Small bites better for closure of midline abdominal incisions

Last Updated: 2015-07-24

By Will Boggs MD

NEW YORK (Reuters Health) - For running closure of midline abdominal incisions, small bites are better than big bites for preventing incisional hernia, researchers from the Netherlands report.

"Older studies showed a stronger holding force when 'single' sutures were placed wider from the wound edge," Dr. Joris J. Harlaar from Erasmus University Medical Center Rotterdam told Reuters Health by email. "For this reason, large bites was the favored suture technique."

But a 2009 study from Sweden showed that a running suture technique with small tissue bites decreased the incidence of incisional hernia compared with a running suture technique with large tissue bites.

Dr. Harlaar and colleagues in the STITCH study compared the common conventional large-bites suture technique with the small-bites technique for fascial closure of midline laparotomy incisions in a multicenter, randomized trial of 560 patients in 10 hospitals in the Netherlands.

One year after surgery, 21% of patients in the large-bites group had incisional hernia, compared with only 13% of patients in the small-bites group (p=0.0131 after adjustment for covariates), the researchers report in The Lancet, online July 16.

The mean fascial defect was 3.4 cm, which did not differ between the groups.

Postoperative complications, readmission rates, and adverse event rates did not differ significantly between the two groups, and the groups had similar pain scores and quality-of-life scores.

"Incisional hernia is for the most cases a preventable complication," Dr. Harlaar said. "Small bites will reduce the incidence but should be placed correctly: at least two times the (number) of stitches per cm wound length. Don't use the double loop suture material; this needle is oversized."

"The small bites technique . . . should be considered the standard closure technique for midline incisions," the researchers conclude.

"The present challenge is for surgeons to acknowledge that sufficient data are available for a surgical standard to be changed, and to change their suture technique accordingly," writes Dr. Leif A. Israelsson from Umea University in Sweden in a linked commentary. "This challenge has been recognized by the European Hernia Society that (recommends) the suture length to wound length ratio to be higher than four and accomplished with small bites."

"Effective implementation, however, is probably only achievable if professionals in charge at local or even national levels direct this change," Dr. Israelsson concludes.

SOURCE: http://bit.ly/1Oq6Fee and http://bit.ly/1JCyGvk

Lancet 2015.