Current practices and attitudes toward rectus sheath closure among surgeons: A cross-sectional study
Hanan M Shamrani1, Sarah Qari1
1Department of Obstetrics and Gynecology, King Abdul Aziz University, Jeddah, Saudi Arabia.
Background:
Rectus sheath closure is a modifiable factor for incisional hernia, wound dehiscence, and surgical site infection. Guidelines recommend continuous small-bites closure using a slowly absorbable monofilament suture with a suture to wound length (SL:WL) ratio of at least 4:1. However, few data are available from obstetrics and gynecology, which is the specialty with the largest number of abdominal closures worldwide.
Methods:
A cross-sectional survey was conducted among 58 surgeons with various levels of training and specialties to assess rectus sheath closure techniques, self-reported complications, and attitudes toward changing practice. Chi-square, Fisher's exact, and Mann-Whitney tests were used to compare professional levels. Predictors of complication occurrence were identified using logistic regression.
Results:
Most participants were obstetricians and gynecologists (84.48%) working in academic hospitals (72.41%). Only 5.17% achieved the recommended SL:WL ratio ≥4:1, whereas 29.31% reported a ratio of 1:1 and 18.97% adhered to no specific ratio. The mean bite size (0.87 cm) and inter-suture distance (0.98 cm) were approximately double the recommended standard of 5 mm. Two-thirds (67.24%) used both monofilament and braided sutures despite the recommendation to only use monofilament. Self-reported incidence of hernia (1.72%) was lower than prospective estimates (11-30%). Surgeons with 6-10 years of experience had significantly higher odds of reporting complications than those with >15 years (odds ratio = 33.54; 95% confidence interval = 1.42-1724.32; p = 0.041). Despite widespread non-compliance, 74.14% expressed high willingness to change their practice, and lack of training was identified as the primary barrier (36.21%).
Conclusion:
Surgeons, mainly obstetricians and gynecologists, significantly deviated from the recommended rectus sheath closure techniques. The high level of non-compliance and willingness to change suggested a lack of infrastructure and training, and structured educational interventions were identified as a priority target.