Peritoneal closure versus no peritoneal closure for patients undergoing non-obstetric abdominal operations

There is no consensus regarding whether the peritoneum should be closed or left open during non-obstetric operations involving laparotomy. Neither is there consensus about the method of closure of the peritoneum (continuous suture versus interrupted suture). If closing the peritoneum could be omitted without complications, or even with benefit for patients, this could result in reductions in the cost of abdominal operations by reducing both the number of sutures used and the operating time.

To compare the benefits and harms of parietal peritoneal closure compared with no parietal peritoneal closure in patients undergoing non-obstetric abdominal operations.

In Februrary 2013 we searched the The Cochrane Wounds Group Specialised Register (searched 14 February 2013); The Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1); The Database of Abstracts of Reviews of Effects (2013, Issue 1); Ovid MEDLINE (1946 to February Week 1, 2013); Ovid EMBASE (1974 to 2013 Week 06); and EBSCO CINAHL 1982 to 8 February 2013).

We included only randomised controlled trials (RCTs) comparing peritoneal closure with no peritoneal closure in patients (adults and children) undergoing non-obstetric abdominal operations. All relevant RCTs irrespective of language, publication status, publication year, or sample size were included in the analysis.

Two review authors independently identified trials and extracted data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for comparing the binary outcomes between the groups, and mean difference (MD) with 95% CI for comparing the continuous outcomes. We performed the meta-analysis using both a fixed-effect model and a random-effects model. Intention-to-treat analysis was performed whenever possible.

Five trials involving 836 participants randomised to peritoneal closure (410 participants) and no peritoneal closure (426 participants) were included in this review. All the trials were at high risk of bias. All the trials included participants undergoing laparotomy (open surgery). Four of the five trials used catgut or chromic catgut for peritoneal closure. Three trials involved vertical incisions and two trials involved transverse incisions. None of the trials reported 30-day mortality. There was no significant difference in the one-year mortality between the two groups (RR 1.11; 95% CI 0.56 to 2.19) in the only trial that reported this outcome. The only serious peri-operative adverse event reported was burst abdomen, which was reported by three trials. Overall, 10/663 (1.5%) of participants developed burst abdomen. There was no significant difference in the proportion of participants who developed burst abdomen between the two groups (RR 0.71; 95% CI 0.22 to 2.35). The same three trials reported the proportion of participants who developed incisional hernia. Details of the follow-up period were only available for one trial, and so we were unable to calculate the incidence rate. Overall, 17/663 (2.5%) of participants developed incisional hernia. There was no significant difference in the proportion of participants who developed incisional hernia between the two groups (RR 0.92; 95% CI 0.37 to 2.28). None of the trials reported quality of life; the incidence rate of, or proportion of participants who developed, intestinal obstruction due to adhesions; or re-operation due to incisional hernia or adhesions. Only one trial reported the length of hospital stay, and this trial did not include readmissions in its calculations. There was no significant difference in the length of hospital stay between the two groups (MD 0.40 days; 95% CI -0.51 to 1.31).

There is no evidence for any short-term or long-term advantage in peritoneal closure for non-obstetric operations. If further trials are performed on this topic, they should have an adequate period of follow-up and adequate measures should be taken to ensure that the results are not subject to bias.