Vijayalakshmi

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

PREVENT BURST ABDOMEN AND INCISIONAL HERNIA IN
MIDLINE LAPORATOMY EMERGENCY ABDOMINAL
SURGERIES”
DISSERTATION SUBMITTED TO
THE TAMIL NADU DR.MGR MEDICAL UNIVERSITY, TAMILNADU
IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE
DEGREE OF
MASTER OF SURGERY
IN
GENERAL SURGERY
DEPARTMENT OF GENERAL SURGERY
GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL
COLLEGE HOSPITAL, SALEM
Year : 2018-2021
GOVERNMENT MOHAN KUMARAMANGALAM
MEDICAL COLLEGE, SALEM
DECLARATION BY THE CANDIDATE
I solemnly declare that this dissertation“A PROSPECTIVE

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

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

Place : Salem Prof.Dr. K.KESAVALINGAM, M.S.,
Professor of General Surgery
GMKMCH, Salem, Tamil Nadu.
ENDORSEMENT BY THE HEAD OF DEPARTMENT

This is to certify that this dissertation entitled “A PROSPECTIVE
LAPORATOMY EMERGENCY ABDOMINAL SURGERIES” IN
COLLEGE HOSPITAL, SALEM is a bonafide and genuine work done by
Dr.C.VIJAYALAKSHMI under the overall guidance and supervision of
Prof.Dr.K.VIJAYAKUMAR M.S., Professor, and Head, Department of
General Surgery, Government Mohan Kumaramangalam Medical College
Hospital, in partial fulfillment of the requirement for the degree of M.S in
General Surgery, examination to be held in May 2021.
Date : Signature and Seal of the Prof & HOD

Place : Salem Prof.Dr. K.VIJAYAKUMAR, M.S.,
Professor and HOD of General Surgery
GMKMCH, Salem, Tamil Nadu.
ENDORSEMENT BY THE DEAN OF THE INSTITUTION

This is to certify that this dissertation titled “A PROSPECTIVE
LAPORATOMY EMERGENCY ABDOMINAL SURGERIES” IN
COLLEGE HOSPITAL, SALEM is a bonafide work done by DrC.
VIJAYALAKSHMI under the guidance and supervision of Prof. Dr. K.
VIJAYAKUMAR M.S., Professor and Head, Department of General Surgery,
Government Mohan Kumaramangalam Medical College Hospital, in partial
fulfillment of the requirement for the degree of M.S in General Surgery,
examination to be held in 2021.
Date :
Place : Salem
Signature and Seal of the Dean
DEAN
Government Mohan Kumaramangalam
Medical College Hospital,
Salem,Tamilnadu, India.
COPYRIGHT
I hereby declare that the Government Mohan
Kumaramangalam Medical College Hospital, Salem, Tamilnadu,India,
shall have the rights to preserve, use and disseminate this dissertation /
thesis in print or electronic format for academic / research purpose.
Signature of the Candidate

Place: Salem Dr.C.VIJAYALAKSHMI
ACKNOWLEDGEMENT
I am extremely thankful to Prof.Dr.R.BALAJINATHAN M.D., Dean,
Govt. Mohan Kumaramangalam Medical College and Hospital, Salem for
allowing me to utilize the hospital facilities for doing this work.
I am also thankful to Prof.Dr.P.V.DHANAPAL,M.S., Medical
Superintendent,Govt.Mohan Kumaramangalam Medical College Hospital,
Salem for his whole hearted support and encouragement for the completion of
this dissertation.
I express my deep sense of gratitude and indebtedness to
Prof.Dr.K.VIJAYAKUMAR,M.S., Head of the Department of General
Surgery, for giving me inspiration, valuable guidance and his unstinting help
in completing the thesis.
I express my deep sense of gratitude and indebtedness to
Prof.Dr.K.KESAVALINGAM ,M.S., Unit chief and Guide, Professor of
Department of General Surgery, for giving me inspiration, valuable guidance
and his unstinting help in completing the thesis.
I thank all surgical unit chiefs Prof.Dr.G.RAJASHOK,M.S.,
Prof.Dr.P.SUMATHI,M.S.,DGO., Prof.Dr.M.RAJASEKAR,.M.S., and
Associate Professors Dr.R.Ravi M.S., and
Dr.M.ARULKUMARAN,M.S.,DA., for their advice and kind help.
I also thank my registrar Dr.R.Swaminathan M.S.,who guided me
to success this study.

It is my privileged duty to profusely thank my assistant professors
DrS.S.MEERA ,M.S.,Dr.T.KARTHIKEYAN ,M.S., DR.A.VIJAY
ANAND ,M.S., Dr.D.VINOTHKMAR ,M.S., who helped and
guided me in many aspects of this study.
I take this opportunity to thank my senior PG’s
DR. TAMILSELVAN M.S., DR.VENKATESHWAR , DR. SRI
PRIYADARSHAN who despite of my shortcoming were eager to teach me. I
thank my colleague
DR.PRASANNA VENKATESH and I thank my junior PG’s
DR.SENTHILKUMAR, DR.THIRUMOORTHY, DR.RAJENDRAN,
DR.ELANCHEZHIAN and my other post graduate colleagues and my house
surgeons who shared majority of my duties so that I could complete this study
with ease.
I cordially thank my parents, my family and friends who have always
been there with me whenever I needed their help and cooperation.
I am deeply obliged to my patients, without whose help the present
study would not have been possible.
DR. C. VIJAYALAKSHMI
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rtify that this dissertation work titled “A PROSPECTIVE
LAPORATOMY EMERGENCY ABDOMINAL SURGERIES” of the
candidate Dr. C.VIJAYALAKSHMI with registration Number
221811411 for the award of M.S DEGREE in the branch of
GENERAL SURGERY - I personally verified the urkund.com
website for the purpose of plagiarism Check. I found that the
uploaded thesis file contains from introduction to conclusion
pages and result shows 9% percentage of plagiarism in the
dissertation.
Guide & Supervisor sign with Seal.

INDEX
S.No Contents Page Number
1 Introduction 1
2 Aim of the study 6
3 Objectives of the study 8
4 Review of Literature 10
5 Material and Methods 21
6 Results 26
7 Discussion 63
8 Summary and Conclusion 76
9 Limitations 80
10 Future Recommendations 82
11 Annexures 84
Abstract
Background
The incidence of incisional hernias varies between open surgeries and
laparoscopic surgeries. A number of studies have been done to ascertain
the best method of closing the abdominal wall; however, it is still
inconclusive. There are studies that suggest that non absorbable sutures
reduce the risk of recurrence and incisional hernia incidence.
Aim and Objective
This study aimed to compare the efficacy of Hughes Abdominal repair
with conventional abdominal closure in midline emergenc abdominal
surgeries and to reduce the incidence of Incisional Hernias.
Material and Methods
A Prospective Comparative study was done among 100 patients planned
for emergency Laparotomy each 50 divided non-randomly in to two
groups from November 2018 to December 2020. The 50 cases of
emergency laparotomy were chosen non randomly and allocated for
Hughes Abdominal Repair. The 50 cases of emergency / elective
laparotomy were chosen non randomly and allocated for conventional
repair. All patients were discharged after suture removal on 10th post-
operative day and 15th post-operative day and monthly follow up to 1

year. Both groups are followed monthly for a period of one year and the
after second year and incidence of incisional hernia in both groups
documented and tabulated. CT abdomen taken at one year and at second
year and any defect was documented. All data were recorded in structured
questionnaires, coded and entered in Microsoft Excel. The data was
analysed using SPSS v23. Student’s t-test was used for comparison.
Results and Conclusions
The mean age of the participants in Hughes repair group is 54.02 years
with a standard deviation of 8.9 years. The mean age of the participants in
conventional repair group is 56 years with a standard deviation of 12.1
years. Among all the cases, majority of them were males (n=77, 77%).
Rest of them were females (n=23, 23%). In the Hughes repair group,
majority of them have hollow viscous perforation (n=10, 20%). In the
conventional repair group, majority of them have hollow viscous
perforation (n=10, 20%). The mean duration of hospital stay in Hughes
repair is 10. 5 days (S.D=2.09 days). The mean duration of hospital stay
in conventional repair is 11. 3 days (S.D=3.02 days). Chi-square analysis
of wound complications shows that the incidence of complications are
higher in the Conventional repair group that is statistically significant
(p<0.05). Chi-square analysis of overall complications shows that the
incidence of complications are higher in the Conventional repair group

that is statistically significant (p<0.05). Hughes Repair (n=1): Only one
incisional hernia was noted first in 11th month. Conventional Repair
(n=4): Incisional hernias were noted in 6th, 8th, 9th and 12th month CT
scan. In the first year; Hughes Repair (n=1): Only one defect was found
but in Conventional Repair (n=3): three defects were found Chi-square
analysis of wound defects shows that the incidence of defects are higher
in the Conventional repair group that is statistically significant (p<0.05).
CT scan in 2nd year showed no defects in both the groups

INTRODUCTION
1
Introduction
Incisional hernias are clinically defined as the gaps in the
abdominal walls in places of postoperative scars. They are found during
clinical examination or imaging1,2. These are the most common
postoperative complications after major abdominal surgery where a
midline closure was done. It impairs quality of life3 and also leads to
higher medical expenses4. The conventional method of abdominal closure
is by closing all the layers of the abdominal wall, a technique of mass
closure using nonabsorbable or slow-resorbing sutures5. The incidence of
incisional hernias vary between open surgeries and laparoscopic
surgeries.
In open surgeries, it varies from 8.6% to 33% whereas in
laparoscopic surgeries, it ranges between 4.7% and 24.3%6-9. The repair
of incisional hernias is not 100% successful. The repair is done either
through sutures or mesh repairs. The recurrence rate of suture repair is 12
to 54% whereas for mesh repair is 2 to 36%10,11. Apart from recurrence,
there are also serious complications of bowel obstruction, chronic pain
and enterocutaneous fistula.
There are a number of factors leading to the development of incisional
hernias;
2
a) Diabetes Mellitus12
b) Obesity13
c) Cachexia14
d) Age >45 years
e) Males15
f) COPD16
g) Post-menopausal women17
h) Anemia
i) History of abdominal aortic aneurysm18
j) Smoking
k) Corticosteroids19
Most of the aforementioned factors are non-modifiable, hence beyond
the control of the surgeon. This explains why there is a need for
developing a good surgical technique that offsets all technical weaknesses
in repairing abdominal wall defects.
A number of studies have been done to ascertain the best method of
closing the abdominal wall, however, it is still inconclusive. There are
studies that suggest that non absorbable sutures reduce the risk of
recurrence and incisional hernia incidence20,21.On the other hand, there
are studies that show that absorbable sutures are of lower risk22. These
differences can be attributed to the methodological variations in various

3
trials, patient selection, type of surgeries, expertise of the surgical team,
etc. Lower sample sizes were also a major reason for incomplete
reporting.
There are two noteworthy trials in this aspect;
The STITCH trial- a multicentric trial reported a lower incidence
of incisional hernias in small-bite than large bite23.
Another ongoing trial CONTINT is being done to compare
interrupted sutures with continuous sutures while closing midline
incisions in emergency laparotomy24.
Hughes Repair
It is also called as ‘far-and-near’ repair or ‘Cardiff repair25’. It was
developed by Professor Leslie Hughes26. This repair combines a standard
mass closure (two loop 1-PDS sutures) with a series of horizontal and two
vertical mattress sutures within a single suture (1 Nylon). This distributes
the load along the width and length of the incision.
Following principles underlie this;
• Use only sound normal tissues for repair that is ascertained through
palpation
4
• For easy approximation, use graduated tension
• Create a pulley system through monofilament nylon suture that
slips through the tissues27
Studies show that Hughes repair is more effective than conventional
repair28. This technique is used for patients who are at a higher risk of
developing incisional hernias post laparostomy and total abdominal
wound dehiscence29.
This study aimed to compare the efficacy of Hughes Abdominal
repair with conventional Abdominal closure in midline emergency
abdominal surgeries and to reduce the incidence of Incisional Hernias.
5
AIM OF THE
STUDY
6
Aim of the Study
• To compare the efficacy of Hughes Abdominal repair with
conventional Abdominal closure in midline emergency abdominal
surgeries
• To reduce the incidence of Incisional Hernias
7
OBJECTIVES
OF THE STUDY
8
Objectives of the study
Primary Objective
• To compare the efficacy of Hughes Abdominal repair with
conventional Abdominal closure in midline emergency abdominal
surgeries
Secondary Objective
• To study the incidence of incisional hernias
• To reduce the incidence of incisional hernias
9
REVIEW OF
LITERATURE
10
Review of literature
Overview of the anatomy of abdomen
The abdominal wall covers the abdominal cavity and protects the inner
organs. It has the following boundaries;
a) Superior margins
Xiphoid process and costal cartilages
b) Inferiorly
Pelvic bones and Inguinal Ligament
c) Posteriorly
Vertebral column
Image 1: Abdominal cavity and its relations to other cavities
11
Quadrants and regions of the abdomen
It is divided into nine regions and four quadrants;
Regions;
a) Epigastric region
b) Umbilical region
c) Hypogastric region
d) Right lumbar region
e) Left lumbar region
f) Right iliac region
g) Left iliac region
h) Right hypochondriac region
i) Left hypochondriac region
Image 2: Quadrants and regions of the abdomen

Quadrants;
a) Right upper quadrant
b) Left upper quadrant
c) Right lower quadrant
d) Left lower quadrant
12
Internal organs
Abdominal cavity has a large number of organs in situ
Image 3: Abdominal organs
Abdominal Wall
It is divided into two sections;
a) Posterior wall
b) Anterolateral wall
From superficial to deep;
1) Skin
2) Superficial fascia
3) Muscles
4) Transversalis fascia
5) Extra peritoneal fat
6) Peritoneum
13
Image 4: Layers of the abdominal wall
Muscles of the anterior abdominal wall
a) Transversus abdominis muscle
b) Internal abdominal oblique
c) Rectus abdominis
d) External abdominal oblique
e) Pyramidalis
14
Image 5: Muscles of the anterior abdominal wall
Muscles of the posterior abdominal wall
a) Psoas major
b) Psoas minor
c) Iliacus
d) Quadratus lumborum
15
Image 6: Muscles of the posterior abdominal wall
Neurovasculature of the abdominal wall
Superficial branches
- Musculophrenic arteries
- Superficial Epigastric arteries
Deep branches
- Superior Epigastric ateries
- Inferior Epigastric arteries
- Intercostal arteries
- Subcostal arteries
16
Image 7: Vascular supply of the abdominal wall
17
Common abdominal incisions
1) Midline
2) Paramedian
3) Kocher
4) Rooftop
5) Mercedes Benz
18
Incisional hernias are clinically defined as the gaps in the abdominal
walls in places of postoperative scars. They are found during clinical
examination or imaging1,2. These are the most common postoperative
complications after major abdominal surgery where a midline closure was
done. It impairs quality of life3 and also leads to higher medical
expenses4. The conventional method of abdominal closure is by closing
all the layers of the abdominal wall, a technique of mass closure using
nonabsorbable or slow-resorbing sutures5. The incidence of incisional
hernias vary between open surgeries and laparoscopic surgeries.
In open surgeries, it varies from 8.6% to 33% whereas in laparoscopic
surgeries, it ranges between 4.7% and 24.3%6-9. The repair of incisional
hernias is not 100% successful. The repair is done either through sutures
or mesh repairs. The recurrence rate of suture repair is 12 to 54% whereas
for mesh repair is 2 to 36%10,11. Apart from recurrence, there are also
serious complications of bowel obstruction, chronic pain and
enterocutaneous fistula.
19
reporting.
wound dehiscence29.
with conventional Abdominal closure in midline emergency abdominal
20
MATERIALS AND
METHODS
21
MATERIALS AND METHODS
STUDY DESIGN
A Prospective Comparative study
STUDY POPULATION
The material for the study is taken from the cases admitted in all the
surgical ward of the Department of General surgery, GMK Medical
College & Hospital, who are planned for emergency Laparotomy
STUDY PERIOD
From NOVEMBER 2018 and DECEMBER 2020
SAMPLE SIZE
100
This study includes 100 patients planned for emergency laparotomy each
50 divided non-randomly in to two groups.
INCLUSION CRITERIA
1. Patients giving informed consent
2. Patients aged above 18 years
3. Midline emergency laporatomy incisions of more than 6 cms
22
EXCLUSION CRITERIA
1. Patients below 18 years
2. Patients not willing and not in sound mind to give consent
3. Mesh repairs
METHODOLOGY
1) Patients were selected from the department of surgery
2) They were recruited after ascertaining their inclusion criteria
3) The 50 cases of emergency laparotomy were chosen non randomly
and allocated for Hughes Abdominal Repair
4) The 50 cases of emergency laparotomy were chosen non randomly
and allocated for conventional repair
Group A Abdomen closed by Hughes abdominal repair
Group B conventional abdominal closure done
5) Both are already proven safe methods for subjects.
6) All patients were discharged after suture removal on 10th post-
operative day and 15th post-operative day and monthly follow up
to 1 year
7) Both groups are followed monthly for a period of one year and the
documented and tabulated.
23
8) CT abdomen taken at one year and at second year and any defect,
documented.
Diagram showing the Hughes closure method using a combination of
conventional closure with series of horizontal and two vertical
mattress sutures within a single suture
When the sutures are pulled to close the defect, the sutures lie
both across and along the incision.
24
PRIVACY/CONFIDENTIALITY OF STUDY SUBJECTS:
Privacy of the subjects shall be maintained.
STATISTICAL ANALYSIS
All data were recorded in structured questionnaires, coded and
entered in Microsoft Excel. The data was then cleaned, checked for
inconsistencies, missing values and prepared for analysis using SPSS
v23. The data was then analyzed for descriptive statistics and inferential
statistics. The tests for significance were run to statistically validate the
data. Student’s t-test was used for comparison.
The results were then tabulated and visualized in Microsoft word.
25
RESULTS
26
Results
The 50 cases of emergency laparotomy were chosen non randomly
and allocated for Hughes Abdominal Repair. The 50 cases of emergency
year and any defect, documented.
The mean age of all the participants is 55 years with a standard
deviation of 10.7 years. The median age is 56 years ranging between 29
and 74 years. The mean age of the participants in Hughes repair group is
54.02 years with a standard deviation of 8.9 years. The median age is 55
years ranging between 36 and 71 years. The mean age of the participants
in conventional repair group is 56 years with a standard deviation of 12.1
years. The median age is 58.5 years ranging between 29 and 74 years.
27
Among all the cases, majority of them were males (n=77, 77%).
Rest of them were females (n=23, 23%). In the Hughes repair, 38 of
them are males and 12 are females. In the conventional repair, 39 of them
are males and 11 are females. In the Hughes repair group, majority of
them have hollow viscous perforation (n=10, 20%). In the conventional
repair group, majority of them have hollow viscous perforation (n=10,
20%).
In all the cases, emergency laparotomy was done. The mean
duration of hospital stay in Hughes repair is 10. 5 days (S.D=2.09 days).
The median duration is 10 days. The range is between 10 and 21 days.
The mean duration of hospital stay in conventional repair is 11. 3 days
(S.D=3.02 days). The median duration is 10 days. The range is between
10 and 22 days. Student t-test shows that the two groups do not differ
significantly in the duration of hospital stay (p> 0.05).
Analysis shows that; in the Hughes repair group 47 of them (94%)
did not have any complications. Out of the remaining three patients, two
of them (4%) had wound dehiscence while one of them (2%) had wound
discharge. Analysis shows that; in the conventional repair group 40 of
them (80%) did not have any complications. Out of the remaining ten
patients, two of them (4%) had wound gaping, wound dehiscence was
present in 10% (n=5) of cases while three of them (6%) had wound
28
discharge. Chi-square analysis of wound complications shows that the
that is statistically significant (p<0.05). Chi-square analysis of overall
complications shows that the incidence of complications are higher in the
Conventional repair group that is statistically significant (p<0.05).
Hughes Repair (n=1): Only one incisional hernia was noted first in
11th month. Conventional Repair (n=4): Incisional hernias were noted in
6th, 8th, 9th and 12th month CT scan. In the first year; Hughes Repair
(n=1): Only one defect was found but in Conventional Repair (n=3): three
defects were found Chi-square analysis of wound defects shows that the
incidence of defects are higher in the Conventional repair group that is
statistically significant (p<0.05).
CT scan in 2nd year: No defects in both the groups
29
Findings
Age Distribution
and 74 years. The following table and figure shows the age distribution of
the participants.
S.No All Cases (N=100) Age (in years)
1 Mean 55.0100
2 Median 56.0000
3 Mode 52.00a
4 Std. Deviation 10.65956
5 Minimum 29.00
6 Maximum 74.00
Table 1: Age Distribution of all the Participants
30
Figure 1: Age Distribution of all the Participants
31
The mean age of the participants in Hughes repair group is 54.02 years
with a standard deviation of 8.9 years. The median age is 55 years
ranging between 36 and 71 years.
S.No Hughes Repair (N=50) Age (in years)
1 Mean 54.02
2 Median 55.00
3 Mode 55
5 Minimum 36
6 Maximum 71
Table 2: Age Distribution of the Participants in the Hughes repair group
32
Figure 2: Age Distribution of the Participants in the Hughes repair group
33
The mean age of the participants in conventional repair group is 56
years with a standard deviation of 12.1 years. The median age is 58.5
years ranging between 29 and 74 years.
S.No Conventional repair (N=50) Age (in years)
1 Mean 56.00
2 Median 58.50
3 Mode 66
5 Minimum 29
6 Maximum 74
Table 3: Age Distribution of the Participants in the Conventional repair
group
34
Figure 3: Age Distribution of the Participants in the Conventional repair
group
35
Gender Distribution
are males and 11 are females.
S.No Gender (All cases) Frequency Percent
1 Male 77 77
2 Female 23 23
Total 100 100
Table 4: Gender Distribution among all cases
Gender (All cases)
Female
23%
Male
77%
Figure 4: Gender Distribution among all cases
36
S.No Gender (Hughes Repair) Frequency Percent
1 Female 12 24
2 Male 38 76
Total 50 100
Table 5: Gender Distribution among Hughes repair
Gender (Hughes Repair)
Female
24%
Male
76%
Figure 5: Gender Distribution among Hughes repair
37
S.No Gender (Conventional Frequency Percent
Repair)
1 Female 11 22
2 Male 39 78
Total 50 100
Table 6: Gender Distribution among conventional repair
Gender (Conventional Repair)
Female
22%
Male
78%
Figure 6: Gender Distribution among conventional repair
38
Comparison of gender distribution among the two groups
In the Hughes repair, 38 of them are males and 12 are females.
In the conventional repair, 39 of them are males and 11 are females.
Female Male Total Chi-square
analysis
Gender 12 38 50 3.53
(Hughes p> 0.05
Repair)
Gender 11 39 50 Not
(Conventional Significant
Repair)
Total 23 77 100
Table 7: Comparison of Gender Distribution among two groups
39
45
40
35
30
25
Female
Male
20
15
10
0
Gender (Hughes Repair) Gender (Conventional Repair)
Figure 7: Comparison of Gender Distribution among two groups
40
Diagnosis
In the Hughes repair group, majority of them have hollow viscous
perforation (n=10, 20%).
Hughes Repair Frequency Percent
Acute intestinal obstruction 5 10.0

Acute mesentric ischemia 2 4.0
Adhesive intestinal obstruction 1 2.0
Appendicular perforation 1 2.0
Blunt injury abdomen 5 10.0
Caecal perforation 2 4.0
Carcinoma stomach 1 2.0
Duodenal perforation 6 12.0
gastric perforation 6 12.0
Hepatic flexure growth 1 2.0
Hollow viscus perforation 10 20.0
Ileal perforation 1 2.0
Ileocaecal growth 4 8.0
Jejunal perforation 1 2.0
Rectosigmiod growth 3 6.0
Stab injury abdomen 1 2.0
Total 50 100.0
Table 8: Diagnosis of Hughes Repair Group
41
Hughes Repair
12
10
4 Hughes Repair
Figure 8: Diagnosis of Hughes Repair Group
42
In the conventional repair group, majority of them have hollow viscous
perforation (n=10, 20%).
Conventional Repair Frequency Percent

Acute intestinal obstruction 9 18.0
Acute mesentric ischemia 2 4.0
Blunt injury abdomen 8 16.0
Bullgore injury 1 2.0
caecal perforation 1 2.0
Caecal volvulus 1 2.0
Duodenal perforation 5 10.0
Gastric antral perforation 5 10.0
Hollow viscus perforation 10 20.0
Perforative peritonitis 2 4.0
Rectosigmoid growth 1 2.0
small bowel obstruction 1 2.0
Spleenic flexure growth 1 2.0
Stab injury abdomen 3 6.0
Total 50 100.0
Table 9: Diagnosis of Conventional Repair Group
43
Conventional Repair
12
10
4 Conventional Repair
Figure 9: Diagnosis of Conventional Repair Group
44
Procedure done
In all the cases, emergency laparotomy was done.
Emergency laparotomy Total
Gender (Hughes 50 50
Repair)
Gender (Conventional 50 50
Repair)
Total 100 100
Table 10: Procedure done
60
50
40
30 Hughes Repair
Conventional Repair
20
10
0
Emergency Laparotomy
Figure10: Procedure done
45
Duration of hospital stay
The mean duration of hospital stay in Hughes repair is 10. 5 days
10 and 21 days.
S.No Hughes Repair (N=50) Duration of hospital stay (in
days)
1 Mean
10.50
2 Median
10.00
3 Mode
10
4 Std. Deviation
2.092
5 Minimum
10
6 Maximum
21
Table 11: Duration of hospital stay (Hughes Repair Group)
46
Figure 11: Duration of hospital stay (Hughes Repair Group)
47
10 and 22 days.
S.No Conventional repair (N=50) Duration of hospital stay (in
days)
1 Mean 11.32
2 Median 10.00
3 Mode 10
5 Minimum 10
6 Maximum 22
Table 12: Duration of hospital stay (Conventional Repair Group)
48
Figure 12: Duration of hospital stay (Conventional Repair Group)
49
The mean duration of hospital stay in Hughes repair is 10. 5 days
10 and 21 days.
10 and 22 days.
S.No Duration of hospital Hughes Repair Conventional
stay (in days) (N=50) repair (N=50)
1 Mean 11.32
10.50
2 Median 10.00
10.00
3 Mode 10
10
2.092
5 Minimum 10
10
6 Maximum 22
21
Table 13: Comparison of duration of hospital stay between the two
groups
50
11.4
11.2
11
10.8
Hughes Repair (N=50)

Conventional repair (N=50)
10.6
10.4
10.2
10
Mean Duration of hospital stay (in days)
Figure 13: Comparison of duration of hospital stay between the two
groups
51
Comparison of duration of hospital stay
Student t-test shows that the two groups do not differ significantly in the
duration of hospital stay (p> 0.05).
S.No Duration of hospital Hughes Repair Conventional
stay (in days) (N=50) repair (N=50)
1 Mean 11.32
10.50
2.092
T-test p-value >0.05
Interpretation The two groups do not significantly
differ in the duration of hospital stay
Table 14: Comparison of duration of hospital stay between the two
groups using T-test
52
Wound Complications
Analysis shows that;
In the Hughes repair group 47 of them (94%) did not have any
complications.
Out of the remaining three patients, two of them (4%) had wound
dehiscence while one of them (2%) had wound discharge.
S.No Hughes Repair Frequency Percent
1 No Complications 47 94
2 Wound Dehiscence 2 4
3 Wound Discharge 1 2
Total 50 100
Table 15: Wound Complications in the Hughes Repair group
53
Hughes Repair
50
45
40
35
30
25
Hughes Repair
20
15
10
0
No Complications Wound Dehiscence Wound Discharge
Figure 14: Wound Complications in the Hughes Repair group
54
Analysis shows that;
In the conventional repair group 40 of them (80%) did not have any
complications.
Out of the remaining ten patients, two of them (4%) had wound gaping,
wound dehiscence was present in 10% (n=5) of cases while three of them
(6%) had wound discharge.
S.No Conventional Repair Frequency Percent
1 No Complications 40 80
2 Wound Dehiscence 5 10
3 Wound Discharge 3 6
4 Wound Gaping 2 4
Total 50 100
Table 16: Wound Complications in the Conventional Repair group
55
Conventional Repair
45
40
35
30
25
20 Conventional Repair
15
10
0
No Complications Wound Wound Discharge Wound Gaping
Dehiscence
Figure 15: Wound Complications in the Conventional Repair group
56
Comparison of wound complications
Chi-square analysis of wound complications shows that the incidence of
complications are higher in the Conventional repair group that is
Wound Complications
Yes No Total Chi-square
analysis
Hughes Repair 3 47 50 4.76
Conventional 10 40 50 P< 0.05
Repair
Statistically
Significant
Total 13 87 100
Table 17: Comparison of wound complications
57
50
45
40
35
30
25 Yes
No
20
15
10
0
Hughes Repair Conventional Repair
Figure 16: Comparison of wound complications
58
Complications
Chi-square analysis of overall complications shows that the incidence of
complications are higher in the Conventional repair group that is
Hughes Repair (n=1): Only one incisional hernia in 11th month
Conventional Repair (n=4): Incisional hernias in 6th, 8th, 9th and 12th
Overall Complications in
24 months
analysis
Repair
Statistically
Significant
Total 5 95 100
Table 18: Comparison of overall complications
59
60
50
40
30 Yes
No
20
10
0
Figure17: Comparison of overall complications
60
CT Scan findings
CT scan in 1st year
In the first year;
Hughes Repair (n=1): Only one defect was found
Conventional Repair (n=3): three defects were found
Chi-square analysis of wound defects shows that the incidence of defects
are higher in the Conventional repair group that is statistically significant
(p<0.05).
CT Scan in 1st year
(Defects)
analysis
Repair
Statistically
Significant
Total 4 96 100
Table 19: CT scan in first year
61
60
50
40
30 Yes
No
20
10
0
Figure 18: CT scan in first year
62
DISCUSSION
63
Discussion
Incisional hernias are clinically defined as the gaps in the
abdominal walls in places of postoperative scars. They are found during
clinical examination or imaging1,2. These are the most common
postoperative complications after major abdominal surgery where a
midline closure was done. It impairs quality of life3 and also leads to
higher medical expenses4. The conventional method of abdominal closure
is by closing all the layers of the abdominal wall, a technique of mass
closure using nonabsorbable or slow-resorbing sutures5. The incidence of
incisional hernias vary between open surgeries and laparoscopic
surgeries.
In open surgeries, it varies from 8.6% to 33% whereas in
laparoscopic surgeries, it ranges between 4.7% and 24.3%6-9. The repair
of incisional hernias is not 100% successful. The repair is done either
through sutures or mesh repairs. The recurrence rate of suture repair is 12
to 54% whereas for mesh repair is 2 to 36%10,11. Apart from recurrence,
there are also serious complications of bowel obstruction, chronic pain
and enterocutaneous fistula.
There are a number of factors leading to the development of incisional
hernias;
64
• Diabetes Mellitus12
• Obesity13
• Cachexia14
• Age >45 years
• Males15
• COPD16
• Post-menopausal women17
• Anemia
• History of abdominal aortic aneurysm18
• Smoking
• Corticosteroids19
Most of the aforementioned factors are non-modifiable, hence beyond
the control of the surgeon. This explains why there is a need for
developing a good surgical technique that offsets all technical weaknesses
in repairing abdominal wall defects.
65
reporting.
There are two noteworthy trials in this aspect;
The STITCH trial- a multicentric trial reported a lower incidence
of incisional hernias in small-bite than large bite23. Another ongoing trial
CONTINT is being done to compare interrupted sutures with continuous
sutures while closing midline incisions in emergency laparotomy24.
Hughes repair is also called as ‘far-and-near’ repair or ‘Cardiff
repair25’. It was developed by Professor Leslie Hughes26. This repair
combines a standard mass closure (two loop 1-PDS sutures) with a series
of horizontal and two vertical mattress sutures within a single suture (1
Nylon). This distributes the load along the width and length of the
incision.
Following principles underlie this;
• Use only sound normal tissues for repair that is ascertained through
palpation
• For easy approximation, use graduated tension
66
• Create a pulley system through monofilament nylon suture that
slips through the tissues27
wound dehiscence29.
67
Among all the cases, majority of them were males (n=77, 77%). Rest
of them were females (n=23, 23%). In the Hughes repair, 38 of them are
males and 12 are females. In the conventional repair, 39 of them are
males and 11 are females. In the Hughes repair group, majority of them
have hollow viscous perforation (n=10, 20%). In the conventional repair
group, majority of them have hollow viscous perforation (n=10, 20%).
In all the cases, emergency laparotomy was done. The mean duration
of hospital stay in Hughes repair is 10. 5 days (S.D=2.09 days). The
median duration is 10 days. The range is between 10 and 21 days. The
mean duration of hospital stay in conventional repair is 11. 3 days
68
Analysis shows that; in the Hughes repair group 47 of them (94%) did
not have any complications. Out of the remaining three patients, two of
them (4%) had wound dehiscence while one of them (2%) had wound
6th, 8th, 9th and 12th month CT scan.
In the first year; Hughes Repair (n=1): Only one defect was found but
in
69
Conventional Repair (n=3): three defects were found Chi-square analysis
of wound defects shows that the incidence of defects are higher in the
70
INTRAOPERATIVE PICTURES
Picture 1 Hughes Abdominal Repair
71
72
73
Pocture 4 Hughes Abdominal Repair
74
75
SUMMARY
AND
CONCLUSION
76
Summary and conclusions
77
are males and 11 are females. In the Hughes repair group, majority of
them have hollow viscous perforation (n=10, 20%). In the conventional
repair group, majority of them have hollow viscous perforation (n=10,
20%).
In all the cases, emergency laparotomy was done. The mean
duration of hospital stay in Hughes repair is 10. 5 days (S.D=2.09 days).
The median duration is 10 days. The range is between 10 and 21 days.
Analysis shows that; in the Hughes repair group 47 of them (94%)
did not have any complications. Out of the remaining three patients, two
of them (4%) had wound dehiscence while one of them (2%) had wound
78
6th, 8th, 9th and 12th month CT scan.
In the first year; Hughes Repair (n=1): Only one defect was found
but in
Conventional Repair (n=3): three defects were found. Chi-square analysis
of wound defects shows that the incidence of defects are higher in the
79
LIMITATIONS
80
Limitations
Following are the limitations of the study;
a) The study is a single centric study
b) Smaller sample size affects the generalizability of the findings
81
FUTURE
RECOMMENDATIONS
82
Future recommendations
Following are the future directions;
a) Multicentric studies must be conducted to help get a better
perspective
b) Larger sample size must be recruited to better generalizability of
findings
c) Randomised control trial is best suited for studies like this
83
ANNEXURES
84
REFERENCES
85
References
1. Korenkov M, Paul A, Sauerland S, et al. Classification and surgical
treatment of incisional hernia. Results of an experts’ meeting.
Langenbecks Arch Surg. 2001;386(1):65–73.
2. Muysoms FE, Miserez M, Berrevoet F, et al. Classification of
primary and incisional abdominal wall hernias. Hernia.
2009;13(4):407–14.
3. van Ramshorst GH, Eker HH, Hop WC, et al. Impact of incisional
hernia on health-related quality of life and body image: a
prospective cohort study. Am J Surg. 2012;204(2):144–50.
4. Burger JW, Luijendijk RW, Hop WC, et al. Long-term follow-up
of a randomized controlled trial of suture versus mesh repair of
incisional hernia. Ann Surg. 2004;240(4):578–83.
5. Sajid MS, Parampalli U, Baig MK, McFall MR. A systematic
review on the effectiveness of slowly-absorbable versus non-
absorbable sutures for abdominal fascial closure following
laparotomy. Int J Surg. 2011;9(8):615–25.
6. Braga M, Frasson M, Vignali A, et al. Laparoscopic vs. open
colectomy in cancer patients: long-term complications, quality of
life, and survival. Dis Colon Rectum. 2005;48(12):2217–23.
86
7. Kuhry E, Schwenk W, Gaupset R, et al. Long-term outcome of
laparoscopic surgery for colorectal cancer: a Cochrane systematic
review of randomised controlled trials. Cancer Treat Rev.
2008;34(6):498–504.
8. Skipworth JR, Khan Y, Motson RW, et al. Incisional hernia rates
following laparoscopic colorectal resection. Int J Surg.
2010;8(6):470–3.
9. Winslow ER, Fleshman JW, Birnbaum EH, Brunt LM. Wound
complications of laparoscopic vs open colectomy. Surg Endosc.
2002;16(10):1420–5.
10.Diener MK, Voss S, Jensen K, et al. Elective midline laparotomy
closure: the INLINE systematic review and meta-analysis. Ann
Surg. 2010;251(5):843–56.
11.van’t Riet M, Steyerberg EW, Nellensteyn J, et al. Meta-analysis of
techniques for closure of midline abdominal incisions. Br J Surg.
2002;89(11):1350–6.
12.Franchi M, Ghezzi F, Buttarelli M, et al. Incisional hernia in
gynecologic oncology patients: a 10-year study. Obstet Gynecol.
2001;97(5 pt 1):696–700.
13.Hoer J, Lawong G, Klinge U, Schumpelick V. Factors influencing
the development of incisional hernia. A retrospective study of
87
2,983 laparotomy patients over a period of 10 years. Chirurg.
2002;73(5):474–80.
14.Mäkelä JT, Kiviniemi H, Juvonen T, Laitinen S. Factors
influencing wound dehiscence after midline laparotomy. Am J
Surg. 1995;170(4):387–90.
15.Sørensen LT, Hemmingsen UB, Kirkeby LT, et al. Smoking is a
risk factor for incisional hernia. Arch Surg. 2005;140(2):119–23.
16.Adell-Carceller R, Segarra-Soria MA, Pellicer-Castell V, et al.
Incisional hernia in colorectal cancer surgery. Associated risk
factors. Cir Esp. 2006;79(1):42–5.
17.Colombo M, Maggioni A, Parma G, et al. A randomized
comparison of continuous versus interrupted mass closure of
midline incisions in patients with gynecologic cancer. Obstet
Gynecol. 1997;89(5 pt 1):684–9.
18.Adye B, Luna G. Incidence of abdominal wall hernia in aortic
surgery. Am J Surg. 1998;175(5):400–2.
19.Junge K, Klinge U, Klosterhalfen B, et al. Review of wound
healing with reference to an unrepairable abdominal hernia. Eur J
Surg. 2002;168(2):67–73.
88
20.Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal
method of abdominal fascial closure: a meta-analysis. Ann Surg.
2000;231(3):436–42.
21.Weiland DE, Bay RC, Del Sordi S. Choosing the best abdominal
closure by meta-analysis. Am J Surg. 1998;176(6):666–70.
22.Diener MK, Voss S, Jensen K, et al. Elective midline laparotomy
closure: the INLINE systematic review and meta-analysis. Ann
Surg. 2010;251(5):843–56.
23.Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites
versus large bites for closure of abdominal midline incisions
(STITCH): a double-blind, multicentre, randomised controlled
trial. Lancet. 2015.
24.Rahbari NN, Knebel P, Kieser M, et al. Design and current status
of CONTINT: continuous versus interrupted abdominal wall
closure after emergency midline laparotomy— a randomized
controlled multicenter trial [NCT00544583]. Trials. 2012;13:72.
25.Shukla VK, Gupta A, Singh H, et al. Cardiff repair of incisional
hernia: a university hospital experience. Eur J Surg.
1998;164(4):271–4.
89
26.Hughes BR, Webster D. Leslie Ernest Hughes – Obituary. BMJ.
2011;343.
27.Mudge M, Harding KG, Hughes LE. Incisional hernia. Br J Surg.
1986;73(1):82.
28.Godara R, Garg P, Shankar G. Comparative evaluation of Cardiff
repair and mesh plasty in incisional hernias. Internet J Surg
[Internet]. 2007;9:about 8 p.
29.Malik R, Scott NA. Double near and far prolene suture closure: a
technique for abdominal wall closure after laparostomy. Br J Surg.
2001;88(1):146–7.
90
PATIENT CONSENT
FORM
91
PATIENT CONSENT FORM
STUDY TITLE:
“A Prospective comparative study of conventional Abdominal closure

with Hughes Abdominal repair to prevent Burst abdomen and
Incisional Hernia in Midline laporatomy emergency abdominal
surgeries, GMKMCH,SALEM ”
Department of General surgery, GMKMCH
PARTICIPANT NAME : AGE : SEX: I.P. NO :

I confirm that I have understood the purpose of surgical/invasive procedure for the
above study. I have the opportunity to ask the question and all my questions and
doubts have been answered to my satisfaction.
I have been explained about the possible complications that may occur during
and after medical/ surgical procedure. I understand that my participation in the study
is voluntary and that I am free to withdraw at any time without giving any reason.
I understand that investigator, regulatory authorities and the ethics committee
will not need my permission to look at my health records both in respect to the current
study and any further research that may be conducted in relation to it, even if I
withdraw from the study. I understand that my identity will not be revealed in any
information released to third parties or published, unless as required under the law. I
agree not to restrict the use of any data or results that arise from the study. I agree to
take photographs of my abdominal incisions and suture lines for research purpose.
I hereby consent to participate in this study for various surgical/invasive
procedures and their outcomes.
Time :
Date : Signature / Thumb Impression Of Patient
Place :
Patient’s name:
Signature of the investigator:______________________
Name of the investigator : _____________________
92
PROFORMA
93
“A Prospective comparative study of conventional Abdominal closure
with Hughes Abdominal repair to prevent Burst abdomen and
Incisional Hernia in Midline laporatomy emergency abdominal
surgeries, GMKMCH,SALEM ”
”
PROFORMA
A.
Name:
Address:
Age/sex:
RELIGION:
O.PNo:
I.P No:
D.O.A:
DATE OF OPERATION:
D.O.D:
B. CHIEF COMPLAINTS:
Duration of symptoms:
C.PAST HISTORY:
1. DM : Yes/ No
2. TB: Yes/ No
3. EPILEPSY
4. MALARIA
5. PREVIOUS SURGERY
6. JAUNDICE
7. CIRRHOSIS
94
D.PERSONAL HISTORY:
SMOKER
ALCOHOLIC
E.INITIAL ASSESSMENT OF PATIENT

1.Vitals:
PR :
BP :
RR :
Temperature :
2.GENERAL SIGNS:
Pallor
Tongue
Skin
Icterus
Cyanosis
Lymphadenopathy:
K.SYSTEMIC EXAMINATION:
CVS
RS
CNS
Abdomen:
LOCAL EXAMINATION :
CLINICAL DIAGNOSIS
INVESTIGATIONS
A. HB%
B. GROUPING & TYPING
95
C. BT/CT
D. PC
E. HIV
F. ECG
G. URINE:
Albumin
Sugar
H. BLOOD:
RBS
BLOOD UREA
SER.CREATININE
I. CHEST XRAY PA VIEW
J. USG Abdomen
K. C T Abdomen
PRE-OPERATIVE DIAGNOSIS:
OPERATIVE PROCEDURE:
METHOD OF ABDOMINAL CLOSURE DONE :
POST- OPERATIVE PERIOD / COMPLICATIONS:
CT ABDOMEN IN ONE YEAR:
RESULT :
96
MASTER CHART
97
GROUP A (Hughes Repair)
s n a s p Diag Pro w da m m m m m m m m m m m m 2 C C
. ame g e t. nosis cedur ound ys of o o o o o o o o o o on o n T T
n e x i e com hosp nt nt nt nt nt nt nt nt nt nt th nt d 1 2
o d done plica ital h h h h h h h h h h 11 h y
. tions stay 1 2 3 4 5 6 7 8 9 1 1 ea
0 2 r
1 E 3 M 5 Duo Em nil 10 n n
swa 9 2 denal ergen - - - - - - - - - - - - - o o
ran 6 perforat cy d d
7 ion lapar e e
otom f f
y e e
c c
t t
2 P 4 M 5 Holl Em nil 10 n n
alan 2 7 ow ergen - - - - - - - - - - - - - o o
iya 8 viscus cy d d
ppa 9 perforat lapar e e
n ion otom f f
y e e
c c
t t
3 K 5 F 5 gastr Em nil 10 n n
ann 7 8 ic ergen - - - - - - - - - - - - - o o
am 0 perforat cy d d
mal 1 ion lapar e e
otom f f
y e e
c c
t t
4 G 3 M 6 Appe Em nil 10 n n
ovi 8 0 ndicula ergen - - - - - - - - - - - - - o o
nth 2 r cy d d
an 1 perforat lapar e e
ion otom f f
y e e
c c
t t
5 K 4 M 6 Acut Em nil 10 n n
um 3 0 e ergen - - - - - - - - - - - - - o o
ar 4 intestin cy d d
3 al lapar e e
obstruc otom f f
tion y e e
c c
t t
6 v 5 F 6 Caec Em w 21 D N
ela 1 4 al ergen ound - - - - - - - - - - - - - e A
mm 3 perforat cy dehis f
al 2 ion lapar cenc e
otom e c
y t
7 A 4 M 6 Rect Em nil 10 n n
lage 9 4 osigmi ergen - - - - - - - - - - - - - o o
san 5 od cy d d
9 growth lapar e e
otom f f
y e e
c c
t t
8 A 5 M 6 Ileoc Em nil 10 n n
run 5 5 aecal ergen - - - - - - - - - - - - - o o
ach 1 growth cy d d
ala 3 lapar e e
m otom f f
y e e
c c
t t
9 u 5 M 6 Holl Em nil 10 n n
day 4 5 ow ergen - - - - - - - - - - - - - o o
apa 4 viscus cy d d
gou 5 perforat lapar e e
nde ion otom f f
r y e e
c c
t t
98
1 K 5 F 6 Hepa Em nil 10 n n
0 aru 7 5 tic ergen - - - - - - - - - - - - - o o
ppa 7 flexure cy d d
yee 8 growth lapar e e
otom f f
y e e
c c
t t
1 K 5 F 6 Duo Em nil 10 n n
1 ana 2 6 denal ergen - - - - - - - - - - - - - o o
ga 5 perforat cy d d
7 ion lapar e e
otom f f
y e e
c c
t t
1 A 5 F 6 Rect Em nil 10 n n
2 riva 6 6 osigmi ergen - - - - - - - - - - - - - o o
lagi 7 od cy d d
5 growth lapar e e
otom f f
y e e
c c
t t
1 R 4 M 6 gastr Em nil 10 n n
3 ajas 6 6 ic ergen - - - - - - - - - - - - - o o
eka 7 perforat cy d d
r 8 ion lapar e e
otom f f
y e e
c c
t t
1 K 5 M 6 Holl Em nil 10 n n
4 um 2 6 ow ergen - - - - - - - - - - - - - o o
ares 9 viscus cy d d
ion otom f f
y e e
c c
t t
1 N 4 M 7 Blun Em nil 10 n n
5 ates 9 2 t injury ergen - - - - - - - - - - - - - o o
am 1 abdome cy d d
oort 3 n lapar e e
hy otom f f
y e e
c c
t t
1 C 5 M 7 Acut Em nil 10 n n
6 hak 6 3 e ergen - - - - - - - - - - - - - o o
kar 4 intestin cy d d
ava 2 al lapar e e
rthy obstruc otom f f
tion y e e
c c
t t
1 A 5 F 7 Ileoc Em W 15 I N N
7 lam 4 5 aecal ergen ound - - - - - - - - - - nc - - A A
elu 6 growth cy disch isi
6 lapar arge on
otom al
y he
rn
ia
1 C 5 F 7 Acut Em nil 10 n n
8 hell 3 6 e ergen - - - - - - - - - - - - - o o
atha 7 mesentr cy d d
yee 6 ic lapar e e
ischemi otom f f
a y e e
c c
t t
1 M 5 M 7 Carci Em nil 10 n n
9 oort 7 7 noma ergen - - - - - - - - - - - - - o o
hy 5 stomac cy d d
4 h lapar e e
otom f f
y e e
c c
99
t t
2 M 4 M 7 Holl Em nil 10 n n
0 ahe 6 6 ow ergen - - - - - - - - - - - - - o o
ndr 8 viscus cy d d
ion otom f f
y e e
c c
t t
2 G 3 F 6 Duo Em nil 10 n n
1 om 7 1 denal ergen - - - - - - - - - - - - - o o
athi 2 perforat cy d d
3 ion lapar e e
otom f f
y e e
c c
t t
2 R 5 M 6 Ileoc Em nil 10 n n
2 ajen 0 9 aecal ergen - - - - - - - - - - - - - o o
dra 8 growth cy d d
n 7 lapar e e
otom f f
y e e
c c
t t
2 R 3 F 6 Holl Em nil 10 n n
3 adh 6 5 ow ergen - - - - - - - - - - - - - o o
a 4 viscus cy d d
3 perforat lapar e e
ion otom f f
y e e
c c
t t
2 M 5 M 6 Acut Em nil 10 n n
4 ariy 0 7 e ergen - - - - - - - - - - - - - o o
app 8 intestin cy d d
an 9 al lapar e e
obstruc otom f f
tion y e e
c c
t t
2 M 6 M 7 Blun Em nil 10 n n
5 ani 0 6 t injury ergen - - - - - - - - - - - - - o o
kka 7 abdome cy d d
m 8 n lapar e e
otom f f
y e e
c c
t t
2 B 5 M 7 Ileal Em nil 10 n n
6 alu 2 8 perforat ergen - - - - - - - - - - - - - o o
6 ion cy d d
7 lapar e e
otom f f
y e e
c c
t t
2 L 5 M 7 gastr Em nil 10 n n
7 ax 6 8 ic ergen - - - - - - - - - - - - - o o
ma 9 perforat cy d d
nan 8 ion lapar e e
otom f f
y e e
c c
t t
2 R 6 M 5 Holl Em nil 10 n n
8 agu 0 6 ow ergen - - - - - - - - - - - - - o o
var 7 viscus cy d d
ion otom f f
y e e
c c
t t
2 M 5 M 5 Adhe Em nil 10 n n
9 ayil 9 5 sive ergen - - - - - - - - - - - - - o o
vag 6 intestin cy d d
ana 8 al lapar e e
100
m obstruc otom f f
tion y e e
c c
t t
2 V 5 M 6 Acut Em nil 10 n n
8 enk 8 3 e ergen - - - - - - - - - - - - - o o
ates 2 intestin cy d d
h 1 al lapar e e
obstruc otom f f
tion y e e
c c
t t
3 D 5 M 6 Blun Em nil 10 n n
1 har 5 6 t injury ergen - - - - - - - - - - - - - o o
mal 7 abdome cy d d
ing 6 n lapar e e
am otom f f
y e e
c c
t t
3 I 5 M 7 Jejun Em w 19 n n
2 yya 8 6 al ergen ound - - - - - - - - - - - - - o o
pan 9 perforat cy dehis d d
6 ion lapar cenc e e
otom e f f
y e e
c c
t t
3 T 6 M 2 gastr em nil 10 n n
3 hul 8 4 ic ergen - - - - - - - - - - - - - o o
asin 5 perforat cy d d
ga 6 ion lapar e e
m 7 otom f f
y e e
c c
t t
3 P 6 M 2 Holl Em nil 1 n n
4 and 4 6 ow ergen O - - - - - - - - - - - - - o o
ura 7 viscus cy d d
nga 5 perforat lapar e e
n 8 ion otom f f
y e e
c c
t t
3 A 5 F 3 Ileoc Em nil 10 n n
5 njal 3 4 aecal ergen - - - - - - - - - - - - - o o
ai 5 growth cy d d
5 lapar e e
2 otom f f
y e e
c c
t t
3 K 5 M 2 Duo Em nil 10 n n
6 aru 5 8 denal ergen - - - - - - - - - - - - - o o
pan 9 perforat cy d d
nan 0 ion lapar e e
0 otom f f
y e e
c c
t t
3 L 6 M 3 Stab Em nil 10 n n
7 oga 7 4 injury ergen - - - - - - - - - - - - - o o
nat 1 abdome cy d d
han 5 n lapar e e
6 otom f f
y e e
c c
t t
3 M 4 M 4 Blun Em nil 10 n n
8 oha 7 5 t injury ergen - - - - - - - - - - - - - o o
n 6 abdome cy d d
2 n lapar e e
1 otom f f
y e e
c c
t t
101
3 M 4 F 4 Rect Em nil 10 n n
9 adh 8 5 osigmi ergen - - - - - - - - - - - - - o o
am 4 od cy d d
mal 4 growth lapar e e
5 otom f f
y e e
c c
t t
4 P 6 M 5 gastr Em nil 10 n n
0 ara 8 5 ic ergen - - - - - - - - - - - - - o o
mas 6 perforat cy d d
iva 7 ion lapar e e
m 8 otom f f
y e e
c c
t t
4 C 7 M 6 Holl Em nil 10 n n
1 hell 1 2 ow ergen - - - - - - - - - - - - - o o
apa 3 viscus cy d d
n 4 perforat lapar e e
1 ion otom f f
y e e
c c
t t
4 K 6 M 4 Duo Em nil 10 n n
2 rish 6 5 denal ergen - - - - - - - - - - - - - o o
na 6 perforat cy d d
mo 7 ion lapar e e
orth 3 otom f f
y y e e
c c
t t
4 N 6 M 5 gastr Em nil 10 D N
3 achi 5 5 ic ergen - - - - - - - - - - - - - e A
yap 6 perforat cy f
an 7 ion lapar e
6 otom c
y t
4 G 6 M 6 Acut Em nil 10 n n
4 uru 7 5 e ergen - - - - - - - - - - - - - o o
mo 2 intestin cy d d
orth 4 al lapar e e
y 1 obstruc otom f f
tion y e e
c c
t t
4 S 6 F 6 Caec Em nil 10 n n
5 aroj 9 7 al ergen - - - - - - - - - - - - - o o
a 6 perforat cy d d
8 ion lapar e e
5 otom f f
y e e
c c
t t
4 S 5 M 6 Holl Em nil 10 n n
6 ada 9 6 ow ergen - - - - - - - - - - - - - o o
yan 0 viscus cy d d
1 ion otom f f
y e e
c c
t t
4 A 5 M 5 Holl Em nil 10 n n
7 mm 5 9 ow ergen - - - - - - - - - - - - - o o
asi 8 viscus cy d d
4 ion otom f f
y e e
c c
t t
4 R 4 M 4 Blun Em nil 10 n n
8 ajes 8 5 t injury ergen - - - - - - - - - - - - - o o
h 3 abdome cy d d
5 n lapar e e
6 otom f f
y e e
c c
t t
102
4 G 5 M 4 Duo Em nil 10 n n
9 opa 8 0 denal ergen - - - - - - - - - - - - - o o
lan 0 perforat cy d d
9 ion lapar e e
8 otom f f
y e e
c c
t t
5 S 3 M 6 Acut Em nil 10 n n
0 elva 6 7 e ergen - - - - - - - - - - - - - o o
ku 6 mesentr cy d d
mar 7 ic lapar e e
7 ischemi otom f f
a y e e
c c
t t
GROUP B ( CONVENTIONAL REPAIR)
s n a s p Dia Pro w da m m m m m m m m m m m m 2 c c
. ame g e t. gnosis cedur ound ys of o o o o o o o o o o o o n t t
n e x i e com hosp n n n n n nt n nt nt nt nt nt d 1 2
o d Done plica ital t t t t t h t h h h h h y
. tions stay h h h h h 6 h 8 9 1 1 1 e
1 2 3 4 5 7 0 1 2 ar
1 k 5 M 1 Gas Em Nil 10 n n
ann 2 4 tric ergen - - - - - - - - - - - - - o o
an 3 antral cy d d
2 perfor Lapor e e
4 ation atom f f
y e e
c c
t t
2 v 6 M 1 cae Em W 18 I N N N N N
eera 6 2 cal ergen ound - - - - - - - nc A A N A N A A
man 6 perfor cy dehi isi A A
i 7 ation Lapor cenc o
4 atom e na
y l
he
rn
ia
3 Ja 4 M 2 sma Em Nil 11 n n
yara 5 1 ll ergen - - - - - - - - - - - - - o o
man 2 bowel cy d d
45 2 obstru Lapor e e
3 ction atom f f
y e e
c c
t t
4 T 6 M 1 Blu Em W 21 n n
hya 4 9 nt ergen ound - - - - - - - - - - - - - o o
gara 0 injury cy gapi d d
jan 8 abdo Lapor ng e e
7 men atom f f
y e e
c c
t t
5 R 5 M 2 Gas Em Nil 10 n n
ajar 2 3 tric ergen - - - - - - - - - - - - - o o
am 0 antral cy d d
9 perfor Lapor e e
8 ation atom f f
y e e
c c
t t
6 Ja 5 M 2 Acu Em Nil 10 n n
yara 7 1 te ergen - - - - - - - - - - - - - o o
ju 4 intesti cy d d
103
5 nal Lapor e e
6 obstrc atom f f
tion y e e
c c
t t
7 R 6 M 2 Blu Em Nil 10 n n
aju 1 0 nt ergen - - - - - - - - - - - - - o o
0 injury cy d d
2 abdo Lapor e e
1 men atom f f
y e e
c c
t t
8 G 5 F 2 Duo Em W 19 D N
oma 5 3 denal ergen ound - - - - - - - - - - - - - e A
thi 4 perfor cy dehi f
1 ation Lapor cenc e
2 atom e c
y t
9 D 7 M 2 Holl Em Nil 10 n n
urai 3 6 ow ergen - - - - - - - - - - - - - o o
sam 5 viscus cy d d
y 4 perfor Lapor e e
3 ation atom f f
y e e
c c
t t
1 K 7 M 2 Acu Em Nil 10 n n
0 and 0 5 te ergen - - - - - - - - - - - - - o o
asa 4 intesti cy d d
my 1 nal Lapor e e
3 obstrc atom f f
tion y e e
c c
t t
1 K 6 M 2 Acu Em Nil 10 n n
1 ali 6 6 te ergen - - - - - - - - - - - - - o o
5 mese cy d d
6 ntric Lapor e e
5 ische atom f f
mia y e e
c c
t t
1 B 6 M 2 Duo Em Nil 10 n n
2 arat 0 7 denal ergen - - - - - - - - - - - - - o o
hy 5 perfor cy d d
4 ation Lapor e e
3 atom f f
y e e
c c
t t
1 S 5 M 2 Sta Em Nil 10 n n
3 eth 6 8 b ergen - - - - - - - - - - - - - o o
upat 6 injury cy d d
hi 7 abdo Lapor e e
5 men atom f f
y e e
c c
t t
1 N 6 M 2 Gas Em W 16 I N N N N N
4 ates 9 9 tric ergen ound - - - - - - - - nc N A A A A A
an 1 antral cy dehi isi A
0 perfor Lapor cenc o
8 ation atom e na
y l
he
rn
ia
-
1 G 5 M 2 Blu Em Nil 10 n n
5 ane 6 8 nt ergen - - - - - - - - - - - - - o o
san 9 injury cy d d
7 abdo Lapor e e
0 men atom f f
y e e
c c
t t
104
1 Ja 6 F 3 Acu Em Nil 10 n n
6 naki 2 4 te ergen - - - - - - - - - - - - - o o
2 intesti cy d d
1 nal Lapor e e
0 obstrc atom f f
tion y e e
c c
t t
1 K 7 F 3 Holl Em Nil 10 n n
7 ama 2 5 ow ergen - - - - - - - - - - - - - o o
tchi 0 viscus cy d d
1 perfor Lapor e e
2 ation atom f f
y e e
c c
t t
1 P 6 M 3 Acu Em Nil 10 n n
8 alan 6 6 te ergen - - - - - - - - - - - - - o o
ivel 1 intesti cy d d
0 nal Lapor e e
1 obstrc atom f f
tion y e e
c c
t t
1 S 6 M 3 Holl Em Nil 10 n n
9 atha 2 7 ow ergen - - - - - - - - - - - - - o o
siva 0 viscus cy d d
m 8 perfor Lapor e e
9 ation atom f f
y e e
c c
t t
2 Ja 5 F 3 Holl Em W 14 D N
0 naki 9 8 ow ergen ound - - - - - - - - - - - - - e A
0 viscus cy dehi f
8 perfor Lapor cenc e
9 ation atom e c
y t
2 K 6 F 3 Acu Em Nil 10 n n
1 ama 3 9 te ergen - - - - - - - - - - - - - o o
la 6 intesti cy d d
5 nal Lapor e e
4 obstrc atom f f
tion y e e
c c
t t
2 M 7 M 4 Blu Em Nil 10 n n
2 aniv 4 0 nt ergen - - - - - - - - - - - - - o o
el 1 injury cy d d
2 abdo Lapor e e
1 men atom f f
y e e
c c
t t
2 M 6 M 4 Holl Em Nil 10 n n
3 urug 9 1 ow ergen - - - - - - - - - - - - - o o
an 2 viscus cy d d
1 perfor Lapor e e
2 ation atom f f
y e e
c c
t t
2 A 4 M 4 Sta Em Nil 10 n n
4 rival 4 3 b ergen - - - - - - - - - - - - - o o
aga 1 injury cy d d
n 0 abdo Lapor e e
8 men atom f f
y e e
c c
t t
2 Si 6 M 4 Acu Em Nil 10 n n
5 vak 3 4 te ergen - - - - - - - - - - - - - o o
uma 5 intesti cy d d
r 6 nal Lapor e e
4 obstrc atom f f
tion y e e
c c
t t
105
2 P 6 M 4 Gas Em Nil 10 n n
6 ugal 2 5 tric ergen - - - - - - - - - - - - - o o
end 6 antral cy d d
hi 7 perfor Lapor e e
4 ation atom f f
y e e
c c
t t
2 D 4 M 4 Cae Em W 12 I N N N
7 urai 8 5 cal ergen ound - - - - - - - - - - - nc A A A
sam 9 volvul cy disch isi
y 1 us Lapor arge o
0 atom na
y l
he
rn
ia
2 S 5 M 4 Blu Em Nil 10 n n
8 ank 8 6 nt ergen - - - - - - - - - - - - - o o
ar 3 injury cy d d
2 abdo Lapor e e
1 men atom f f
y e e
c c
t t
2 V 6 M 4 Bull Em Nil 10 n n
9 enk 6 6 gore ergen - - - - - - - - - - - - - o o
atac 1 injury cy d d
hala 1 Lapor e e
m 0 atom f f
y e e
c c
t t
3 G 5 F 4 Acu Em Nil 10 n n
0 ovin 3 6 te ergen - - - - - - - - - - - - - o o
tha 7 intesti cy d d
mm 5 nal Lapor e e
al 6 obstrc atom f f
tion y e e
c c
t t
3 S 3 M 4 Spl Em Nil 10 n n
1 ubr 2 5 eenic ergen - - - - - - - - - - - - - o o
ama 0 flexur cy d d
ni 0 e Lapor e e
9 growt atom f f
h y e e
c c
t t
3 L 3 M 4 Duo Em Nil 10 n n
2 oga 9 6 denal ergen - - - - - - - - - - - - - o o
nath 8 perfor cy d d
an 8 ation Lapor e e
9 atom f f
y e e
c c
t t
3 M 4 F 4 Perf Em W 13 n n
3 ahe 4 6 orativ ergen ound - - - - - - - - - - - - - o o
swa 6 e cy disch d d
ri 7 perito Lapor arge e e
0 nitis atom f f
y e e
c c
t t
3 k 3 M 4 Acu Em Nil 10 n n
4 athi 3 6 te ergen - - - - - - - - - - - - - o o
resa 1 mese cy d d
n 2 ntric Lapor e e
1 ische atom f f
mia y e e
c c
t t
3 S 4 F 5 Holl Em Nil 10 n n
5 uma 0 0 ow ergen - - - - - - - - - - - - - o o
thy 0 viscus cy d d
1 perfor Lapor e e
2 ation atom f f
y e e
106
c c
t t
3 M 4 M 3 Blu Em Nil 10 n n
6 uth 5 0 nt ergen - - - - - - - - - - - - - o o
u 0 injury cy d d
9 abdo Lapor e e
8 men atom f f
y e e
c c
t t
3 A 5 M 5 Acu Em W 17 n n
7 nba 2 0 te ergen ound - - - - - - - - - - - - - o o
rasa 2 intesti cy gapi d d
n 3 nal Lapor ng e e
1 obstrc atom f f
tion y e e
c c
t t
3 K 6 F 5 Duo Em Nil 10 I N N N N N N N N
8 ulla 3 8 denal ergen - - - - - nc A N A A A A A A A
mm 7 perfor cy isi A
al 6 ation Lapor o
5 atom na
y l
he
rn
ia
9 arut 7 7 ow ergen - - - - - - - - - - - - - o o
ham 6 viscus cy d d
uth 7 perfor Lapor e e
u 8 ation atom f f
y e e
c c
t t
4 S 7 M 5 Rec Em Nil 10 n n
0 ada 4 8 tosig ergen - - - - - - - - - - - - - o o
gop 8 moid cy d d
an 8 growt Lapor e e
9 h atom f f
y e e
c c
t t
4 N 6 M 5 Blu Em Nil 10 n n
1 atar 6 8 nt ergen - - - - - - - - - - - - - o o
ajan 0 injury cy d d
9 abdo Lapor e e
0 men atom f f
y e e
c c
t t
4 M 5 M 5 Acu Em W 13 n n
2 oha 9 9 te ergen ound - - - - - - - - - - - - - o o
nas 0 intesti cy disch d d
und 8 nal Lapor arge e e
ara 6 obstrc atom f f
m tion y e e
c c
t t
4 T 6 F 5 Perf Em Nil 10 n n
3 hula 9 0 orativ ergen - - - - - - - - - - - - - o o
si 1 e cy d d
2 perito Lapor e e
3 nitis atom f f
y e e
c c
t t
4 K 4 M 5 Sta Em Nil 10 n n
4 aru 2 6 b ergen - - - - - - - - - - - - - o o
nag 7 injury cy d d
aran 8 abdo Lapor e e
9 men atom f f
y e e
c c
t t
107
5 ahe 4 0 ow ergen - - - - - - - - - - - - - o o
ndr 0 viscus cy d d
an 1 perfor Lapor e e
2 ation atom f f
y e e
c c
t t
4 Sr 2 M 6 Duo Em Nil 10 n n
6 idha 9 0 denal ergen - - - - - - - - - - - - - o o
r 4 perfor cy d d
5 ation Lapor e e
1 atom f f
y e e
c c
t t
4 K 4 F 6 Holl Em W 22 D N
7 uma 7 1 ow ergen ound - - - - - - - - - - - - - e A
ri 0 viscus cy dehi f
9 perfor Lapor cenc e
0 ation atom e c
y t
4 C 7 M 6 Holl Em Nil 10 n n
8 hith 2 1 ow ergen - - - - - - - - - - - - - o o
amb 9 viscus cy d d
ara 8 perfor Lapor e e
m 7 ation atom f f
y e e
c c
t t
4 K 4 M 6 Gas Em Nil 10 n n
9 ana 6 4 tric ergen - - - - - - - - - - - - - o o
gav 5 antral cy d d
el 3 perfor Lapor e e
2 ation atom f f
y e e
c c
t t
5 R 5 M 6 Blu Em Nil 10 n n
0 agu 4 5 nt ergen - - - - - - - - - - - - - o o
6 injury cy d d
5 abdo Lapor e e
4 men atom f f
y e e
c c
t t
108

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“A PROSPECTIVE COMPARATIVE STUDY OF CONVENTIONAL

ABDOMINAL CLOSURE WITH HUGHES ABDOMINAL REPAIR TO

THE TAMIL NADU DR.MGR MEDICAL UNIVERSITY, TAMILNADU

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

DEPARTMENT OF GENERAL SURGERY

GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL

COLLEGE HOSPITAL, SALEM

DECLARATION BY THE CANDIDATE

I solemnly declare that this dissertation“A PROSPECTIVE

Place : Salem Signature of the Candidate

CERTIFICATE BY THE GUIDE

This is to certify that this dissertation entitled “A

PROSPECTIVE COMPARATIVE STUDY OF CONVENTIONAL

ABDOMINAL CLOSURE WITH HUGHES ABDOMINAL REPAIR TO

PREVENT BURST ABDOMEN AND INCISIONAL HERNIA IN

MIDLINE LAPORATOMY EMERGENCY ABDOMINAL

SURGERIES" is a work done by Dr. C. VIJAYALAKSHMI under my

partial fulfilment of the award of M.S Degree in General Surgery, (Branch I)

examination to be held in May 2021 by Tamilnadu Dr.M.G.R Medical

University , Chennai – 32.

Date : Signature and seal of the Guide

ENDORSEMENT BY THE HEAD OF DEPARTMENT

Date : Signature and Seal of the Prof & HOD

ENDORSEMENT BY THE DEAN OF THE INSTITUTION

Kumaramangalam Medical College Hospital, Salem, Tamilnadu,India,

thesis in print or electronic format for academic / research purpose.

Signature of the Candidate

I am extremely thankful to Prof.Dr.R.BALAJINATHAN M.D., Dean,

Govt. Mohan Kumaramangalam Medical College and Hospital, Salem for

allowing me to utilize the hospital facilities for doing this work.

I am also thankful to Prof.Dr.P.V.DHANAPAL,M.S., Medical

Superintendent,Govt.Mohan Kumaramangalam Medical College Hospital,

I express my deep sense of gratitude and indebtedness to

Prof.Dr.K.VIJAYAKUMAR,M.S., Head of the Department of General

in completing the thesis.

I express my deep sense of gratitude and indebtedness to

Prof.Dr.K.KESAVALINGAM ,M.S., Unit chief and Guide, Professor of

Department of General Surgery, for giving me inspiration, valuable guidance

and his unstinting help in completing the thesis.

I thank all surgical unit chiefs Prof.Dr.G.RAJASHOK,M.S.,

Prof.Dr.P.SUMATHI,M.S.,DGO., Prof.Dr.M.RAJASEKAR,.M.S., and

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

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

I also thank my registrar Dr.R.Swaminathan M.S.,who guided me

to success this study.

DrS.S.MEERA ,M.S.,Dr.T.KARTHIKEYAN ,M.S., DR.A.VIJAY

ANAND ,M.S., Dr.D.VINOTHKMAR ,M.S., who helped and

guided me in many aspects of this study.

I take this opportunity to thank my senior PG’s

DR. TAMILSELVAN M.S., DR.VENKATESHWAR , DR. SRI

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

DR.PRASANNA VENKATESH and I thank my junior PG’s

DR.SENTHILKUMAR, DR.THIRUMOORTHY, DR.RAJENDRAN,

DR.ELANCHEZHIAN and my other post graduate colleagues and my house

I cordially thank my parents, my family and friends who have always

been there with me whenever I needed their help and cooperation.

I am deeply obliged to my patients, without whose help the present

study would not have been possible.

rtify that this dissertation work titled “A PROSPECTIVE

COMPARATIVE STUDY OF CONVENTIONAL ABDOMINAL

CLOSURE WITH HUGHES ABDOMINAL REPAIR TO PREVENT

BURST ABDOMEN AND INCISIONAL HERNIA IN MIDLINE

LAPORATOMY EMERGENCY ABDOMINAL SURGERIES” of the