgery in patients with high-risk factors for wound complications. Some randomized clinical trials with moderate certainty of evidence were considered. The principal outcomes in these studies were heterogeneous, but surgical infections and wound dehiscence were typically investigated. In addition, follow-up was too short to identify any major laparotomy complications, even in oncological patients [72,73,74,75,76,77,78,79].

Anyhow, the evidence considered seems to suggest a lower incidence of wound dehiscence in the retention suture group. On the other hand, there is higher postoperative pain in the group of patients treated with retention sutures. Accordingly, retention sutures could be considered as a possible addition to suture closure of emergency laparotomy only in case of patients with very high-risk conditions for incisional hernia and wound dehiscence.

3.2 Is there any difference between using a blunt tapered needle or a sharp needle in closing the abdominal wall after an emergency laparotomy?

There are very limited data about a blunt tapered or sharp needle in closing different layers of emergency laparotomies. Therefore, no recommendations can be made, and further studies are needed to clarify this concept.

$${\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{D}}{-}{\varvec{Very}}\;{\varvec{low}}$$

No voting was requested for this statement as there were no recommendations included in this statement.

Only one randomized clinical trial comparing blunt tapered and the standard sharp needle in elective and emergency general surgery has been published [80]. This trial included 200 patients, and the main outcome was the surgical team safety in terms of the number of procedures with one or more glove perforations. The secondary outcome was the number of procedures with omentum or bowel puncture comparing the use of the blunt tapered or sharp needle. No data about surgical outcomes, such as incisional hernia, fascial dehiscence, wound complications, or postoperative pain were reported. On the other hand, additional evidence comes from gynecological studies: only in the RCT published by Stafford wound infections were the main outcome [81, 82]. Therefore, no recommendations can be given on the use of a different type of needle, but we can recommend the use of blunt tapered needles as an important tool in decreasing the number of incidental glove and visceral perforation.

Section 4

4. Perioperative care

4.1/4.2 Wound irrigation in emergency laparotomy closure

4.1 To decrease surgical site infection occurrence after emergency surgery, we suggest prophylactic wound irrigation in clean, clean-contaminated, and contaminated fields of the surgery. We recommend not to use antibiotic irrigation. (2C).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{C}}{-}{\varvec{Low}}{\mathbf{/\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{122}/{\text{Vote}}\,{\text{percentage}}:{99}.{1}\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{90}}.{\mathbf{0}}\% } \right] \\ \end{aligned}$$

4.2 Povidone–iodine wound irrigation has been associated with lower SSI rates, but recent data suggest that this consideration should be reconsidered. We recommend future prospective high-quality trials to clarify this point (2C).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{C}}{\mathbf{-}}{\varvec{Low}}{\mathbf{/\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{121}/{\text{Vote}}\;{\text{percentage}}:{99}.{1}\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{93}}.{\mathbf{3}}\% } \right] \\ \end{aligned}$$

Surgical site infections (SSIs) are one of the most common hospital-acquired infections. SSIs are a preventable complication, responsible for substantial costs to health services that can result in poorer patient outcomes, increased mortality, morbidity, and reoperation rates. While the cause of SSIs is multifactorial, wounds can be classified by their level of contamination as suggested by the Centers for Disease Control and Prevention (CDC):

  • Class I/Clean

  • Class II/Clean—Contaminated

  • Class III/Contaminated

  • Class IV/Dirty—Infected

Based on the included trial evidence, there is currently no clear difference in the incidence of SSIs between patients treated with irrigation and without irrigation, with low-grade certainty of less incidence of SSIs when irrigation is performed [83, 84].

In addition, there is not a clear indication about the type of surgical wound irrigation that could be more beneficial in the setting of emergency laparotomies: evidence from Norman et al. Cochrane systematic review and meta-analysis support the implementation of antibacterial irrigation compared with non-antibacterial irrigation, whereas de Jonge et al. systematic review and meta-analysis show that antibiotic irrigation does not offer a benefit, contribute to antimicrobial resistance and prophylactic incisional wound irrigation to prevent SSI rates with an aqueous povidone–iodine solution should be considered [85, 86]. According to this evidence, povidone–iodine wound irrigation is associated with lower SSI rates compared to saline-only wound irrigation: this consideration is not specific to emergency surgery but is based on elective surgery settings [87]. Recent data from Chinese and Japanese RCTs query the povidone–iodine wound irrigation superiority in the prevention of SSIs, suggesting that the current recommendation should be reconsidered in light of future prospective high-quality trials [88, 89].

Therefore, our group suggest the use of wound irrigation, but future evidence on the best irrigation technique is necessary.

4.3 Subcutaneous drains in emergency laparotomy incisions

There is currently no evidence supporting the routine use of subcutaneous drains. Therefore, we suggest AGAINST the routine use of subcutaneous drains after emergency laparotomy (2A).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{A}}{\mathbf{-}}{\varvec{High}}{\mathbf{/\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{124}/{\text{Vote}}\,{\text{percentage}}:{99}.{1}\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{95}}.{\mathbf{9}}\% } \right] \\ \end{aligned}$$

Surgical site infection (SSI) is considered a postoperative complication after surgery that increases patient morbidity and mortality rates. Some authors suggest the use of a subcutaneous drain to prevent wound infection, but high-quality-of-evidence systematic reviews and meta-analyses demonstrate that the routine placement of a subcutaneous drain during the closure of abdominal wall incision does not confer any advantage in preventing postoperative wound infection [13].

Coletta et al. systematic review and meta-analysis in 2019 suggest that subcutaneous drains should not be used routinely, as it does not confer any advantage in preventing postoperative wound infection, but this does not exclude that there might be a benefit in a specific risk group of patients [90]. We found a recent RCT of moderate level of evidence by Harish et al., which stated that subcutaneous suction drains have been shown to reduce SSIs in a large number of patients [91]. One hundred patients were studied in this trial; however, the inconsistency in the results and publication bias means that our group cannot make a strong recommendation [91]. It is important to obliterate any dead space by using quilting sutures.

Therefore, our group is not recommending the implementation of drains in perioperative treatment of midline laparotomy incision until evidence from future trials of low risk of bias.

4.4/4.5 Delayed Closure of the Skin (DCS)—Leaving skin open after midline laparotomy.

4.4 There is currently no evidence to support or refute delayed laparotomy closure: because of the high risk of SSIs, we suggest surgeons should consider DCS of surgical wounds compared to primary closure in case of contaminated and dirty incisions with purulent contamination (2B).

$$\begin{aligned} & {\mathbf{\# }}\user2{CoE:B}{\mathbf{-}}{\varvec{Moderate}}/{\mathbf{\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{124}/{\text{Vote}}\;{\text{percentage}}:{99}.{1}\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:\;{\mathbf{83}}.{\mathbf{5}}\% } \right] \\ \end{aligned}$$

4.5 When delayed closure of surgical incision is performed, we recommend a revision between two and five days postoperatively (1B).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{B}}{\mathbf{-}}{\varvec{Moderate}}/{\mathbf{\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Strong}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{95}/{\text{Vote}}\;{\text{percentage}}:{98}.{9}\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{96}}.{\mathbf{8}}\% } \right] \\ \end{aligned}$$

Surgical site infections (SSI) following abdominal surgery are common and confer significant morbidity. Therefore, there is a strong interest in reducing the rate of SSI globally.

In addition to the practical tools for the proper closure of laparotomy incisions, some procedures and techniques for skin closure have been investigated to achieve a lower rate of SSI. Delayed primary closure (DPC) and primary closure (PC) are the most commonly used methods: DPC can be used when contaminated and dirty wounds with purulent contamination are created and it consists in leaving the skin open to allow soft tissue drains, PC is the classical direct closure of all anatomical layers—skin included -. Currently, there is no consensus on the optimal method and no indication of the best clinical practice has been reported [92, 93].

Emergency surgery procedures are at significant risk of contamination due to the types of interventions that are performed daily. Therefore, we were able to find some high and moderate level-of-evidence randomized clinical trials comparing DPC and PC in our search. Based on evidence by Banghu et al., delayed skin closure seems to reduce SSI rates, but the trial had a high risk of bias, and random effect model showed no evidence of difference [94]. There is no strong evidence to support one method over another.

Finally, we found concordant data on a surgical second look with closure, if no wound complications are noticed, between the second and fifth postoperative day [92,93,94].

4.6 Postoperative restriction of activity

No recommendation about postoperative physical restriction after open abdominal surgery can be made due to the lack of evidence, and further trials are necessary.

No voting was requested for this statement because no specific recommendation is being made.

There are very limited data on the optimal time of physical restriction of activity after open laparotomy surgery. In the literature research, only one systematic review was found surgeons suggest a variable period of convalescence and physical inactivity to reduce the risk of incisional hernia, but this period usually ranged from 1 week and 3 months for different types of approaches and procedures [95].

On the other hand, as stated by Enhanced Recovery After Surgery (ERAS) Society Recommendations in elective colorectal surgery, early mobilization after abdominal surgery is widely regarded as an important component of perioperative care. Prolonged immobilization is associated with various adverse effects and patients should therefore be encouraged to increase a rapid return to movements and walks after surgery. No data are available about the timing of early mobilization in terms of postoperative days [96].

Therefore, no recommendations can be given on restriction of activity after open abdominal surgery and randomized controlled trials are necessary to state a safe period of recovery.

4.7/4.8 Negative pressure wound therapy (NPWT) for wound healing after emergency laparotomy

4.7 In patients undergoing primary closure after emergency laparotomy with high risk for surgical site infections, we recommend prophylactic incisional NPWT dressing on the closed skin (1A).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{A}}{-}{\varvec{High}}/{\mathbf{\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Strong}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{125}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{92}}.{\mathbf{8}}\% } \right] \\ \end{aligned}$$

4.8 No recommendation about a specific type of incisional NPWT dressing can be made due to the lack of evidence.

No voting was requested for this statement as there was no recommendation.

Patients undergoing emergency laparotomy—with or without bowel surgery—are particularly at risk for surgical site infections (SSI). Incisional negative pressure wound therapy (iNPWT) has been shown to reduce surgical site infections in the elective setting, but until recently data were limited to the emergency setting [15]. Some observational retrospective studies with propensity-matched analysis, systematic reviews and meta-analysis, and a Cochrane review have been published after 2019 aiming to assess the role of iNPWT in trauma and emergency surgery [97,98,99,100].

Data suggest that in a population at high risk of development of SSI, iNPWT resulted in a lower risk of wound infections. Patients undergoing emergency laparotomy for a gastrointestinal procedure and at high risk of developing SSI, seem to be the target population in which iNPWT has beneficial effects [101, 102].

No specific data about the type of iNPWT to be used (e.g., PICO, PREVENA, others) were identified; thus, our group could not make any specific recommendation about it.

Section 5

5. Prophylactic mesh augmentation

5.1 Is prophylactic mesh augmentation beneficial for the closure of laparotomies in emergency settings?

The original version of this statementin light of the evidence from literature and after the open discussion at the 9th WSES International Congress in Perth, Western Australiawas submitted in a Delphi process to the WSES Board of Directors and experts: the panel did not reach an agreement of at least 80%, and consequently, this statement will not be considered as a recommendation in the current guidelines.

We report the original version of the statement with the agreed percentage from the panel polling.

We suggest the use of prophylactic mesh augmentation in the closure of midline laparotomies in emergency settings to decrease the risk of incisional hernia (2B).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{B}}{-}{\varvec{Moderate}}{\mathbf{/\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{121}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{67}}.{\mathbf{7}}\% } \right] \\ \end{aligned}$$

The current evidence on the efficacy of prophylactic mesh augmentation is overwhelming. Data highlight a significant reduction in the incisional hernia rate in elective settings, and trends suggest a significantly lower rate of incisional hernia in emergency laparotomies [13, 15, 103]. Prophylactic mesh augmentation after midline incision significantly impacts incisional hernia and does not predict an increased risk of postoperative complications [104,105,106,107,108,109,110,111,112,113,114,115]. However, a systematic review on the use of mesh in emergency surgery included only two small RCTs. The evidence does not suggest that the wound failure is lower in the mesh group [104]. Other observational studies are likely biased, and data must be regarded carefully, specifically about SSI rates. A large number of surgeons are still concerned about mesh reinforcement in cases of contaminated surgery.

Recent meta-analyses confirm robust evidence supporting the role of mesh as prophylactic augmentation in the closure of the abdominal wall after laparotomy: incisional hernia rate decreased significantly, but on the other hand, an increased trend in wound complications was identified. Consequently, we decided to downgrade our recommendation to a suggestion.

Anyhow, in the closure of midline laparotomy incisions in an emergency setting– specifically in the case of high-risk patients for fascial dehiscence—prophylactic mesh augmentation appears to be effective in preventing incisional hernia and safe for postoperative hospitalization.

5.2 Which type of patients should be considered for prophylactic mesh augmentation?

We suggest considering prophylactic mesh augmentation, particularly in patients with an increased risk of incisional hernia development (2B).

$$\begin{aligned} & & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{B}}{\mathbf{-}}{\varvec{Moderate}}/{\mathbf{\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{113}/{\text{Vote}}\;{\text{percentage}}:{97}.{3}\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{80}}\% } \right] \\ \end{aligned}$$

Risk factors for postoperative hernia development are already reported in the introduction section of this paper [11, 12].

5.3 Which type of mesh, which mesh position, and which type of mesh fixation should be considered for prophylactic mesh augmentation?

In light of current evidence, for prophylactic mesh augmentation no specific type of mesh can be recommended.

There is uncertainty about the type, position, or the type of fixation that should be used when prophylactic mesh augmentation is performed after emergency laparotomy. Evidence about mesh positioning is heterogeneous: onlay mesh position and retromuscular position are both recommended, even in emergency surgery, but future perspectives are needed to clarify the role of other types of meshes—absorbable and biological, for example, as well as other mesh placement positions (2C).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{QoE}}{\mathbf{:}}{\varvec{C}}{\mathbf{-}}{\varvec{Low}}{\mathbf{/\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{117}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{87}}.{\mathbf{1}}\% } \right] \\ \end{aligned}$$

No studies specifically compare the types of mesh used as prophylactic mesh augmentation. In terms of incisional hernia and postoperative surgical incision complications, in the series we analyzed, different types of mesh were analyzed: absorbable synthetic, non-absorbable synthetic, and biological meshes [116, 118]. Most guidelines and systematic reviews try to investigate any difference in the wound dehiscence rate after absorbable or non-absorbable mesh implantation, but clear data are lacking. None of the randomized clinical trials we considered highlight any significant differences in incisional hernia rates between different prophylactic mesh types. In addition, only a few randomized clinical trials specifically investigated prophylactic mesh types in the emergency setting and the occurrence of incisional hernias or postoperative complications. Accordingly, synthetic non-absorbable, absorbable, and biological meshes should be considered even in the emergency setting. Future studies are needed to clarify the most appropriate mesh position and fixation techniques.

Only a few randomized clinical trials compared different prophylactic mesh placements, without a high level of evidence in these analyses. Most studies investigated the role of mesh implantation in an onlay or retromuscular positions showing a significant reduction in the incidence of incisional hernias; however, a higher risk of wound complications has been reported in most series when compared to primary closure alone [117]. In the specific subgroup of cases treated in the emergency setting, prophylactic onlay or retromuscular mesh augmentation the evidence reported in the elective setting is confirmed [12]. Although a lower rate of incisional hernia was reported, there is a lack of evidence about long-term complications following the intraperitoneal prophylactic mesh positioning. In addition, there are several concerns about the use in contaminated fields and the increased risk of adhesive complications. No data were found about outcomes according to different techniques of mesh fixation.

Section 6

6. Trocar wounds for laparoscopic surgery and single-port surgery

6.1/6.2 Trocar size and type

6.1 Trocar-site hernia rates increase when trocars of 10 mm or larger are used and when trocars are introduced midline. We recommend using the smaller trocar size appropriate for the procedure and on an off-midline location when possible (2C).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{C}}{\mathbf{-}}{\varvec{Low}}/{\mathbf{\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{117}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{89}}.{\mathbf{7}}\% } \right] \\ \end{aligned}$$

6.2 Trocar-site hernia may increase when bladed trocars are used. Surgeons may consider using non-bladed trocars when available (2C).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{C}}{\mathbf{-}}{\varvec{Low}}/{\mathbf{\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{117}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{89}}.{\mathbf{7}}\% } \right] \\ \end{aligned}$$

6.3 Closure of trocar incision

We suggest closing the fascial defect caused by the trocar placement when trocars of 10 mm or of larger sizes are used (2C).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{C}}{\mathbf{-}}{\varvec{Low}}{\mathbf{/\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{116}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{93}}.{\mathbf{9}}\% } \right] \\ \end{aligned}$$

6.4/6.5 Single incision laparoscopic surgery and incisional hernia

6.4 We recommend conventional laparoscopic procedures over single incision laparoscopic surgery (SILS) due to a higher risk of incisional hernia with the SILS technique (1B).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{B}}{\mathbf{ - }}{\varvec{Moderate}}{\mathbf{/\# }}\user2{SoR:Strong} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{116}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{89}}.{\mathbf{6}}\% } \right] \\ \end{aligned}$$

6.5 When SILS is performed, surgeons might consider meticulous fascia closure to decrease the risk of incisional hernia formation (2C).

$$\begin{aligned} & {\mathbf{\# }}{\varvec{CoE}}{\mathbf{:}}{\varvec{C}}{\mathbf{ - }}{\varvec{Low}}{\mathbf{/\# }}{\varvec{SoR}}{\mathbf{:}}{\varvec{Weak}} \\ & \left[ {{\text{Panel}}\;{\text{participants}}:{116}/{\text{Vote}}\;{\text{percentage}}:{1}00\% /{\mathbf{Agreement}}\;{\mathbf{percentage}}:{\mathbf{99}}.{\mathbf{1}}\% } \right] \\ \end{aligned}$$

Trocar-site hernia (TSH) is a rare complication of laparoscopic surgery with a likely under-reported incidence of 0.1–1.0%. The literature on the topic is heterogeneous and typically reports data on elective and bariatric surgery cases. In our search, we identified only four systematic reviews including patients treated in the emergency setting and without any subgroup analysis; the quality of evidence was very low/low/moderate [119,120,121].

Regarding trocar size and location, there appears to be a higher risk of TSH when trocars of 10 mm or larger are used and when trocars are placed in the midline [122, 123]. In addition, clear evidence comparing bladed versus non-bladed trocars underlines a statistically significant lower incidence of TSH with non-bladed instruments.

Before the recent systematic review by Gutierrez et al., there was a consensus on the indication of fascial closure for trocar sites of 10 mm or more; in this recent paper, comparing fascial closure between 5 and 10 mm ports, no difference in TSH was reported, although leaving the fascia open may reduce operative time [124]. No specific data about the emergency setting is reported on this topic. Accordingly, we downgraded the strength of recommendation of our statement as further studies are necessary to clarify this issue.

Two systematic reviews of moderate certainty about single incision laparoscopic surgery (SILS) compared to traditional multiport laparoscopic surgery were published. The first reports on a variety of surgical procedures, and the second focuses only on laparoscopic cholecystectomy cases [125, 126]. Both studies showed an increased risk of incisional hernia after SILS compared to conventional laparoscopy. Therefore, we recommend conventional laparoscopy procedures instead of SILS. If SILS is performed, meticulous fascia closure is mandatory.


Incisional hernias and postoperative complications (wound dehiscence, fascial dehiscence, and surgical site infections) represent frequent complications after midline laparotomy, which is still the best approach to the abdomen in case of emergency settings for trauma, intra-abdominal sepsis management, and other acute abdominal conditions. The estimated incidence of IHs following major abdominal surgery ranges from 2 to 40% across studies, considering both elective and emergency procedures [1, 2]. The previous version of international guidelines investigated the abdominal wall closure techniques exclusively in elective surgery but provided no specific recommendations about emergency surgery cases.

A panel of experts from the World Society of Emergency Surgery discussed a series of key questions in a double-step process, firstly during the 9th World Congress of the WSES and then through a Delphi questionnaire among the WSES Board of Directors. The ECLAPTE project defined the optimal technique to close a laparotomy incision performed in the emergency setting, the optimal suture material, the role of retention sutures, and provided some advice about perioperative care. Our review focused on innovative and modern aspects of acute care surgery and trauma care. We examined the role of prophylactic mesh augmentation and provided suggestions about laparoscopic surgery when performed.

Moreover, areas for important future research were identified. Wound irrigation solutions, period of restriction from physical activity, the type and position of prophylactic mesh are relevant topics for future investigations. In addition, a significant point missing in literature, notorious neglected IHs site, is drain site incision: future perspectives are needed to clarify also the best closure technique for this incision.

Finally, the WSES advocates the adoption of these guidelines as a safe and evidence-based common approach in the emergency setting, but at the same time it encourages the development of local pathways based on the available evidence and resources.

Availability of data and materials

Not applicable.

Change history



Incisional hernia


World Society of Emergency Surgery


European Hernia Society


Certainty of evidence


Strength of recommendation


Randomized clinical trials


Suture length


Wound length


Surgical site infections


Center for Disease Control and Prevention


Delayed laparotomy closure


Primary closure


Enhanced Recovery After Surgery


Incisional negative pressure wound therapy


Trocar-site hernia


Single Laparoscopic Surgery


  1. Patel SV, Paskar DD, Nelson RL, Vedula SS, Steele SR. Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. Cochrane Database Syst Rev. 2017;11(11):CD005661.

    Article  PubMed  Google Scholar 

  2. Bosanquet DC, Ansell J, Abdelrahman T, Cornish J, Harries R, Stimpson A, Davies L, Glasbey JC, Frewer KA, Frewer NC, Russell D, Russell I, Torkington J. Systematic review and meta-regression of factors affecting midline incisional hernia rates: analysis of 14,618 patients. PLoS ONE. 2015;10(9):e0138745.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Santora TA, Roslyn JJ. Incisional hernia. Surg Clin N Am. 1993;73(3):557–70.

    Article  CAS  PubMed  Google Scholar 

  4. Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ. 2012;344:e2843.

    Article  PubMed  Google Scholar 

  5. Holihan JL, Alawadi Z, Martindale RG, Roth JS, Wray CJ, Ko TC, Kao LS, Liang MK. Adverse events after ventral hernia repair: the vicious cycle of complications. J Am Coll Surg. 2015;221(2):478–85.

    Article  PubMed  Google Scholar 

  6. Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg. 1998;133(4):378–82.

    Article  CAS  PubMed  Google Scholar 

  7. Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Br Med J (Clin Res Ed). 1982;284(6320):931–3.

    Article  CAS  PubMed  Google Scholar 

  8. Spencer RJ, Hayes KD, Rose S, Zhao Q, Rathouz PJ, Rice LW, Al-Niaimi AN. Risk factors for early-occurring and late-occurring incisional hernias after primary laparotomy for ovarian cancer. Obstet Gynecol. 2015;125(2):407–13.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Höer J, Lawong G, Klinge U, Schumpelick V. Einflussfaktoren der Narbenhernienentstehung. Retrospektive Untersuchung an 2.983 laparotomierten Patienten über einen Zeitraum von 10 Jahren [Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years]. Chirurg. 2002;73(5):474–80. (German).

    Article  PubMed  Google Scholar 

  10. Connelly TM, Tappouni R, Mathew P, Salgado J, Messaris E. Risk factors for the development of an incisional hernia after sigmoid resection for diverticulitis: an analysis of 33 patients, operative and disease-associated factors. Am Surg. 2015;81(5):492–7.

    Article  PubMed  Google Scholar 

  11. Sugerman HJ, Kellum JM Jr, Reines HD, DeMaria EJ, Newsome HH, Lowry JW. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg. 1996;171(1):80–4.

    Article  CAS  PubMed  Google Scholar 

  12. Goodenough CJ, Ko TC, Kao LS, Nguyen MT, Holihan JL, Alawadi Z, Nguyen DH, Flores JR, Arita NT, Roth JS, Liang MK. Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project). J Am Coll Surg. 2015;220(4):405–13.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D, de Beaux AC, Deerenberg EB, East B, Fortelny RH, Gillion JF, Henriksen NA, Israelsson L, Jairam A, Jänes A, Jeekel J, López-Cano M, Miserez M, Morales-Conde S, Sanders DL, Simons MP, Śmietański M, Venclauskas L, Berrevoet F, European Hernia Society. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia. 2015;19(1):1–24.

    Article  CAS  PubMed  Google Scholar 

  14. Henriksen NA, Deerenberg EB, Venclauskas L, Fortelny RH, Miserez M, Muysoms FE. Meta-analysis on materials and techniques for laparotomy closure: the MATCH review. World J Surg. 2018;42(6):1666–78.

    Article  CAS  PubMed  Google Scholar 

  15. Deerenberg EB, Henriksen NA, Antoniou GA, Antoniou SA, Bramer WM, Fischer JP, Fortelny RH, Gök H, Harris HW, Hope W, Horne CM, Jensen TK, Köckerling F, Kretschmer A, López-Cano M, Malcher F, Shao JM, Slieker JC, de Smet GHJ, Stabilini C, Torkington J, Muysoms FE. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. Br J Surg. 2022;109(12):1239–50.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ, GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Andrews JC, Schünemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA, Rind D, Montori VM, Brito JP, Norris S, Elbarbary M, Post P, Nasser M, Shukla V, Jaeschke R, Brozek J, Djulbegovic B, Guyatt G. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726–35.

    Article  PubMed  Google Scholar 

  18. Oxford Centre for Evidence-based Medicine – Levels of Evidence (March 2009) – CEBM [Internet]. Available from:

  19. Pisano M, Allievi N, Gurusamy K, Borzellino G, Cimbanassi S, Boerna D, Coccolini F, Tufo A, Di Martino M, Leung J, Sartelli M, Ceresoli M, Maier RV, Poiasina E, De Angelis N, Magnone S, Fugazzola P, Paolillo C, Coimbra R, Di Saverio S, De Simone B, Weber DG, Sakakushev BE, Lucianetti A, Kirkpatrick AW, Fraga GP, Wani I, Biffl WL, Chiara O, Abu-Zidan F, Moore EE, Leppäniemi A, Kluger Y, Catena F, Ansaloni L. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg. 2020;15(1):61.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, Biffl W, Peitzman A, Horer T, Abu-Zidan FM, Sartelli M, Fraga GP, Cicuttin E, Ansaloni L, Parra MW, Millán M, DeAngelis N, Inaba K, Velmahos G, Maier R, Khokha V, Sakakushev B, Augustin G, di Saverio S, Pikoulis E, Chirica M, Reva V, Leppaniemi A, Manchev V, Chiarugi M, Damaskos D, Weber D, Parry N, Demetrashvili Z, Civil I, Napolitano L, Corbella D, Catena F, WSES Expert Panel. Liver trauma: WSES 2020 guidelines. World J Emerg Surg. 2020;15(1):24.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Grantcharov TP, Rosenberg J. Vertical compared with transverse incisions in abdominal surgery. Eur J Surg. 2001;167(4):260–7.

    Article  CAS  PubMed  Google Scholar 

  22. Burger JW, van’t Riet M, Jeekel J. Abdominal incisions: techniques and postoperative complications. Scand J Surg. 2002;91(4):315–21.

    Article  CAS  PubMed  Google Scholar 

  23. Brown SR, Goodfellow PB. Transverse verses midline incisions for abdominal surgery. Cochrane Database Syst Rev. 2005;2005(4):CD005199.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Le Huu NR, Mege D, Ouaïssi M, Sielezneff I, Sastre B. Incidence and prevention of ventral incisional hernia. J Visc Surg. 2012;149(5 Suppl):e3-14.

    Article  Google Scholar 

  25. Bickenbach KA, Karanicolas PJ, Ammori JB, Jayaraman S, Winter JM, Fields RC, Govindarajan A, Nir I, Rocha FG, Brennan MF. Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery. Am J Surg. 2013;206(3):400–9.

    Article  PubMed  Google Scholar 

  26. Mathai M, Hofmeyr GJ, Mathai NE. Abdominal surgical incisions for caesarean section. Cochrane Database Syst Rev. 2013;5:CD004453.

    Article  Google Scholar 

  27. van’t Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg. 2002;89(11):1350–6.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  29. van Rooijen MMJ, Lange JF. Preventing incisional hernia: closing the midline laparotomy. Tech Coloproctol. 2018;22(8):623–5.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Seiler CM, Bruckner T, Diener MK, Papyan A, Golcher H, Seidlmayer C, Franck A, Kieser M, Büchler MW, Knaebel HP. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ann Surg. 2009;249(4):576–82.

    Article  PubMed  Google Scholar 

  31. Peponis T, Bohnen JD, Muse S, Fuentes E, van der Wilden GM, Mejaddam A, Alam H, Kaafarani HMA, Fagenholz PJ, King DR, Yeh DD, Velmahos GC, de Moya MA. Interrupted versus continuous fascial closure in patients undergoing emergent laparotomy: a randomized controlled trial. J Trauma Acute Care Surg. 2018;85(3):459–65.

    Article  PubMed  Google Scholar 

  32. Rahbari NN, Knebel P, Diener MK, Seidlmayer C, Ridwelski K, Stöltzing H, Seiler CM. Current practice of abdominal wall closure in elective surgery—Is there any consensus? BMC Surg. 2009;15(9):8.

    Article  Google Scholar 

  33. Gurusamy KS, Cassar Delia E, Davidson BR. Peritoneal closure versus no peritoneal closure for patients undergoing non-obstetric abdominal operations. Cochrane Database Syst Rev. 2013;2013(7):CD010424.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Ellis H, Heddle R. Does the peritoneum need to be closed at laparotomy? Br J Surg. 1977;64(10):733–6.

    Article  CAS  PubMed  Google Scholar 

  35. Gilbert JM, Ellis H, Foweraker S. Peritoneal closure after lateral paramedian incision. Br J Surg. 1987;74(2):113–5.

    Article  CAS  PubMed  Google Scholar 

  36. Hugh TB, Nankivell C, Meagher AP, Li B. Is closure of the peritoneal layer necessary in the repair of midline surgical abdominal wounds? World J Surg. 1990;14(2):231–3. (discussion 233–4).

    Article  CAS  PubMed  Google Scholar 

  37. Demirel Y, Gursoy S, Duran B, Erden O, Cetin M, Balta O, Cetin A. Closure or nonclosure of the peritoneum at gynecological operations. Effect on postoperative pain. Saudi Med J. 2005;26(6):964–8.

    PubMed  Google Scholar 

  38. Suresh B, Ambi U, Anilkumar G, Shaileshl E, Lamani Y. Postoperative analgesic requirement in non-closure and closure of peritoneum during open appendectomy—a randomized controlled study. J Clin Diagn Res. 2012;6(2):264–6.

    Google Scholar 

  39. Berretta R, Rolla M, Patrelli TS, Piantelli G, Merisio C, Melpignano M, Nardelli GB, Modena AB. Randomised prospective study of abdominal wall closure in patients with gynaecological cancer. Aust N Z J Obstet Gynaecol. 2010;50(4):391–6.

    Article  PubMed  Google Scholar 

  40. Jenkins TP. The burst abdominal wound: a mechanical approach. Br J Surg. 1976;63(11):873–6.

    Article  CAS  PubMed  Google Scholar 

  41. Anderson JR. Suture length to wound length ratio and healing of midline laparotomy incisions. Br J Surg. 1994;81(2):312.

    Article  CAS  PubMed  Google Scholar 

  42. Israelsson LA, Millbourn D. Closing midline abdominal incisions. Langenbecks Arch Surg. 2012;397(8):1201–7.

    Article  PubMed  Google Scholar 

  43. Nicolajsen CW, Eldrup N. Abdominal closure and the risk of incisional hernia in aneurysm surgery—a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2020;59(2):227–36.

    Article  PubMed  Google Scholar 

  44. Israelsson LA, Jonsson T. Suture length to wound length ratio and healing of midline laparotomy incisions. Br J Surg. 1993;80(10):1284–6.

    Article  CAS  PubMed  Google Scholar 

  45. Israelsson LA. Bias in clinical trials: the importance of suture technique. Eur J Surg. 1999;165(1):3–7.

    Article  CAS  PubMed  Google Scholar 

  46. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg. 2009;144(11):1056–9.

    Article  PubMed  Google Scholar 

  47. Neidhardt JPH, Caillot JL. Anatomia chirurgica della parete addominale antero-laterale. Vie d’accesso alla parete addominale. Celiotomie, laparotomie, approcci combinati toraco-addominali. E.M.C. Roma-Parigi – Tecniche Chirurgiche Addominali, 40040.

  48. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FPH, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet. 2015;386(10000):1254–60.

    Article  PubMed  Google Scholar 

  49. Albertsmeier M, Hofmann A, Baumann P, Riedl S, Reisensohn C, Kewer JL, Hoelderle J, Shamiyeh A, Klugsberger B, Maier TD, Schumacher G, Köckerling F, Pession U, Weniger M, Fortelny RH. Effects of the short-stitch technique for midline abdominal closure: short-term results from the randomised-controlled ESTOIH trial. Hernia. 2022;26(1):87–95.

    Article  CAS  PubMed  Google Scholar 

  50. Bloemen A, van Dooren P, Huizinga BF, Hoofwijk AGM. Randomized clinical trial comparing polypropylene or polydioxanone for midline abdominal wall closure. Br J Surg. 2011;98(5):633–9.

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  52. Albertsmeier M, Seiler CM, Fischer L, Baumann P, Hüsing J, Seidlmayer C, Franck A, Jauch KW, Knaebel HP, Büchler MW. Evaluation of the safety and efficacy of MonoMax® suture material for abdominal wall closure after primary midline laparotomy-a controlled prospective multicentre trial: ISSAAC [NCT005725079]. Langenbecks Arch Surg. 2012;397(3):363–71.

    Article  PubMed  Google Scholar 

  53. Naz S, Memon SA, Jamali MA, Ahmed MR, Almani T. Polydioxanone versus polypropylene closure for midline abdominal incisions. J Ayub Med Coll Abbottabad. 2017;29(4):591–4.

    PubMed  Google Scholar 

  54. Hsiao W-C, Young K-C, Wang S-T, Lin P-W. Incisional hernia after laparotomy: prospective randomized comparison between early-absorbable and late-absorbable suture materials. World J Surg. 2000;24(6):747–52.

    Article  CAS  PubMed  Google Scholar 

  55. Justinger C, Slotta JE, Schilling MK. Incisional hernia after abdominal closure with slowly absorbable versus fast absorbable, antibacterial-coated sutures. Surgery. 2012;151(3):398–403.

    Article  PubMed  Google Scholar 

  56. Ohira G, Kawahira H, Miyauchi H, Suzuki K, Nishimori T, Hanari N, Mori M, Tohma T, Gunji H, Horibe D, Narushima K, Matsubara H. Synthetic polyglycomer short-term absorbable sutures vs. polydioxanone long-term absorbable sutures for preventing incisional hernia and wound dehiscence after abdominal wall closure: a comparative randomized study of patients treated for gastric or colon cancer. Surg Today. 2015;45(7):841–5.

    Article  CAS  PubMed  Google Scholar 

  57. Baracs J, Huszár O, Sajjadi SG, Horváth OP. Surgical site infections after abdominal closure in colorectal surgery using triclosan-coated absorbable suture (PDS Plus) vs. uncoated sutures (PDS II): a randomized multicenter study. Surg Infect. 2011;12(6):483–9.

    Article  Google Scholar 

  58. Justinger C, Slotta JE, Ningel S, Gräber S, Kollmar O, Schilling MK. Surgical-site infection after abdominal wall closure with triclosan-impregnated polydioxanone sutures: results of a randomized clinical pathway facilitated trial (NCT00998907). Surgery. 2013;154(3):589–95.

    Article  PubMed  Google Scholar 

  59. Diener MK, Knebel P, Kieser M, Schüler P, Schiergens TS, Atanassov V, Neudecker J, Stein E, Thielemann H, Kunz R, von Frankenberg M, Schernikau U, Bunse J, Jansen-Winkeln B, Partecke LI, Prechtl G, Pochhammer J, Bouchard R, Hodina R, Beckurts KT, Leißner L, Lemmens HP, Kallinowski F, Thomusch O, Seehofer D, Simon T, Hyhlik-Dürr A, Seiler CM, Hackert T, Reissfelder C, Hennig R, Doerr-Harim C, Klose C, Ulrich A, Büchler MW. Effectiveness of triclosan-coated PDS Plus versus uncoated PDS II sutures for prevention of surgical site infection after abdominal wall closure: the randomised controlled PROUD trial. Lancet. 2014;384(9938):142–52.

    Article  CAS  PubMed  Google Scholar 

  60. Thomas ED, Nugent EK, MacAllister MC, Moxley KM, Landrum L, L Walker J, McMeekin DS, Mannel RS, McGwin G, Moore KN. Effectiveness of cyanoacrylate microbial sealant in the reduction of surgical site infection in gynecologic oncology procedures: a phase III single institution prospective randomized trial. Gynecol Oncol. 2017;144(1):193–9.

    Article  CAS  PubMed  Google Scholar 

  61. Sandini M, Mattavelli I, Nespoli L, Uggeri F, Gianotti L. Systematic review and meta-analysis of sutures coated with triclosan for the prevention of surgical site infection after elective colorectal surgery according to the PRISMA statement. Medicine. 2016;95(35):e4057.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Takeno S, Yamashita K, Yamashita Y, Yamada K, Hoshino S, Yamauchi Y, Noritomi T. The results of a propensity score matching analysis of the efficacy of abdominal fascia and skin closure using PDS® plus antibacterial (Polydioxanone) sutures on the incidence of superficial incisional surgical site infections after gastroenterologic surgery. Surg Infect. 2016;17(1):94–9.

    Article  Google Scholar 

  63. Yamashita K, Takeno S, Hoshino S, Shiwaku H, Aisu N, Yoshida Y, Tanimura S, Yamashita Y. Triclosan sutures for surgical site infection in colorectal cancer. J Surg Res. 2016;206(1):16–21.

    Article  CAS  PubMed  Google Scholar 

  64. de Jonge SW, Atema JJ, Solomkin JS, Boermeester MA. Meta-analysis and trial sequential analysis of triclosan-coated sutures for the prevention of surgical-site infection. Br J Surg. 2017;104(2):e118–33.

    Article  CAS  PubMed  Google Scholar 

  65. Elsolh B, Zhang L, Patel SV. The effect of antibiotic-coated sutures on the incidence of surgical site infections in abdominal closures: a meta-analysis. J Gastrointest Surg. 2017;21(5):896–903.

    Article  PubMed  Google Scholar 

  66. Henriksen NA, Deerenberg EB, Venclauskas L, Fortelny RH, Garcia-Alamino JM, Miserez M, Muysoms FE. Triclosan-coated sutures and surgical site infection in abdominal surgery: the TRISTAN review, meta-analysis and trial sequential analysis. Hernia. 2017;21(6):833–41.

    Article  CAS  PubMed  Google Scholar 

  67. Olmez T, Berkesoglu M, Turkmenoglu O, Colak T. Effect of triclosan-coated suture on surgical site infection of abdominal fascial closures. Surg Infect. 2019;20(8):658–64.

    Article  Google Scholar 

  68. Uchino M, Mizuguchi T, Ohge H, Haji S, Shimizu J, Mohri Y, Yamashita C, Kitagawa Y, Suzuki K, Kobayashi M, Kobayashi M, Sakamoto F, Yoshida M, Mayumi T, Hirata K, SSI Prevention Guideline Committee of the Japan Society for Surgical Infection. The efficacy of antimicrobial-coated sutures for preventing incisional surgical site infections in digestive surgery: a systematic review and meta-analysis. J Gastrointest Surg. 2018;22(10):1832–41.

    Article  PubMed  Google Scholar 

  69. Ahmed I, Boulton AJ, Rizvi S, Carlos W, Dickenson E, Smith NA, Reed M. The use of triclosan-coated sutures to prevent surgical site infections: a systematic review and meta-analysis of the literature. BMJ Open. 2019;9(9):e029727.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Ruiz-Tovar J, Llavero C, Jimenez-Fuertes M, Duran M, Perez-Lopez M, Garcia-Marin A. Incisional surgical site infection after abdominal fascial closure with triclosan-coated barbed suture vs triclosan-coated polydioxanone loop suture vs polydioxanone loop suture in emergent abdominal surgery: a randomized clinical trial. J Am Coll Surg. 2020;230(5):766–74.

    Article  PubMed  Google Scholar 

  71. Irvin TT, Stoddard CJ, Greaney MG, Duthie HL. Abdominal wound healing: a prospective clinical study. Br Med J. 1977;2(6083):351–2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  72. Rink AD, Goldschmidt D, Dietrich J, Nagelschmidt M, Vestweber KH. Negative side-effects of retention sutures for abdominal wound closure. A prospective randomised study. Eur J Surg. 2000;166(12):932–7.

    Article  CAS  PubMed  Google Scholar 

  73. Iltar E, Ureyen I, Toptas T, Doğan S, Uysal A. Prophylactic subcutaneous retention sutures in the prevention of superficial wound separation of midline laparotomy. Int J Gynecol Cancer. 2021;31(9):1260–7.

    Article  PubMed  Google Scholar 

  74. Ito E, Yoshida M, Suzuki N, Imakita T, Tsutsui N, Ohdaira H, Kitajima M, Suzuki Y. Prophylactic retention suture for surgical site infection: a retrospective cohort study. J Surg Res. 2018;221:58–63.

    Article  PubMed  Google Scholar 

  75. Khorgami Z, Shoar S, Laghaie B, Aminian A, Hosseini Araghi N, Soroush A. Prophylactic retention sutures in midline laparotomy in high-risk patients for wound dehiscence: a randomized controlled trial. J Surg Res. 2013;180(2):238–43.

    Article  PubMed  Google Scholar 

  76. Agarwal A, Hossain Z, Agarwal A, Das A, Chakraborty S, Mitra N, Gupta M, Ray U. Reinforced tension line suture closure after midline laparotomy in emergency surgery. Trop Doct. 2011;41(4):193–6.

    Article  PubMed  Google Scholar 

  77. Matsuoka J, Gohchi A, Kamikawa Y, Sakagami K, Orita K. Chopstick retention suture for the closure of abdominal wounds. J Am Coll Surg. 1995;181(5):471–4.

    CAS  PubMed  Google Scholar 

  78. Urschel JD. Laparotomy closure reinforced with buried polyglyconate retention sutures. Am J Surg. 1991;161(6):687–9.

    Article  CAS  PubMed  Google Scholar 

  79. Hubbard TB Jr, Rever WB Jr. Retention sutures in the closure of abdominal incisions. Am J Surg. 1972;124(3):378–80.

    Article  PubMed  Google Scholar 

  80. Nordkam RA, Bluyssen SJ, van Goor H. Randomized clinical trial comparing blunt tapered and standard needles in closing abdominal fascia. World J Surg. 2005;29(4):441–5. (discussion 445).

    Article  PubMed  Google Scholar 

  81. Stafford MK, Pitman MC, Nanthakumaran N, Smith JR. Blunt-tipped versus sharp-tipped needles: wound morbidity. J Obstet Gynaecol. 1998;18(1):18–9.

    Article  CAS  PubMed  Google Scholar 

  82. Anderson ER, Gates S. Techniques and materials for closure of the abdominal wall in caesarean section. Cochrane Database Syst Rev. 2004;2004(4):CD004663.

    Article  PubMed  PubMed Central  Google Scholar 

  83. Nikfarjam M, Weinberg L, Fink MA, Muralidharan V, Starkey G, Jones R, Staveley-O’Carroll K, Christophi C. Pressurized pulse irrigation with saline reduces surgical-site infections following major hepatobiliary and pancreatic surgery: randomized controlled trial. World J Surg. 2014;38(2):447–55.

    Article  PubMed  Google Scholar 

  84. Mueller TC, Loos M, Haller B, Mihaljevic AL, Nitsche U, Wilhelm D, Friess H, Kleeff J, Bader FG. Intra-operative wound irrigation to reduce surgical site infections after abdominal surgery: a systematic review and meta-analysis. Langenbecks Arch Surg. 2015;400(2):167–81.

    Article  PubMed  Google Scholar 

  85. Norman G, Atkinson RA, Smith TA, Rowlands C, Rithalia AD, Crosbie EJ, Dumville JC. Intracavity lavage and wound irrigation for prevention of surgical site infection. Cochrane Database Syst Rev. 2017;10(10):CD012234.

    Article  PubMed  Google Scholar 

  86. de Jonge SW, Boldingh QJJ, Solomkin JS, Allegranzi B, Egger M, Dellinger EP, Boermeester MA. Systematic review and meta-analysis of randomized controlled trials evaluating prophylactic intra-operative wound irrigation for the prevention of surgical site infections. Surg Infect. 2017;18(4):508–19.

    Article  Google Scholar 

  87. Monstrey SJ, Govaers K, Lejuste P, Lepelletier D, Ribeiro de Oliveira P. Evaluation of the role of povidone-iodine in the prevention of surgical site infections. Surg Open Sci. 2023;16(13):9–17.

    Article  Google Scholar 

  88. Zhao LY, Zhang WH, Liu K, Chen XL, Yang K, Chen XZ, Hu JK. Comparing the efficacy of povidone-iodine and normal saline in incisional wound irrigation to prevent superficial surgical site infection: a randomized clinical trial in gastric surgery. J Hosp Infect. 2023;131:99–106.

    Article  CAS  PubMed  Google Scholar 

  89. Maemoto R, Noda H, Ichida K, Miyakura Y, Kakizawa N, Machida E, Aizawa H, Kato T, Iseki M, Fukui T, Muto Y, Fukai S, Tsujinaka S, Hatsuzawa Y, Watanabe F, Nagamori M, Takahashi J, Kimura Y, Maeda S, Takayama N, Sakio R, Takahashi R, Takenami T, Matsuzawa N, Mieno M, Rikiyama T. Aqueous povidone-iodine versus normal saline for intraoperative wound irrigation on the incidence of surgical site infection in clean-contaminated wounds after gastroenterological surgery: a single institute, prospective, blinded-endpoint. Randomized Control Trial Ann Surg. 2022.

    Article  PubMed  Google Scholar 

  90. Coletta D, Del Basso C, Giuliani G, Guerra F. Subcutaneous suction drains do not prevent surgical site infections in clean-contaminated abdominal surgery-results of a systematic review and meta-analysis. Langenbecks Arch Surg. 2019;404(6):663–8.

    Article  PubMed  Google Scholar 

  91. Harish R, Kazi FN, Sharma JVP. Efficacy of subcutaneous closed suction drain in reduction of postoperative surgical site infection. Surg J. 2021;7(4):e275–80.

    Article  CAS  Google Scholar 

  92. Cohn SM, Giannotti G, Ong AW, Varela JE, Shatz DV, McKenney MG, Sleeman D, Ginzburg E, Augenstein JS, Byers PM, Sands LR, Hellinger MD, Namias N. Prospective randomized trial of two wound management strategies for dirty abdominal wounds. Ann Surg. 2001;233(3):409–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  93. Chiang RA, Chen SL, Tsai YC. Delayed primary closure versus primary closure for wound management in perforated appendicitis: a prospective randomized controlled trial. J Chin Med Assoc. 2012;75(4):156–9.

    Article  PubMed  Google Scholar 

  94. Bhangu A, Singh P, Lundy J, Bowley DM. Systemic review and meta-analysis of randomized clinical trials comparing primary vs delayed primary skin closure in contaminated and dirty abdominal incisions. JAMA Surg. 2013;148(8):779–86.

    Article  PubMed  Google Scholar 

  95. Loor MM, Shah P, Olavarria OA, Dhanani N, Franz MG, Trautner BW, Liang MK. Postoperative work and activity restrictions after abdominal surgery: a systematic review. Ann Surg. 2021;274(2):290–7.

    Article  PubMed  Google Scholar 

  96. Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS®) society recommendations: 2018. World J Surg. 2019;43(3):659–95.

    Article  CAS  PubMed  Google Scholar 

  97. Scalise A, Calamita R, Tartaglione C, Pierangeli M, Bolletta E, Gioacchini M, Gesuita R, Di Benedetto G. Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature. Int Wound J. 2016;13(6):1260–81.

    Article  PubMed  Google Scholar 

  98. Boland PA, Kelly ME, Donlon NE, Bolger JC, Mehigan BJ, McCormick PH, Larkin JO. Prophylactic negative pressure wound therapy for closed laparotomy wounds: a systematic review and meta-analysis of randomised controlled trials. Ir J Med Sci. 2021;190(1):261–7.

    Article  PubMed  Google Scholar 

  99. Liu DS, Cheng C, Islam R, Tacey M, Sidhu A, Lam D, Strugnell N. Prophylactic negative-pressure dressings reduce wound complications and resource burden after emergency laparotomies. J Surg Res. 2021;257:22–31.

    Article  PubMed  Google Scholar 

  100. Norman G, Goh EL, Dumville JC, Shi C, Liu Z, Chiverton L, Stankiewicz M, Reid A. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev. 2020;6(6):CD009261.

    Article  PubMed  Google Scholar 

  101. Cheong Chung JN, Ali O, Hawthornthwaite E, Watkinson T, Blyth U, McKigney N, Harji DP, Griffiths B. Closed incision negative pressure wound therapy is associated with reduced surgical site infection after emergency laparotomy: a propensity matched-cohort analysis. Surgery. 2021;170(5):1568–73.

    Article  PubMed  Google Scholar 

  102. Kabir I, Nguyen T, Heaton J, Peterson K, Martyak M. Incisional negative pressure wound therapy to decrease the incidence of surgical site infections in trauma laparotomy wounds. Am Surg. 2022;6:31348211054529.

    Article  Google Scholar 

  103. Depuydt M, Allaeys M, de Carvalho LA, Vanlander A, Berrevoet F. Prophylactic mesh after midline laparotomy: evidence is out there, but why do surgeons hesitate? World J Surg. 2021;45(5):1349–61.

    Article  PubMed  Google Scholar 

  104. Albendary M, Mohamedahmed AYY, Alamin A, Rout S, George A, Zaman S. Efficacy and safety of mesh closure in preventing wound failure following emergency laparotomy: a systematic review and meta-analysis. Langenbecks Arch Surg. 2022;407(4):1333–44.

    Article  PubMed  Google Scholar 

  105. Jairam AP, López-Cano M, Garcia-Alamino JM, Pereira JA, Timmermans L, Jeekel J, Lange J, Muysoms F. Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis. BJS Open. 2020;4(3):357–68.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  106. Pizza F, D’Antonio D, Ronchi A, Lucido FS, Brusciano L, Marvaso A, Dell’Isola C, Gambardella C. Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS). Br J Surg. 2021;108(6):638–43.

    Article  CAS  PubMed  Google Scholar 

  107. Lima HVG, Rasslan R, Novo FCF, Lima TMA, Damous SHB, Bernini CO, Montero EFS, Utiyama EM. Prevention of fascial dehiscence with onlay prophylactic mesh in emergency laparotomy: a randomized clinical trial. J Am Coll Surg. 2020;230(1):76–87.

    Article  PubMed  Google Scholar 

  108. Glauser PM, Brosi P, Speich B, Käser SA, Heigl A, Rosenberg R, Maurer CA. Prophylactic intraperitoneal onlay mesh following midline laparotomy-long-term results of a randomized controlled trial. World J Surg. 2019;43(7):1669–75.

    Article  PubMed  Google Scholar 

  109. Fortelny RH. Abdominal wall closure in elective midline laparotomy: the current recommendations. Front Surg. 2018;23(5):34.

    Article  Google Scholar 

  110. Kohler A, Lavanchy JL, Lenoir U, Kurmann A, Candinas D, Beldi G. Effectiveness of prophylactic intraperitoneal mesh implantation for prevention of incisional hernia in patients undergoing open abdominal surgery: a randomized clinical trial. JAMA Surg. 2019;154(2):109–15.

    Article  PubMed  Google Scholar 

  111. Payne R, Aldwinckle J, Ward S. Meta-analysis of randomised trials comparing the use of prophylactic mesh to standard midline closure in the reduction of incisional herniae. Hernia. 2017;21(6):843–53.

    Article  CAS  PubMed  Google Scholar 

  112. Brosi P, Glauser PM, Speich B, Käser SA, Maurer CA. Prophylactic intraperitoneal onlay mesh reinforcement reduces the risk of incisional hernia, two-year results of a randomized clinical trial. World J Surg. 2018;42(6):1687–94.

    Article  PubMed  Google Scholar 

  113. Jairam AP, Timmermans L, Eker HH, Pierik REGJM, van Klaveren D, Steyerberg EW, Timman R, van der Ham AC, Dawson I, Charbon JA, Schuhmacher C, Mihaljevic A, Izbicki JR, Fikatas P, Knebel P, Fortelny RH, Kleinrensink GJ, Lange JF, Jeekel HJ. Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement versus primary suture only in midline laparotomies (PRIMA): 2-year follow-up of a multicentre, double-blind, randomised controlled trial. Lancet. 2017;390(10094):567–76.

    Article  PubMed  Google Scholar 

  114. Muysoms FE, Detry O, Vierendeels T, Huyghe M, Miserez M, Ruppert M, Tollens T, Defraigne JO, Berrevoet F. Prevention of incisional hernias by prophylactic mesh-augmented reinforcement of midline laparotomies for abdominal aortic aneurysm treatment: a randomized controlled trial. Ann Surg. 2016;263(4):638–45.

    Article  PubMed  Google Scholar 

  115. García-Ureña MÁ, López-Monclús J, Hernando LA, Montes DM, Valle de Lersundi AR, Pavón CC, Ceinos CJ, Quindós PL. Randomized controlled trial of the use of a large-pore polypropylene mesh to prevent incisional hernia in colorectal surgery. Ann Surg. 2015;261(5):876–81.

    Article  PubMed  Google Scholar 

  116. Sarr MG, Hutcher NE, Snyder S, Hodde J, Carmody B. A prospective, randomized, multicenter trial of Surgisis Gold, a biologic prosthetic, as a sublay reinforcement of the fascial closure after open bariatric surgery. Surgery. 2014;156(4):902–8.

    Article  PubMed  Google Scholar 

  117. Caro-Tarrago A, Olona Casas C, Jimenez Salido A, Duque Guilera E, Moreno Fernandez F, Vicente GV. Prevention of incisional hernia in midline laparotomy with an onlay mesh: a randomized clinical trial. World J Surg. 2014;38(9):2223–30.

    Article  CAS  PubMed  Google Scholar 

  118. Bali C, Papakostas J, Georgiou G, Kouvelos G, Avgos S, Arnaoutoglou E, Papadopoulos G, Matsagkas M. A comparative study of sutured versus bovine pericardium mesh abdominal closure after open abdominal aortic aneurysm repair. Hernia. 2015;19(2):267–71.

    Article  CAS  PubMed  Google Scholar 

  119. Helgstrand F, Rosenberg J, Bisgaard T. Trocar site hernia after laparoscopic surgery: a qualitative systematic review. Hernia. 2011;15(2):113–21.

    Article  CAS  PubMed  Google Scholar 

  120. Owens M, Barry M, Janjua AZ, Winter DC. A systematic review of laparoscopic port site hernias in gastrointestinal surgery. Surgeon. 2011;9(4):218–24.

    Article  CAS  PubMed  Google Scholar 

  121. Swank HA, Mulder IM, la Chapelle CF, Reitsma JB, Lange JF, Bemelman WA. Systematic review of trocar-site hernia. Br J Surg. 2012;99(3):315–23.

    Article  CAS  PubMed  Google Scholar 

  122. Yamamoto M, Minikel L, Zaritsky E. Laparoscopic 5-mm trocar site herniation and literature review. JSLS. 2011;15(1):122–6.

    Article  PubMed  PubMed Central  Google Scholar 

  123. Karampinis I, Lion E, Grilli M, Hetjens S, Weiss C, Vassilev G, Seyfried S, Otto M. Trocar site hernias in bariatric surgery-an underestimated issue: a qualitative systematic review and meta-analysis. Obes Surg. 2019;29(3):1049–57.

    Article  PubMed  Google Scholar 

  124. Gutierrez M, Stuparich M, Behbehani S, Nahas S. Does closure of fascia, type, and location of trocar influence occurrence of port site hernias? A literature review. Surg Endosc. 2020;34(12):5250–8.

    Article  PubMed  Google Scholar 

  125. Connell MB, Selvam R, Patel SV. Incidence of incisional hernias following single-incision versus traditional laparoscopic surgery: a meta-analysis. Hernia. 2019;23(1):91–100.

    Article  CAS  PubMed  Google Scholar 

  126. Lyu Y, Cheng Y, Wang B, Zhao S, Chen L. Single-incision versus conventional multiport laparoscopic cholecystectomy: a current meta-analysis of randomized controlled trials. Surg Endosc. 2020;34(10):4315–29.

    Article  PubMed  Google Scholar 

Download references


Not applicable.


No funding sources to disclose.

Author information

Authors and Affiliations



SF, LC, PF, and LA wrote the draft of the manuscript. Pavia Organizational Group provided initial draft (CNF, JP, SZ, JV, MT, TD, EC). All authors reviewed and approved the manuscript.

Corresponding author

Correspondence to Simone Frassini.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Frassini, S., Cobianchi, L., Fugazzola, P. et al. ECLAPTE: Effective Closure of LAParoTomy in Emergency—2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings. World J Emerg Surg 18, 42 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: