Small-bites fascial closure reduces long-term risk of incisional hernia after midline laparotomy

1. The small-bites fascial closure technique reduced the long-term incidence of incisional hernias compared to the traditional large-bites technique after elective midline laparotomy.

2. Hernias in the small-bites group were smaller and progressed more slowly, although hernia repair rates were similar between the two groups.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Incisional hernias are a common postoperative complication following midline laparotomy, leading to pain, impaired abdominal function, and decreased quality of life. This study evaluated the long-term effects and incidence of incisional hernias after midline fascial closure with a small-bites technique compared to a large-bites technique. Patients across 10 centers were randomized 1:1 to either a small-bites or large-bites group and followed for 13 years after index laparotomy. At the final follow-up, the small-bites group had a significantly lower rate of incisional hernias compared to the large-bites group. Additionally, hernias in the small-bites group were smaller and grew more slowly. There was also a lower incidence of large hernias, defined as width greater than 20 mm, in the small-bites group. Despite these differences, hernia repair rates were similar between the groups. Patients with incisional hernias reported a significantly lower quality of life compared to those without. These findings suggest that the small-bites closure technique may be more effective in preventing both the development and progression of incisional hernias after midline laparotomy. Overall, this study supports the use of a small-bites fascial closure technique as the standard of care, at least in preventing postoperative incisional hernias. Strengths of this study included its long-term follow-up and robust randomization process, which enhanced the reliability and generalizability of the findings. Limitations included restricted quality-of-life data due to consent requirements and the retrospective nature of some imaging data.

Click to read the study in JAMA Surgery

Relevant Reading: Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial

In-Depth [randomized controlled trial]: This study was a multicenter, double-blind randomized controlled trial conducted across 10 hospitals in the Netherlands between October 2009 and March 2012. In total, 559 patients were randomized to undergo either small-bites fascial closure (n = 275) or large-bites fascial closure (n = 284). The primary outcome was the cumulative incidence of incisional hernia, with secondary outcomes including hernia width, repair rates, and patient-reported quality of life assessments. At final follow-up, the small-bites group had a significantly lower incidence of incisional hernias compared to the large-bites group (HR 0.61, 95% CI 0.43-0.86), with 34% of patients in the small-bites group developing a hernia compared to 49% in the large-bites group. Secondary outcomes revealed that hernias in the small-bites group were significantly smaller both at the time of diagnosis and at final follow-up. At initial diagnosis, the mean hernia width in the small-bites group was 20 mm (95% CI, 14-25 mm) compared to 28 mm (95% CI, 21-35 mm) in the large-bites group. At final follow-up, the small-bites group had a mean hernia size of 25 mm (95% CI, 18-32 mm), while hernias in the large-bites group featured a mean size of 43 mm (95% CI, 34-52 mm). The difference in hernia growth over time was also significantly lower in the small-bites group (P = .02). Additionally, there was no significant difference in hernia repair rates between groups, with 5% of patients in both groups requiring repair. Quality of life measures, including EQ-5D-5L and EQ-VAS scores, did not differ significantly between the two groups. However, patients with incisional hernias reported lower quality of life scores than those without hernias, suggesting a clinically meaningful impact on patient well-being if hernias can be prevented by a small-bites closure technique.

Image: PD

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