For they Know not What They do… Surgeons and Surgical Sutures

Incisional Hernia (IH) formation is the complication in abdominal surgery most often requiring re-operation and has a considerable medical and socio-economic impact. Efforts to reduce IH incidence have mainly focused on suture material and suture technique in the last 50 years and have to be judged as ineffective. This review has its focus on the surgeon as an underestimated risk factor for IH formation and the effects of inadequate suture tension on the sutured tissue and the dynamics of suture tension. Surgeons are not able to control suture tension and tend to apply high suture tension when asked to repeatedly knot sutures with identical suture tension. High suture tension leads to a significant reduction of tissue perfusion of the abdominal wall in animal experiments and impaired tissue perfusion is a risk factor for IH formation. Fascial sutures in the abdominal wall show a spontaneous loss of suture tension of 50 % in vivo in animals under anesthesia for 24 hours and a complete loss of suture tension if an elevated intra-abdominal pressure is applied to simulate abdominal distension and muscular activity. Further research to solve the problem of IH formation has to focus on the surgeon with the aim to define a tissue-specific suture tension optimum. The complexity of the problems requires the cooperation of surgeons and technical engineers