In a multicenter randomized clinical trial, small-bite fascial closure reduced the long-term incidence of incisional hernia compared with large-bite closure among patients undergoing elective midline laparotomy.
Researchers evaluated 559 patients across 10 centers in the Netherlands who were randomly assigned to small-bite closure (5 × 5 mm spacing) or large-bite closure (10 × 10 mm). Long-term follow-up extended 13 to 15 years after the initial surgery, with a median time to censoring of about 8 years. The findings were published in JAMA Surgery.
At 13 years, the cumulative incidence of incisional hernia was 34% in the small-bite group compared with 49% in the large-bite group. Clinically relevant hernias larger than 20 mm occurred in 17% of patients in the small-bite group vs 34% in the large-bite group.
Hernias that developed after small-bite closure were also smaller and progressed more slowly over time. At final follow-up, mean hernia width was 25 mm with small-bite closure vs 43 mm with large-bite closure. Hernia repair rates were similar at about 5% in each group.
Quality-of-life outcomes did not differ between closure strategies overall. However, patients with incisional hernia reported worse health status on some measures compared with those without hernia.
Sensitivity analyses suggested a similar effect of small-bite closure among patients with obesity, although estimates were imprecise because of small subgroup size.
Differences between groups emerged primarily within the first 2 years following surgery and then remained stable over time, which the researchers suggested may reflect early differences in wound healing and mechanical strain.
Limitations included loss to follow-up over the extended study period, reliance in part on retrospectively identified imaging, and availability of long-term quality-of-life data only among surviving participants who consented to follow-up.
Commentary Highlights Ongoing Adoption Gap
In an invited commentary, Nicole L. Petcka, MD, of the Department of Surgery at Emory University, and S. Scott Davis Jr, MD, of Emory University Healthcare, both in Atlanta, noted that the findings reinforce more than a decade of evidence supporting small-bite closure and are consistent with results from other trials.
They pointed out that updated guidelines from the European and American Hernia Societies already recommend continuous small-bite closure for elective midline incisions, yet adoption in clinical practice remains inconsistent.
One survey found that only 20% of surgeons report regularly using the technique. The commentators also emphasized that some surgeons who report using small bites may not be performing the technique as intended, including failure to achieve the recommended suture-to-wound length ratio.
“Continuous education will be vital to displace generations of surgical culture,” they wrote, adding that improvements in patient outcomes will likely require better standardization of technique across surgeons.
They also noted concern that incisional hernia rates remain substantial even with current techniques, underscoring the need for continued efforts to improve both adoption and execution of evidence-based closure methods.
Disclosures
The original STITCH trial and its long-term follow-up were supported by Ethicon, a subsidiary of Johnson & Johnson. Eva B. Deerenberg, MD, PhD, reported receiving grant funding from Ethicon and Johnson & Johnson, as well as personal fees from Medtronic and Gore unrelated to the submitted work. No other disclosures were reported.
Source: JAMA Surgery Original Investigation