Table 2 Statements summary

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)

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

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

1.1 Continuous suturing versus interrupted sutures

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)

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)

1.3 Mass closure versus single-layer 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)

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)

1.5 Small bites technique versus large bites 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)

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)

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)

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)

2.4 Sutures impregnated with antibiotics

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)

3. Suture needles and retention suture

3.1 Is there a role for retention sutures when closing a laparotomy in emergency settings?

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

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

3.2 Is there any difference using blunt tapered needle or sharp needle in closing abdominal wall after 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

4. Perioperative care

4.1/4.2 Wound irrigation in emergency laparotomy closure

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)

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)

4.3 Subcutaneous drains in 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)

4.4/4.5 Leaving skin open after midline laparotomy—delayed laparotomy closure

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)

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

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

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

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)

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

5. Prophylactic mesh augmentation

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

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)

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

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)

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)

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

6.1/6.2 Trocar size and type

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)

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

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)

6.4/6.5 Single incision laparoscopic surgery and incisional hernia

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

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