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Original Article |

Smoking Is a Risk Factor for Incisional Hernia FREE

Lars Tue Sørensen, MD; Ulla B. Hemmingsen, RN; Lene T. Kirkeby, MD; Finn Kallehave, MD; Lars Nannestad Jørgensen, MD, DMSci
[+] Author Affiliations

Author Affiliations: Department of Surgery, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.


Arch Surg. 2005;140(2):119-123. doi:10.1001/archsurg.140.2.119.
Text Size: A A A
Published online

Hypothesis  A number of risk factors for incisional hernia have been identified, but the pathogenesis remains unclear. Based on previous findings of smoking as a risk factor for wound complications and recurrence of groin hernia, we studied whether smoking is associated with incisional hernia.

Design  Cohort study. Clinical follow-up study for incisional hernia 33 to 57 months following laparotomy for gastrointestinal disease. Variables predictive for incisional hernia were assessed by multiple regression analysis.

Setting  Department of Surgery, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.

Patients  All 916 patients undergoing laparotomy from 1997 through 1998. Surgeons performed clinical examination in 310 patients; patients who failed to meet for examination, died, or were lost to follow-up were excluded.

Main Outcome Measures  Thirty-four variables related to patient history, preoperative clinical condition, operative severity and findings, and the surgeon’s training.

Results  The incidence of incisional hernia was 26% (81/310). Smokers had a 4-fold higher risk of incisional hernia (odds ratio [OR], 3.93 [95% confidence interval (CI), 1.82-8.49]) independent of other risk factors and confounders. Relaparotomy was the strongest factor associated with hernia (OR, 5.89 [95% CI, 1.78-19.48]). Other risk factors were postoperative wound complications (OR, 3.91 [95% CI, 1.99-7.66]), age (OR, 1.04 [95% CI, 1.02-1.06]), and male sex (OR, 2.17 [95% CI, 1.21-3.91]).

Conclusion  Smoking is a significant risk factor for incisional hernia in line with relaparotomy, postoperative wound complications, older age, and male sex.

Incisional hernia is a late complication following abdominal surgery, occurring as a result of breakdown or loss of fascial closure and, as such, a iatrogenic disease.1 The incidence after laparotomy has been reported as ranging between 4% and 12% in large series,26 but the true incidence is probably underestimated.7 Many incisional hernias are asymptomatic, but if symptoms are present, an incisional hernia may be associated with major morbidity, loss of time from productive employment, and diminished quality of life.1 Given the financial cost of incisional hernia repair and the disappointing recurrence rates up to 45%,4,8 incisional hernia remains a significant challenge for most surgeons.

A number of factors associated with incisional hernia have been identified, some of which are local, such as wound infection and surgical technique,2,9 and some, systemic, such as older age, male sex, and altered collagen metabolism.5,10 In addition, a lifestyle factor like obesity has been found to be associated with incisional hernia.5,11,12 Based on a previous study where we identified smoking as an independent predictor of inguinal hernia recurrence,13 we hypothesized that smoking is associated with incisional hernia following laparotomy. Thus, the aim of this study was to identify and assess factors predictive of incisional hernia when adjusting for potential confounders through multiple logistic regression analysis.

From January 1997 through December 1998, a total of 1066 elective and emergency laparotomies and relaparotomies were performed in 916 patients. The operations were performed at the Department of Surgery, Bispebjerg Hospital, Copenhagen, Denmark, and included open gastroduodenal, biliary, and pancreatic surgery as well as operations on the small bowel, colon, and rectum. In October 2001 (ie, 33-57 months following laparotomy), a clinical examination for incisional hernia was conducted. All patients alive at the time of follow-up were eligible for clinical examination except those who were lost to follow-up.

Data on variables related to the patient history, characteristics of the disease, preoperative clinical condition, operative severity and findings, and the surgeon’s training were recorded prospectively in a clinical database.14 Data regarding patient history (family, employment and functional dependent status, smoking and drinking habits, and comorbidity [defined as a medical disease in current treatment]) were collected from questionnaires completed prior to surgery by the patient or surgeon at hospital admission or at referral to the outpatient clinic. These data and data from the operation and clinical record were recorded on a database sheet by the surgeon preoperatively or postoperatively except data on transfusions, which were extracted from the local blood bank facility.

Postoperative complications occurring within 30 days after surgery were recorded by the surgeon at hospital discharge or at readmission. In case of admission to other departments of the hospital within 30 days, relevant data were extracted from retrieved clinical records and hospital discharge letters. Thus, only complications requiring hospitalization were recorded.

The data were entered in the database using EPI-INFO 6.0 software (Centers for Disease Control and Prevention, Atlanta, Ga). Data entry for all patients was ensured by continual control procedures.14 Subsequently, the database was validated manually by matching the data with the clinical record of each patient.

At follow-up, additional supplementary data not recorded in the database were obtained from the clinical record such as height and weight, fascial closure, and localization of incision. We obtained a detailed smoking history from the patient to validate the smoking data recorded at the time of surgery, as well as indications of increased intra-abdominal pressure (hard labor or treatment for chronic obstructive lung disease, constipation, or prostate hypertrophy). If the clinical examination disclosed an incisional hernia, data regarding discomfort, pain, and treatment were recorded. An incisional hernia was defined as a palpable defect of the fascia under or adjacent to an incision of the abdominal wall with a protrusion of tissue through the defect on Valsalva maneuver. Thus, this definition included parastomal hernia.

The analysis was performed as a multiple logistic regression analysis using SPSS 10.0 software (SPSS Inc, Chicago, Ill). Incisional hernia recorded at follow-up was the dependent variable. First, a univariate analysis was performed with patient age and sex as fixed covariates. Based on this model, the odds ratio of each variable listed in Table 1 was estimated. Second, a forward selection procedure was carried out where variables likely associated with incisional hernia (P≤.20) were included in a multivariate model. In this model, all variables not significantly associated with hernia (P>.05) were discarded by a backward elimination procedure. Finally, test results for linearity and interaction terms between variables were examined. All results were described with odds ratios and 95% confidence intervals.

Table Graphic Jump LocationTable 1. Patient Characteristics at the Time of Laparotomy*

To test for any selection bias in the material, a “dropout” and “best case/worst case” analysis was performed including all patients eligible for follow-up. Level of statistical significance was P≤.05.

Three hundred ten patients were examined; 491 patients (53.5%) died before examination, 22 patients (2.4%) were lost to follow-up, and 93 patients (10.1%) failed to meet for examination. The incidence of incisional hernia was 26% (81/310). In 85% (66/81), the hernia was located in a midline incision (P<.05). An existing ostomy or sutured ostomy wound was present in 6% (18/310), in which 6 patients had a parastomal or incisional hernia. All fascial closures were made with absorbable suture (Vicryl 0-0; Ethicon, Johnson & Johnson Intl, St Stevens-Woluwe, Belgium) using a continuous or interrupted suture technique.

The median span from operation to an incisional hernia becoming symptomatic was 3 months (interquartile range, 2-6), and in 74% (60/81), the hernia occurred within the first year after laparotomy. Forty-nine percent (40/81) had discomfort or pain, and 25% (19/81) used a corset or an abdominal binder. Incisional hernia repair was performed in 23% (17/81).

Data recorded in the database related to patient history, preoperative clinical condition, operative severity and findings, and postoperative complications with a possible relation to incisional hernia are listed in Table 1. Overall, the results showed that patients who had been operated on electively were largely operated on by specialist surgeons, had malignant colorectal disease, experienced a larger blood loss, and had fewer postoperative wound complications (Table 1). In contrast, the patients operated on emergently mainly underwent gastroduodenal or small-bowel surgery, were in poor preoperative clinical condition with abnormal blood values and peritonitis, and had a high incidence of postoperative wound complications (Table 1).

The multiple regression analysis disclosed that older age, male sex, daily smoking, postoperative wound complication, and relaparotomy were independently associated with incisional hernia (Table 2). No significant interaction between postoperative wound complications and smoking or wound complications and relaparotomy were found. Neither emergency surgery nor conditions associated with increased intra-abdominal pressure were independent predictors of incisional hernia.

Table Graphic Jump LocationTable 2. Variables Associated With Incisional Hernia Following Laparotomy: The Final Model*

A dropout analysis of patients eligible for follow-up disclosed that the examined patients had a higher prevalence of risk factors associated with incisional hernia (Table 3). No significant changes in the estimates of the multivariate analysis were found when performing a best case/worst case analysis, testing for selection bias owing to a hypothetical difference in the incidence of incisional hernia between patients who were examined and those who were not.

Table Graphic Jump LocationTable 3. Dropout Analysis of 403 Patients Eligible for Follow-up*

This study demonstrates that smokers have a 4-fold higher risk of incisional hernia than nonsmokers, independent of confounders and risk factors previously recognized to be associated with incisional hernia.2,5,11

The majority of incisional hernia was in midline incisions and occurred during the first year after laparotomy, which confirms previous studies.15 The incidence of incisional hernia in this study was higher than reported by others.25 However, as a considerable number of incisional hernias are known to be asymptomatic,3,16 the incidence found in this study may be owing to the long follow-up and the fact that all patients were physically examined by surgeons. In addition, parastomal hernias were included in our definition of incisional hernia, which may explain the high hernia rate because ostomies have been reported as being associated with the formation of incisional hernia.17

Postoperative wound infection is a well-documented risk factor for early dehiscence of incisional wounds and fascia and for later development of incisional hernia.2,5 The pathogenesis is related to proliferation of bacteria in a wound, which affects each process involved in healing leading to decreased collagen synthesis, decreased bursting strength of the abdominal wall, and an increased risk of dehiscence.1820

Smokers have a higher risk of surgical site infections, dehiscence of tissue and wounds, and recurrence of groin hernia.13,2124 Following this study, incisional hernia may be added to the list.

The proportion of smokers with incisional hernia was high as reported by other studies of patients with abdominal-wall hernia.13,25 Several pathogenic mechanisms seem to be involved. Smoking and peripheral tissue hypoxia, which may be caused by smoking,26,27 increase the risk of wound infection and dehiscence presumably through reduction of the oxidative killing mechanism of neutrophils, which constitute a critical defense against surgical pathogens.2830 In addition, decreased collagen deposition in surgical test wounds has been found in smokers,31 a mechanism that may further attenuate the fascia in addition to the reduced collagen I–collagen III ratio present in incisional hernia.10 Degradation of connective tissue caused by an imbalance between proteases and their inhibitors may also be responsible.32 The latter mechanism, which is enhanced by smoking, is believed to cause tissue-destructive disorders like abdominal aorta aneurysm and pulmonary emphysema.3337 Both diseases are associated with abdominal-wall herniation.38,39 In fact, the incisional hernia rate has been reported as high as 31% following midline laparotomy for abdominal aorta–aneurysm repair.40,41

In this study, a relaparotomy was the strongest predictor for incisional hernia. Reoperations have previously been found to increase the rate of abdominal wound dehiscence and may also be responsible for the development of incisional hernia.42 Insufficient healing due to resuture of relatively nonvascular scar tissue of the fascia has been suggested.43 In addition, patients undergoing relaparotomy are likely to have bacterial contamination of the wound and may in addition have peritonitis, which increase the risk of wound infection and delayed healing.17

Older age and male sex were independently associated with the development of incisional wall hernia, confirming other reports.1,5,17,44 In both, delayed wound healing and decreased collagen synthesis may be involved.4547 Contrary to others, we did not find obesity to be associated with incisional hernia.5,11,12

The majority of the patients undergoing laparotomy died before follow-up. This relatively high mortality rate may be because the patient population was unselected and the hospital covers a central urban area with considerable social problems and drug and alcohol abuse. One may therefore question whether the examined patients are representative of a population undergoing laparotomy for gastrointestinal disease. Yet, in patients who survive their laparotomy by 2.5 years, we believe that our findings are representative supported on the fact that no selection bias was present.

In conclusion, smokers have a high risk of incisional hernia formation independent of other recognized risk factors, presumably owing to the detrimental effect of smoking on wound healing. This finding may encourage surgeons to advise patients to quit smoking prior to surgery. However, as the evidence of the effect of smoking cessation prior to surgery is conflicting,21,48 long-term smoking-cessation intervention studies are needed to determine whether smoking cessation may reduce incisional herniation.

Correspondence: Lars Tue Sørensen, MD, Department of Surgery K, Bispebjerg Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen NV, Denmark (lts@dadlnet.dk).

Accepted for Publication: July 27, 2004.

Funding/Support: This study was supported by grant 9801273 from The Danish Research Council, Copenhagen.

Acknowledgment: We thank Peer Wille-Jørgensen, MD, DMSci, Johan Kjaergaard, MD, DMSci, and Torben Jørgensen, MD, DMSci, for preceding work in the database steering group; Rikke Roel and Mathilde Winckler for assistance at follow-up; and Edzard Domela for retrieving data from the blood bank.

Santora  TARoslyn  JJ Incisional hernia. Surg Clin North Am 1993;73557- 570
PubMed
Carlson  MALudwig  KACondon  RE Ventral hernia and other complications of 1,000 midline incisions. South Med J 1995;88450- 453
PubMed Link to Article
Pollock  AVEvans  M Early prediction of late incisional hernias. Br J Surg 1989;76953- 954
PubMed Link to Article
Mudge  MHughes  LE Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985;7270- 71
PubMed Link to Article
Bucknall  TECox  PJEllis  H Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. BMJ (Clin Res Ed) 1982;284931- 933
PubMed Link to Article
Irvin  TTStoddard  CJGreaney  MGDuthie  HL Abdominal wound healing: a prospective clinical study. BMJ 1977;2351- 352
PubMed Link to Article
Yahchouchy-Chouillard  EAura  TPicone  OEtienne  JCFingerhut  A Incisional hernias, I: related risk factors. Dig Surg 2003;203- 9
PubMed Link to Article
Gecim  IEKocak  SErsoz  SBumin  CAribal  D Recurrence after incisional hernia repair: results and risk factors. Surg Today 1996;26607- 609
PubMed Link to Article
Hodgson  NCMalthaner  RAOstbye  T The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000;231436- 442
PubMed Link to Article
Klinge  USi  ZYZheng  HSchumpelick  VBhardwaj  RSKlosterhalfen  B Abnormal collagen I to III distribution in the skin of patients with incisional hernia. Eur Surg Res 2000;3243- 48
PubMed Link to Article
Israelsson  LAJonsson  T Overweight and healing of midline incisions: the importance of suture technique. Eur J Surg 1997;163175- 180
PubMed
Sugerman  HJKellum  JM  JrReines  HDDeMaria  EJNewsome  HHLowry  JW Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg 1996;17180- 84
PubMed Link to Article
Sorensen  LTFriis  EJorgensen  T  et al.  Smoking is a risk factor for recurrence of groin hernia. World J Surg 2002;26397- 400
PubMed Link to Article
Wille-Jorgensen  PASorensen  LTRoodpashti  AMJorgensen  TMeisner  S Difficulties with implementation and maintenance of a clinical database [in Danish]. Ugeskr Laeger 1999;1616359- 6362
PubMed
Burger  JWvan 't Riet  MJeekel  J Abdominal incisions: techniques and postoperative complications. Scand J Surg 2002;91315- 321
Harding  KGMudge  MLeinster  SJHughes  LE Late development of incisional hernia: an unrecognised problem. BMJ (Clin Res Ed) 1983;286519- 520
Link to Article
Riou  JPCohen  JRJohnson  H  Jr Factors influencing wound dehiscence. Am J Surg 1992;163324- 330
PubMed Link to Article
Graham  DJStevenson  JTMcHenry  CR The association of intra-abdominal infection and abdominal wound dehiscence. Am Surg 1998;64660- 665
PubMed
Robson  MC Wound infection: a failure of wound healing caused by an imbalance of bacteria. Surg Clin North Am 1997;77637- 650
PubMed Link to Article
De Haan  BBEllis  HWilks  M The role of infection on wound healing. Surg Gynecol Obstet 1974;138693- 700
PubMed
Sorensen  LTJorgensen  T Short-term pre-operative smoking cessation intervention does not affect postoperative complications in colorectal surgery: a randomized clinical trial. Colorectal Dis 2003;5347- 352
PubMed Link to Article
Sorensen  LTHorby  JFriis  EPilsgaard  BJorgensen  T Smoking as a risk factor for wound healing and infection in breast cancer surgery. Eur J Surg Oncol 2002;28815- 820
PubMed Link to Article
Myles  PSIacono  GAHunt  JO  et al.  Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers versus nonsmokers. Anesthesiology 2002;97842- 847
PubMed Link to Article
Sorensen  LTJorgensen  TKirkeby  LTSkovdal  JVennits  BWille-Jorgensen  P Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery. Br J Surg 1999;86927- 931
PubMed Link to Article
Dunne  JRMalone  DLTracy  JKNapolitano  LM Abdominal wall hernias: risk factors for infection and resource utilization. J Surg Res 2003;11178- 84
PubMed Link to Article
Willis  NMogridge  J Indicators of histohypoxia. Acta Anaesthesiol Scand Suppl 1995;10745- 48
PubMed Link to Article
Jensen  JAGoodson  WHHopf  HWHunt  TK Cigarette smoking decreases tissue oxygen. Arch Surg 1991;1261131- 1134
PubMed Link to Article
Allen  DBMaguire  JJMahdavian  M  et al.  Wound hypoxia and acidosis limit neutrophil bacterial killing mechanisms. Arch Surg 1997;132991- 996
PubMed Link to Article
Sorensen  LTNielsen  HBKharazmi  AGottrup  F Effect of smoking and abstention on oxidative burst and reactivity of neutrophils and monocytes. Surgery 2004;1361047- 1053
PubMed Link to Article
Babior  BM Oxygen-dependent microbial killing by phagocytes (first of two parts). N Engl J Med 1978;298659- 668
PubMed Link to Article
Jorgensen  LNKallehave  FChristensen  ESiana  JEGottrup  F Less collagen production in smokers. Surgery 1998;123450- 455
PubMed Link to Article
Cannon  DJRead  RC Metastatic emphysema: a mechanism for acquiring inguinal herniation. Ann Surg 1981;194270- 278
PubMed Link to Article
Lindholt  JSJorgensen  BKlitgaard  NAHenneberg  EW Systemic levels of cotinine and elastase, but not pulmonary function, are associated with the progression of small abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2003;26418- 422
PubMed Link to Article
Vardulaki  KAWalker  NMDay  NEDuffy  SWAshton  HAScott  RA Quantifying the risks of hypertension, age, sex and smoking in patients with abdominal aortic aneurysm. Br J Surg 2000;87195- 200
PubMed Link to Article
Anderson  BOBrown  JMHarken  AH Mechanisms of neutrophil-mediated tissue injury. J Surg Res 1991;51170- 179
PubMed Link to Article
Janoff  A Elastases and emphysema: current assessment of the protease-antiprotease hypothesis. Am Rev Respir Dis 1985;132417- 433
PubMed
Cannon  DJCasteel  LRead  RC Abdominal aortic aneurysm, Leriche's syndrome, inguinal herniation, and smoking. Arch Surg 1984;119387- 389
PubMed Link to Article
Holland  AJCastleden  WMNorman  PEStacey  MC Incisional hernias are more common in aneurysmal arterial disease. Eur J Vasc Endovasc Surg 1996;12196- 200
PubMed Link to Article
van Laarhoven  CJBorstlap  ACBerge Henegouwen  DPPalmen  FMVerpalen  MCSchoemaker  MC Chronic obstructive pulmonary disease and abdominal aortic aneurysms. Eur J Vasc Surg 1993;7386- 390
PubMed Link to Article
Raffetto  JDCheung  YFisher  JB  et al.  Incision and abdominal wall hernias in patients with aneurysm or occlusive aortic disease. J Vasc Surg 2003;371150- 1154
PubMed Link to Article
Adye  BLuna  G Incidence of abdominal wall hernia in aortic surgery. Am J Surg 1998;175400- 402
PubMed
Israelsson  LA The surgeon as a risk factor for complications of midline incisions. Eur J Surg 1998;164353- 359
PubMed Link to Article
Lamont  PMEllis  H Incisional hernia in re-opened abdominal incisions: an overlooked risk factor. Br J Surg 1988;75374- 376
PubMed Link to Article
Penninckx  FMPoelmans  SVKerremans  RPBeckers  JP Abdominal wound dehiscence in gastroenterological surgery. Ann Surg 1979;189345- 352
PubMed Link to Article
Jorgensen  LNSorensen  LTKallehave  FVange  JGottrup  F Premenopausal women deposit more collagen than men during healing of an experimental wound. Surgery 2002;131338- 343
PubMed Link to Article
Lenhardt  RHopf  HWMarker  E  et al.  Perioperative collagen deposition in elderly and young men and women. Arch Surg 2000;13571- 74
PubMed Link to Article
Ashcroft  GSHoran  MAFerguson  MW Aging is associated with reduced deposition of specific extracellular matrix components, an upregulation of angiogenesis, and an altered inflammatory response in a murine incisional wound healing model. J Invest Dermatol 1997;108430- 437
PubMed Link to Article
Sorensen  LTKarlsmark  TGottrup  F Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg 2003;2381- 5
PubMed

Figures

Tables

Table Graphic Jump LocationTable 1. Patient Characteristics at the Time of Laparotomy*
Table Graphic Jump LocationTable 2. Variables Associated With Incisional Hernia Following Laparotomy: The Final Model*
Table Graphic Jump LocationTable 3. Dropout Analysis of 403 Patients Eligible for Follow-up*

References

Santora  TARoslyn  JJ Incisional hernia. Surg Clin North Am 1993;73557- 570
PubMed
Carlson  MALudwig  KACondon  RE Ventral hernia and other complications of 1,000 midline incisions. South Med J 1995;88450- 453
PubMed Link to Article
Pollock  AVEvans  M Early prediction of late incisional hernias. Br J Surg 1989;76953- 954
PubMed Link to Article
Mudge  MHughes  LE Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985;7270- 71
PubMed Link to Article
Bucknall  TECox  PJEllis  H Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. BMJ (Clin Res Ed) 1982;284931- 933
PubMed Link to Article
Irvin  TTStoddard  CJGreaney  MGDuthie  HL Abdominal wound healing: a prospective clinical study. BMJ 1977;2351- 352
PubMed Link to Article
Yahchouchy-Chouillard  EAura  TPicone  OEtienne  JCFingerhut  A Incisional hernias, I: related risk factors. Dig Surg 2003;203- 9
PubMed Link to Article
Gecim  IEKocak  SErsoz  SBumin  CAribal  D Recurrence after incisional hernia repair: results and risk factors. Surg Today 1996;26607- 609
PubMed Link to Article
Hodgson  NCMalthaner  RAOstbye  T The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000;231436- 442
PubMed Link to Article
Klinge  USi  ZYZheng  HSchumpelick  VBhardwaj  RSKlosterhalfen  B Abnormal collagen I to III distribution in the skin of patients with incisional hernia. Eur Surg Res 2000;3243- 48
PubMed Link to Article
Israelsson  LAJonsson  T Overweight and healing of midline incisions: the importance of suture technique. Eur J Surg 1997;163175- 180
PubMed
Sugerman  HJKellum  JM  JrReines  HDDeMaria  EJNewsome  HHLowry  JW Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg 1996;17180- 84
PubMed Link to Article
Sorensen  LTFriis  EJorgensen  T  et al.  Smoking is a risk factor for recurrence of groin hernia. World J Surg 2002;26397- 400
PubMed Link to Article
Wille-Jorgensen  PASorensen  LTRoodpashti  AMJorgensen  TMeisner  S Difficulties with implementation and maintenance of a clinical database [in Danish]. Ugeskr Laeger 1999;1616359- 6362
PubMed
Burger  JWvan 't Riet  MJeekel  J Abdominal incisions: techniques and postoperative complications. Scand J Surg 2002;91315- 321
Harding  KGMudge  MLeinster  SJHughes  LE Late development of incisional hernia: an unrecognised problem. BMJ (Clin Res Ed) 1983;286519- 520
Link to Article
Riou  JPCohen  JRJohnson  H  Jr Factors influencing wound dehiscence. Am J Surg 1992;163324- 330
PubMed Link to Article
Graham  DJStevenson  JTMcHenry  CR The association of intra-abdominal infection and abdominal wound dehiscence. Am Surg 1998;64660- 665
PubMed
Robson  MC Wound infection: a failure of wound healing caused by an imbalance of bacteria. Surg Clin North Am 1997;77637- 650
PubMed Link to Article
De Haan  BBEllis  HWilks  M The role of infection on wound healing. Surg Gynecol Obstet 1974;138693- 700
PubMed
Sorensen  LTJorgensen  T Short-term pre-operative smoking cessation intervention does not affect postoperative complications in colorectal surgery: a randomized clinical trial. Colorectal Dis 2003;5347- 352
PubMed Link to Article
Sorensen  LTHorby  JFriis  EPilsgaard  BJorgensen  T Smoking as a risk factor for wound healing and infection in breast cancer surgery. Eur J Surg Oncol 2002;28815- 820
PubMed Link to Article
Myles  PSIacono  GAHunt  JO  et al.  Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers versus nonsmokers. Anesthesiology 2002;97842- 847
PubMed Link to Article
Sorensen  LTJorgensen  TKirkeby  LTSkovdal  JVennits  BWille-Jorgensen  P Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery. Br J Surg 1999;86927- 931
PubMed Link to Article
Dunne  JRMalone  DLTracy  JKNapolitano  LM Abdominal wall hernias: risk factors for infection and resource utilization. J Surg Res 2003;11178- 84
PubMed Link to Article
Willis  NMogridge  J Indicators of histohypoxia. Acta Anaesthesiol Scand Suppl 1995;10745- 48
PubMed Link to Article
Jensen  JAGoodson  WHHopf  HWHunt  TK Cigarette smoking decreases tissue oxygen. Arch Surg 1991;1261131- 1134
PubMed Link to Article
Allen  DBMaguire  JJMahdavian  M  et al.  Wound hypoxia and acidosis limit neutrophil bacterial killing mechanisms. Arch Surg 1997;132991- 996
PubMed Link to Article
Sorensen  LTNielsen  HBKharazmi  AGottrup  F Effect of smoking and abstention on oxidative burst and reactivity of neutrophils and monocytes. Surgery 2004;1361047- 1053
PubMed Link to Article
Babior  BM Oxygen-dependent microbial killing by phagocytes (first of two parts). N Engl J Med 1978;298659- 668
PubMed Link to Article
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