Incidence Of Incisional Hernia After Laparotomy
Abstract
Introduction: Incisional hernia is a common complication following laparotomy. We aim to estimate the incidence of incisional hernia during the 5 years post-laparotomy and, secondarily, to study the risk factors for its development.
Methods: We performed a retrospective cohort study in patients (age>18 years old) who were submitted to a laparotomy for general surgery procedures, between June 2015 and May 2018, in São João Hospital and University Centre. Variables analyzed, through univariate and multivariate analysis, included patients’ characteristics, surgical techniques employed and post-surgery complications. The statistical analysis was carried out with R studio and IBM SPSS version 29.0.
Results: The cumulative incidence of incisional hernia was 22.7% at 5 years, among the 1134 participants analyzed. In the multivariate analysis, we found that higher body mass index (OR 1.056; p=0.007), superficial (OR 3.001; p=0.024) and organ-space (OR 2.686; p=0.004) surgical site infection and wound dehiscence (OR 4.787; p<0.001) were independently associated with incisional hernia development. In contrast, transverse incision (OR 0.189; p=0.007) and layered closure of the abdominal (OR 0.503; p<0.001) were associated with a lower risk for incisional hernia, compared with midline incision and mass closure, respectively.
Conclusion: Elevated body mass index, surgical site infection and wound dehiscence seem to present as risk factors for incisional hernia, while the use of transverse incision and employing a layered closure of the abdominal wall are associated with a reduced incisional hernia occurrence. Efforts aimed at optimizing preoperative patients’ characteristics, surgical technique and implementation of effective infection prevention measures can play a crucial role in mitigating the high incidence of this complication post-laparotomy.
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References
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4. Chen-Xu J, Bessa-Melo R, Graça L, Costa-Maia J. Incisional hernia in hepatobiliary and pancreatic surgery: incidence and risk factors. Hernia: the journal of hernias and abdominal wall surgery. 2019; 23(1): 67–79. https://doi.org/10.1007/s10029-018-1847-4
5. Fischer JP, Basta MN, Mirzabeigi MN, Bauder AR, Fox JP, Drebin JA, et al. A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention. Annals of surgery. 2016; 263(5): 1010–1017. https://doi.org/10.1097/SLA.0000000000001394
6. Walming S, Angenete E, Block M, Bock D, Gessler B, Haglind E. Retrospective review of risk factors for surgical wound dehiscence and incisional hernia. BMC surgery. 2017; 17(1): 19. https://doi.org/10.1186/s12893-017-0207-0
7. Sørensen LT, Hemmingsen UB, Kirkeby LT, Kallehave F, Jørgensen LN. Smoking is a risk factor for incisional hernia. Archives of surgery (Chicago, Ill.: 1960). 2005; 140(2): 119–123. https://doi.org/10.1001/archsurg.140.2.119
8. Sanders DL, Pawlak MM, Simons MP, Aufenacker T, Balla A, Berger C, et al. Midline incisional hernia guidelines: the European Hernia Society. The British journal of surgery. 2023; 110(12): 1732–1768. https://doi.org/10.1093/bjs/znad284
9. Deerenberg EB, Henriksen NA, Antoniou GA, Antoniou SA, Bramer WM, Fischer JP, et al. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. The British journal of surgery. 2022; 109(12): 1239–1250. https://doi.org/10.1093/bjs/znac302
10. Wehrle CJ, Shukla P, Miller BT, Blake KE, Prabhu AS, Petro CC, et al. Incisional hernia rates following midline laparotomy in the obese patient: a retrospective review. Hernia: the journal of hernias and abdominal wall surgery. 2023; 27(3): 557–563. https://doi.org/10.1007/s10029-022-02688-6
11. Halm JA, Lip H, Schmitz PI, Jeekel, J. Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision. Hernia: the journal of hernias and abdominal wall surgery. 2009; 13(3): 275–280. https://doi.org/10.1007/s10029-008-0469-7
12. Bickenbach KA, Karanicolas PJ, Ammori JB, Jayaraman S, Winter JM, Fields RC. Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery. American journal of surgery. 2013; 206(3): 400–409. https://doi.org/10.1016/j.amjsurg.2012.11.008
13. Stabilini C, Garcia-Urena MA, Berrevoet F, Cuccurullo D, Capoccia Giovannini S, Dajko M, et al. An evidence map and synthesis review with meta-analysis on the risk of incisional hernia in colorectal surgery with standard closure. Hernia: the journal of hernias and abdominal wall surgery. 2022; 26(2): 411–436. https://doi.org/10.1007/s10029-021-02555-w
14. Henriksen NA, Deerenberg EB, Venclauskas L, Fortelny RH, Miserez M, Muysoms FE. Meta-analysis on Materials and Techniques for Laparotomy Closure: The MATCH Review. World journal of surgery. 2018; 42(6): 1666–1678. https://doi.org/10.1007/s00268-017-4393-9
15. Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. Annals of surgery. 2000; 231(3): 436–442. https://doi.org/10.1097/00000658-200003000-00018
16. van 't Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel, J. Meta-analysis of techniques for closure of midline abdominal incisions. The British journal of surgery. 2002; 89(11): 1350–1356. https://doi.org/10.1046/j.1365-2168.2002.02258.x
17. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Archives of surgery (Chicago, Ill.: 1960). 2009; 144(11): 1056–1059. https://doi.org/10.1001/archsurg.2009.189
18. Patel SV, Paskar DD, Nelson RL, Vedula SS, Steele SR. Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. The Cochrane database of systematic reviews. 2017 11(11): CD005661. https://doi.org/10.1002/14651858.CD005661.pub2
19. Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia: the journal of hernias and abdominal wall surgery. 2015; 19(1): 1–24. https://doi.org/10.1007/s10029-014-1342-5
20. Jairam AP, López-Cano M, Garcia-Alamino JM, Pereira JA, Timmermans L, Jeekel J, et al. Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis. BJS open. 2020; 4(3): 357–368. https://doi.org/10.1002/bjs5.50261
21. Tansawet A, Numthavaj P, Techapongsatorn S, Wilasrusmee C, Attia J, Thakkinstian A. Mesh position for hernia prophylaxis after midline laparotomy: A systematic review and network meta-analysis of randomized clinical trials. International journal of surgery (London, England). 2020; 83: 144–151. https://doi.org/10.1016/j.ijsu.2020.08.059
22. AbdelDayem AM, Nashed GA, Balamoun HA, Mostafa MS. Effectiveness of 3-Day Prophylactic Negative Pressure Wound Therapy on Closed Abdominal Incisions in the Prevention of Wound Complications: A Randomized Controlled Trial. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. 2023; 27(8): 1702–1709. https://doi.org/10.1007/s11605-023-05752-3
23. Wells CI, Ratnayake CBB, Perrin J, Pandanaboyana S. Prophylactic Negative Pressure Wound Therapy in Closed Abdominal Incisions: A Meta-analysis of Randomised Controlled Trials. World journal of surgery. 2019; 43(11): 2779–2788. https://doi.org/10.1007/s00268-019-05116-6
24. Schurtz E, Differding J, Jacobson E, Maki C, Ahmeti M. Evaluation of negative pressure wound therapy to closed laparotomy incisions in acute care surgery. American journal of surgery. 2018; 215(1): 113–115. https://doi.org/10.1016/j.amjsurg.2017.08.009
25. Bueno-Lledó J, Rubio-Pérez I, Moreno-Gijón M, Olona-Casas C, Barbosa E, Molina JM, et al. Prophylactic use of incisional negative pressure wound therapy for the prevention of surgical site occurrences in general surgery: Consensus document. Surgery. 2023; 173(4): 1052–1059. https://doi.org/10.1016/j.surg.2022.11.033
26. Gillion JF, Sanders D, Miserez M, Muysoms F. The economic burden of incisional ventral hernia repair: a multicentric cost analysis. Hernia: the journal of hernias and abdominal wall surgery. 2016; 20(6): 819–830. https://doi.org/10.1007/s10029-016-1480-z
27. van Ramshorst GH, Eker HH, Hop WC, Jeekel J, Lange JF. Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study. American journal of surgery.2012; 204(2): 144–150. https://doi.org/10.1016/j.amjsurg.2012.01.012
28. Conze J, Klinge U, Schumpelick V. Narbenhernien [Incisional hernia]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2005; 76(9): 897–910. https://doi.org/10.1007/s00104-005-1072-4
29. Altemeier WA, Burke JF, Pruitt BA, Sandusky WR. Manual on control of infection in surgical patients, 2nd edn. JB Lippincott, Philadelphia; 1984.
30. Goodenough CJ, Ko TC, Kao LS, Nguyen MT, Holihan JL, Alawadi Z, et al. Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project). Journal of the American College of Surgeons. 2015; 220(4): 405–413. https://doi.org/10.1016/j.jamcollsurg.2014.12.027
31. Xu Z, Qu H, Kanani G, Guo Z, Ren Y, Chen X. Update on risk factors of surgical site infection in colorectal cancer: a systematic review and meta-analysis. International journal of colorectal disease. 2020; 35(12): 2147–2156. https://doi.org/10.1007/s00384-020-03706-8
32. Grąt, M, Morawski M, Krasnodębski M, Borkowski J, Krawczyk P, Grąt K, et al. Incisional Surgical Site Infections After Mass and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a Randomized Controlled Trial. Annals of surgery. 2021; 274(5): 690–697. https://doi.org/10.1097/SLA.0000000000005128
33. Yılmaz KB, Akıncı M, Doğan L, Karaman N, Özaslan C, Atalay C. A prospective evaluation of the risk factors for development of wound dehiscence and incisional hernia. Ulusal cerrahi dergisi. 2013; 29(1): 25–30. https://doi.org/10.5152/UCD.2013.06
34. Murray BW, Cipher DJ, Pham T, Anthony T. The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery. American journal of surgery. 2011; 202(5): 558–560. https://doi.org/10.1016/j.amjsurg.2011.06.014
35. Itatsu K, Yokoyama Y, Sugawara G, Kubota H, Tojima Y, Kurumiya Y, et al. Incidence of and risk factors for incisional hernia after abdominal surgery. The British journal of surgery. 2014; 101(11): 1439–1447. https://doi.org/10.1002/bjs.9600
36. Justinger C, Moussavian MR, Schlueter C, Kopp B, Kollmar O, Schilling MK. Antibacterial [corrected] coating of abdominal closure sutures and wound infection. Surgery. 2009; 145(3): 330–334. https://doi.org/10.1016/j.surg.2008.11.007
37. van Ramshorst GH, Eker HH, van der Voet JA, Jeekel J, Lange JF. Long-term outcome study in patients with abdominal wound dehiscence: a comparative study on quality of life, body image, and incisional hernia. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. 2013; 17(8): 1477–1484. https://doi.org/10.1007/s11605-013-2233-2
38. González-Abós C, Pineda C, Arrocha C, Farguell J, Gil I, Ausania F. Incisional Hernia Following Open Pancreaticoduodenectomy: Incidence and Risk Factors at a Tertiary Care Centre. Current oncology (Toronto, Ont.). 2023; 30(8): 7089–7098. https://doi.org/10.3390/curroncol30080514
39. James K, Glasswell A, Costa B. Single-use negative pressure wound therapy versus conventional dressings for the reduction of surgical site infections in closed surgical incisions: Systematic literature review and meta-analysis. American journal of surgery. 2024; 228: 70–77. https://doi.org/10.1016/j.amjsurg.2023.10.031
2. Fink C, Baumann P, Wente MN, Knebel P, Bruckner T, Ulrich A, et al. Incisional hernia rate 3 years after midline laparotomy. The British journal of surgery. 2014; 101(2): 51–54. https://doi.org/10.1002/bjs.9364
3. Gignoux B, Bayon Y, Martin D, Phan R, Augusto V, Darnis B, et al. Incidence and risk factors for incisional hernia and recurrence: Retrospective analysis of the French national database. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland. 2021; 23(6): 1515–1523. https://doi.org/10.1111/codi.15581
4. Chen-Xu J, Bessa-Melo R, Graça L, Costa-Maia J. Incisional hernia in hepatobiliary and pancreatic surgery: incidence and risk factors. Hernia: the journal of hernias and abdominal wall surgery. 2019; 23(1): 67–79. https://doi.org/10.1007/s10029-018-1847-4
5. Fischer JP, Basta MN, Mirzabeigi MN, Bauder AR, Fox JP, Drebin JA, et al. A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention. Annals of surgery. 2016; 263(5): 1010–1017. https://doi.org/10.1097/SLA.0000000000001394
6. Walming S, Angenete E, Block M, Bock D, Gessler B, Haglind E. Retrospective review of risk factors for surgical wound dehiscence and incisional hernia. BMC surgery. 2017; 17(1): 19. https://doi.org/10.1186/s12893-017-0207-0
7. Sørensen LT, Hemmingsen UB, Kirkeby LT, Kallehave F, Jørgensen LN. Smoking is a risk factor for incisional hernia. Archives of surgery (Chicago, Ill.: 1960). 2005; 140(2): 119–123. https://doi.org/10.1001/archsurg.140.2.119
8. Sanders DL, Pawlak MM, Simons MP, Aufenacker T, Balla A, Berger C, et al. Midline incisional hernia guidelines: the European Hernia Society. The British journal of surgery. 2023; 110(12): 1732–1768. https://doi.org/10.1093/bjs/znad284
9. Deerenberg EB, Henriksen NA, Antoniou GA, Antoniou SA, Bramer WM, Fischer JP, et al. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. The British journal of surgery. 2022; 109(12): 1239–1250. https://doi.org/10.1093/bjs/znac302
10. Wehrle CJ, Shukla P, Miller BT, Blake KE, Prabhu AS, Petro CC, et al. Incisional hernia rates following midline laparotomy in the obese patient: a retrospective review. Hernia: the journal of hernias and abdominal wall surgery. 2023; 27(3): 557–563. https://doi.org/10.1007/s10029-022-02688-6
11. Halm JA, Lip H, Schmitz PI, Jeekel, J. Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision. Hernia: the journal of hernias and abdominal wall surgery. 2009; 13(3): 275–280. https://doi.org/10.1007/s10029-008-0469-7
12. Bickenbach KA, Karanicolas PJ, Ammori JB, Jayaraman S, Winter JM, Fields RC. Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery. American journal of surgery. 2013; 206(3): 400–409. https://doi.org/10.1016/j.amjsurg.2012.11.008
13. Stabilini C, Garcia-Urena MA, Berrevoet F, Cuccurullo D, Capoccia Giovannini S, Dajko M, et al. An evidence map and synthesis review with meta-analysis on the risk of incisional hernia in colorectal surgery with standard closure. Hernia: the journal of hernias and abdominal wall surgery. 2022; 26(2): 411–436. https://doi.org/10.1007/s10029-021-02555-w
14. Henriksen NA, Deerenberg EB, Venclauskas L, Fortelny RH, Miserez M, Muysoms FE. Meta-analysis on Materials and Techniques for Laparotomy Closure: The MATCH Review. World journal of surgery. 2018; 42(6): 1666–1678. https://doi.org/10.1007/s00268-017-4393-9
15. Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. Annals of surgery. 2000; 231(3): 436–442. https://doi.org/10.1097/00000658-200003000-00018
16. van 't Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel, J. Meta-analysis of techniques for closure of midline abdominal incisions. The British journal of surgery. 2002; 89(11): 1350–1356. https://doi.org/10.1046/j.1365-2168.2002.02258.x
17. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Archives of surgery (Chicago, Ill.: 1960). 2009; 144(11): 1056–1059. https://doi.org/10.1001/archsurg.2009.189
18. Patel SV, Paskar DD, Nelson RL, Vedula SS, Steele SR. Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. The Cochrane database of systematic reviews. 2017 11(11): CD005661. https://doi.org/10.1002/14651858.CD005661.pub2
19. Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia: the journal of hernias and abdominal wall surgery. 2015; 19(1): 1–24. https://doi.org/10.1007/s10029-014-1342-5
20. Jairam AP, López-Cano M, Garcia-Alamino JM, Pereira JA, Timmermans L, Jeekel J, et al. Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis. BJS open. 2020; 4(3): 357–368. https://doi.org/10.1002/bjs5.50261
21. Tansawet A, Numthavaj P, Techapongsatorn S, Wilasrusmee C, Attia J, Thakkinstian A. Mesh position for hernia prophylaxis after midline laparotomy: A systematic review and network meta-analysis of randomized clinical trials. International journal of surgery (London, England). 2020; 83: 144–151. https://doi.org/10.1016/j.ijsu.2020.08.059
22. AbdelDayem AM, Nashed GA, Balamoun HA, Mostafa MS. Effectiveness of 3-Day Prophylactic Negative Pressure Wound Therapy on Closed Abdominal Incisions in the Prevention of Wound Complications: A Randomized Controlled Trial. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. 2023; 27(8): 1702–1709. https://doi.org/10.1007/s11605-023-05752-3
23. Wells CI, Ratnayake CBB, Perrin J, Pandanaboyana S. Prophylactic Negative Pressure Wound Therapy in Closed Abdominal Incisions: A Meta-analysis of Randomised Controlled Trials. World journal of surgery. 2019; 43(11): 2779–2788. https://doi.org/10.1007/s00268-019-05116-6
24. Schurtz E, Differding J, Jacobson E, Maki C, Ahmeti M. Evaluation of negative pressure wound therapy to closed laparotomy incisions in acute care surgery. American journal of surgery. 2018; 215(1): 113–115. https://doi.org/10.1016/j.amjsurg.2017.08.009
25. Bueno-Lledó J, Rubio-Pérez I, Moreno-Gijón M, Olona-Casas C, Barbosa E, Molina JM, et al. Prophylactic use of incisional negative pressure wound therapy for the prevention of surgical site occurrences in general surgery: Consensus document. Surgery. 2023; 173(4): 1052–1059. https://doi.org/10.1016/j.surg.2022.11.033
26. Gillion JF, Sanders D, Miserez M, Muysoms F. The economic burden of incisional ventral hernia repair: a multicentric cost analysis. Hernia: the journal of hernias and abdominal wall surgery. 2016; 20(6): 819–830. https://doi.org/10.1007/s10029-016-1480-z
27. van Ramshorst GH, Eker HH, Hop WC, Jeekel J, Lange JF. Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study. American journal of surgery.2012; 204(2): 144–150. https://doi.org/10.1016/j.amjsurg.2012.01.012
28. Conze J, Klinge U, Schumpelick V. Narbenhernien [Incisional hernia]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2005; 76(9): 897–910. https://doi.org/10.1007/s00104-005-1072-4
29. Altemeier WA, Burke JF, Pruitt BA, Sandusky WR. Manual on control of infection in surgical patients, 2nd edn. JB Lippincott, Philadelphia; 1984.
30. Goodenough CJ, Ko TC, Kao LS, Nguyen MT, Holihan JL, Alawadi Z, et al. Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project). Journal of the American College of Surgeons. 2015; 220(4): 405–413. https://doi.org/10.1016/j.jamcollsurg.2014.12.027
31. Xu Z, Qu H, Kanani G, Guo Z, Ren Y, Chen X. Update on risk factors of surgical site infection in colorectal cancer: a systematic review and meta-analysis. International journal of colorectal disease. 2020; 35(12): 2147–2156. https://doi.org/10.1007/s00384-020-03706-8
32. Grąt, M, Morawski M, Krasnodębski M, Borkowski J, Krawczyk P, Grąt K, et al. Incisional Surgical Site Infections After Mass and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a Randomized Controlled Trial. Annals of surgery. 2021; 274(5): 690–697. https://doi.org/10.1097/SLA.0000000000005128
33. Yılmaz KB, Akıncı M, Doğan L, Karaman N, Özaslan C, Atalay C. A prospective evaluation of the risk factors for development of wound dehiscence and incisional hernia. Ulusal cerrahi dergisi. 2013; 29(1): 25–30. https://doi.org/10.5152/UCD.2013.06
34. Murray BW, Cipher DJ, Pham T, Anthony T. The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery. American journal of surgery. 2011; 202(5): 558–560. https://doi.org/10.1016/j.amjsurg.2011.06.014
35. Itatsu K, Yokoyama Y, Sugawara G, Kubota H, Tojima Y, Kurumiya Y, et al. Incidence of and risk factors for incisional hernia after abdominal surgery. The British journal of surgery. 2014; 101(11): 1439–1447. https://doi.org/10.1002/bjs.9600
36. Justinger C, Moussavian MR, Schlueter C, Kopp B, Kollmar O, Schilling MK. Antibacterial [corrected] coating of abdominal closure sutures and wound infection. Surgery. 2009; 145(3): 330–334. https://doi.org/10.1016/j.surg.2008.11.007
37. van Ramshorst GH, Eker HH, van der Voet JA, Jeekel J, Lange JF. Long-term outcome study in patients with abdominal wound dehiscence: a comparative study on quality of life, body image, and incisional hernia. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. 2013; 17(8): 1477–1484. https://doi.org/10.1007/s11605-013-2233-2
38. González-Abós C, Pineda C, Arrocha C, Farguell J, Gil I, Ausania F. Incisional Hernia Following Open Pancreaticoduodenectomy: Incidence and Risk Factors at a Tertiary Care Centre. Current oncology (Toronto, Ont.). 2023; 30(8): 7089–7098. https://doi.org/10.3390/curroncol30080514
39. James K, Glasswell A, Costa B. Single-use negative pressure wound therapy versus conventional dressings for the reduction of surgical site infections in closed surgical incisions: Systematic literature review and meta-analysis. American journal of surgery. 2024; 228: 70–77. https://doi.org/10.1016/j.amjsurg.2023.10.031
Published
2024-07-29
How to Cite
SÁ, Beatriz et al.
Incidence Of Incisional Hernia After Laparotomy.
Revista Portuguesa de Cirurgia, [S.l.], n. 57, p. 101-113, july 2024.
ISSN 2183-1165.
Available at: <https://revista.spcir.com/index.php/spcir/article/view/1049>. Date accessed: 19 aug. 2024.
doi: https://doi.org/10.34635/rpc.1049.
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Section
Original Papers
