Research in context
Evidence before this study
Incisional hernia is a frequent complication of abdominal operations with an incidence of more than 10%, which can increase to 38% in specific risk groups. Findings from meta-analyses have shown that a running technique with long-lasting monofilament suture material reduced the incidence of incisional hernia compared with interrupted suture techniques. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials up to and Dec 29, 2014, with the search terms “Large OR small OR long OR short”, “suture OR sutures OR stitch”, “midline incision OR median laparotomy”, “randomized controlled trial” to identify randomised controlled trials comparing small bites with large bites for closure of the abdominal fascia after midline laparotomy for prevention of incisional hernia. We manually cross-searched the reference lists of the retrieved reports for additional publications. Only one randomised controlled trial was identified comparing small tissue bites with large tissue bites. This quasi-randomised single-centre study 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.
Added value of this study
Our findings confirm the effectiveness of the small bites suture technique for prevention of incisional hernia. The small bites technique was not associated with more pain or adverse events than the large bites technique.
Implications of all the available evidence
Our findings and those from the previous quasi-randomised controlled trial of small versus large bites provide strong evidence supporting closure of an abdominal midline incision with a continuous small bite suture technique with at least twice as many small stitches as the incision length in cm. The small bites suture technique should be considered as the standard closure technique for midline incisions.