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| Cleveland Clinic Department of General Surgery Dr. R. Michael Walsh common mass closure promoted as 'common practice' even though it causes a painful |
| 26th of Nov, 2011 by User610210 |
Common mass ‘continuous’ suture closure of abdominal wall surgeries (appendectomy, laparotomy, etc) has clinical trade-offs in complications of chronic pain, abdominal wall deformities, and abdominal ‘rigidity’ from closing fascia/muscles that contract in different direction within a common ‘seam.’ [It's bad sewing technique.] Supposedly this is done to prevent incisional hernias, or the wound breaking open (dehiscence). However, all the surgical studies only follow patients at most for a year, and 35% of the incisional hernias occur after 3 years - so it's a deformity for a questionable benefit.
Mass common closure seems to do better with incisional hernias for the first year, but you have to be a patient at risk of an incisional hernia to appreciate this at the cost of a painful deformity (cost:benefit analysis). The deformities are also signature surgical ‘moves’ – with no two such deformities the same – tissue mounds - you can pick the model.
The surgical literature meta-analysis articles recommend mass closure after bundling poor-quality studies to supposedly report high-quality evidence – evidence where none of the authors seems to have ever had a mass common closure deformity done to them. Surgeons do not know statistics.
The Cleveland Clinic is going with the literature, and even has hired an ombudsperson to call physicians that mass closure is ‘common,’ therefore ok, and no one will at this time repair it – even though Dr. Sharon Grundfest-Broniatowski MD can – or so she says before she finds out that a male Jewish colleague of hers did the damage. And it wasn't for money?????
The Cleveland Clinic is doing face transplants, but can’t repair a common closure tissue deformity of the abdominal wall – figure that. Many of these deformities are painful, and hurt with every abdominal crunch. They are unnecessary over-doing it – as surgeons do – male or female.
Mass common closure was a technique restricted in the 1980s to trauma, obese, and cancer patients – where wound healing, or incision strength, was the primary concern. Only the seriously ill patients with high risk of dehiscence were randomized to this closure before 1990. You couldn’t do it on students, children, or patients less than 50 – the patient (or parents) would complain bitterly.
In the 1980s, surgical trainees didn’t mind getting the experience of the layered closure techniques, and seeing the better results – notso today at Cleveland & Mayo Clinics. For elderly, and younger athletic patients (runners), decreased ‘compliance' - or give - of the abdominal wall can be a problem with the mass closure technique. The mass closure destroys abdominal muscle contours as a trade-off for less hernia risk – which destroys the length-tension strength of all the abdominal muscles involved. Layered closures appear to be better for early exercise and patient rehabilitation, pulmonary considerations, and cosmetics.
Common mass closures are useful for the subset of patients that have heavier abdominal walls (bariatric surgeries), or where swelling may be a problem (intra-abdominal tumors). It is faster, easier for surgical assistants or residents, requires less suture, and has a higher ‘bursting strength,’ but that is of less concern with a female patient, or child – where aesthetics is desired. For the younger patient, the common mass closure is dependent on a single strand of suture material, and a rupture will cause the whole incision to open. It’s not a risk worth taking for a few more minutes of surgical ‘care’ and competence – an hour of Dr. Sharon Grundfest-Broniatowski's time - who has spent hours complaining why she can't do this repair, but she says she can.
Surgeons at Cleveland Clinic are favoring the mass closure technique based on statistical meta-analyses of poor-quality, short-term follow-up studies with variable patient factors. Dr. Grundfest claims that she can undo these closures for younger patients wanting a reversal of the deformities, she just can't schedule them.
Surgeons at Mayo Clinic (Dr. Michael Sarr), Cleveland Clinic, and University Hospitals have not been allowing patients to choose the closures - just fast & easy for the guys. However, it is not known if Dr. Grundfest has done this recently – so it’s imperative that patients question the closures that will be used in their surgeries (if they want to wear clothes or bathing suits), and the complications of each method of closure. Dr. Sarr deforms every woman with common mass closure except his daughter - as most surgeons draw the fine line.
Undoing abdominal wall deformities after-the-fact is difficult. So far Dr. Grundfest has allowed the common closures of her male colleagues to remain as deformities for female patients – some of whom even objected to this ‘closure’ pre-op, i.e. never consented to this closure having seen the problems with it. So Dr. Grundfest, (Cleveland Clinic, Cleveland) has yet to put her surgical skills to the test even though she knows the technique. Her boss, Dr. RM Walsh, claims that no one can undo common mass closure defects at Cleveland Clinic – they just do them. Maybe they should talk?
Dr. Thomas Stellato, of University Hospitals of Cleveland, who has a graduate management degree from Weatherhead and knows the stats, has yet to weigh in on the two techniques for different types of patients. He did many layered closures in the 1980s, and has done a huge amount of bariatrics and scope surgery – having started the Department of Bariatric Surgery at University Hospitals. Whether any of these surgeons would chose a painful deformity over rat ‘burst-strength’ for fast, easy, and a few suture lengths less cost is the question? In the meantime, patients should question the types of closure as well as the other aspects of procedures at the Cleveland Clinic = you might get the resident random pick-of-the-day (RRPOTD).
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