Figure-of-eights vs running suture for fascial closure of large ventral hernias: do figure-of-eights induce ischemia?

INTRODUCTION: Many techniques can reapproximate fascia during herniorrhaphy. Reports suggest utility of interrupted figure-of-eights for large defects less amenable to running suture closures. However, anecdotal concerns regarding 'ischemic' qualities of figure-of-eights may dissuade utilization, despite no substantiating evidence. This study compares wound morbidity for figure-of-eights vs running sutures for fascial closure during open ventral hernia repair (VHR). METHODS: A prospectively maintained hernia-specific registry was queried for open VHRs from 1/1/2014 to 12/31/2023 with fascial closure, ≥ 10 cm defect width, CDC Class 1 wound, fascial closure via figure-of-eights or running suture, and clinical follow-up at 30 days. Cases featuring anterior myofascial or cutaneous flaps were excluded. Surgical site occurrence (SSO), surgical site infection (SSI), SSO/SSI requiring procedural intervention (SSO/I-PI), recurrence, and patient-reported quality-of-life (QoL) at 30-day and 1-year intervals were considered. SSO at 30 days was selected as the primary outcome to serve as a surrogate for suture line ischemia, and 1-year recurrence was a key secondary outcome of interest. Baseline factors including age, BMI, gender, race, ASA class, immunosuppressant use, smoking, diabetes, hernia width, and hernia length were controlled via multivariable regression. RESULTS: A total 4195 cases met criteria and 31% utilized figure-of-eights (n = 1317). Multivariable logistic regression found no increased risk of 30-day SSO or 1-year recurrence for figure-of-eight vs running suture closure. Adjusted odds of SSI (OR 1.47; 95% CI 1.11, 1.95) and SSO/I-PI (OR 1.31; 1.02, 1.70) were greater for figure-of-eight closures. No associations were identified regarding patient-reported QoL or 1-year outcomes. CONCLUSIONS: This retrospective analysis of wound morbidity in clean cases identified an increased risk of SSI and SSO/I-PI for figure-of-eight closures at 30 days vs running closures. Though the association may relate to residual confounding from selective utilization in high complexity repairs rather than an ischemic nature, the results suggest figure-of-eights should perhaps be reserved for challenging or high-tension fascial reapproximation.