STITCH — Small Bites vs Large Bites for Midline Closure

One-line takeaway: For elective midline laparotomy closure, a small-bites suture technique reduces the 1-year incisional hernia rate from 21% to 13% compared with the traditional large-bites technique, without increasing wound complications.

Clinical Question

• In patients undergoing elective abdominal surgery through a midline laparotomy, does fascial closure with small (5 mm × 5 mm) bites reduce the incidence of incisional hernia compared with large (1 cm × 1 cm) bites?

Bottom Line

• Small bites for fascial closure after midline laparotomy is more effective than large bites at preventing incisional hernia at 1 year (13% vs 21%, P = 0.0220; adjusted OR 0.52, 95% CI 0.31–0.87, P = 0.0131).
• No significant difference in post-operative complications, surgical-site infection, burst abdomen, or length of stay.
• Fascial closure is a few minutes slower with small bites (14 vs 10 min) and uses slightly more suture — a reasonable trade.

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Major Points

• Incisional hernia is one of the most frequent complications after abdominal surgery, historically occurring in 10–38% of patients. Most cause pain and discomfort, and a minority strangulate — a surgical emergency.
• Prior work had already established that (1) continuous running closure beats interrupted closure, (2) slowly-absorbing monofilament is preferred, and (3) smaller bites out-perform larger bites in single-center data (Millbourn/Israelsson).
• STITCH tested whether the small-bites finding would generalize in a multicenter, double-blind RCT and define the technique prospectively.
• The authors concluded that fascial closure with small bites is an effective way to reduce incisional hernia (13% vs 21%) with only a modest increase in operative time (14 vs 10 minutes, P < 0.001) and no increase in adverse events or post-operative pain.

Guidelines

• At the time of publication, no guidelines had been published that reflected the results of this trial.

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Design

• Type: Prospective, multicenter, double-blind, randomized controlled trial
• N: 560 (small bites n = 276, large bites n = 284)
• Setting: 10 surgical and gynecological centers in the Netherlands
• Enrollment: October 20, 2009 – August 20, 2012
• Mean follow-up: 1 year
• Analysis: Intention-to-treat
• Primary outcome: Occurrence of incisional hernia at 1 year
• Registration: ClinicalTrials.gov NCT01132209

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Population

Inclusion Criteria

• Elective abdominal surgery through a midline incision
• Age ≥ 18 years

Exclusion Criteria

• History of incisional hernia after midline laparotomy
• History of fascial dehiscence after midline laparotomy
• History of abdominal surgery through a midline incision in the last 3 months
• Pregnancy
• Participation in another trial

Baseline Characteristics

(Large-bites group shown; arms were well balanced.)

• Male sex: 49%
• Mean age: 63 years (IQR 54–71)
• Mean BMI: 24 kg/m² (IQR 22–27)
• Smoking: 23%
• Diabetes mellitus: 14%
• COPD: 10%
• Cardiovascular disease: 41%
• Corticosteroid use: 6%
• Non-incisional hernias: 12%
• Abdominal aortic aneurysm: 15%
• Previous laparotomy: 15%
• ASA 1 / 2 / ≥ 3: 20% / 64% / 15%
• Pre-operative chemotherapy: 26%
• Pre-operative radiotherapy: 19%
• Procedure: gynecologic 14%, upper GI 31%, lower GI 47%, vascular 7%

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Interventions

Patients were randomized to small-bites or large-bites fascial closure. Both arms used continuous single-layer aponeurotic closure with slowly-absorbing monofilament (PDS Plus II), started at both ends of the incision and met in the middle with ≥ 2 cm overlap; sutures were separately knotted with an optional additional knot joining them. Number of stitches, wound length, and remaining suture were recorded, and suture length–to–wound length ratio was calculated with a target of ≥ 4:1. Follow-up occurred at 1 month and 1 year post-operatively.

Small-bites arm

• Suture: USP 2-0 PDS Plus II on a 31 mm needle
• Bite pattern: 5 mm from the wound edge, 5 mm between stitches
• Number of stitches: at least 2× the incisional length (cm)
• Fascial bites only — fat and muscle avoided

Large-bites arm

• Suture: USP #1 double-loop PDS Plus II on a 48 mm needle
• Bite pattern: 1 cm from the wound edge, 1 cm between stitches
• Fascial bites only — fat and muscle avoided

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Outcomes

Comparisons are large bites vs small bites except where noted.

Primary Outcome

• Incisional hernia at 1 year: 21% vs 13%; P = 0.0220
• Adjusted odds ratio 0.52 (95% CI 0.31–0.87), P = 0.0131

Secondary Outcomes

• Number of stitches: 25 ± 10 vs 45 ± 12; P < 0.0001
• Total suture length used (cm): 95 ± 34 vs 110 ± 39; P < 0.0001
• Wound length (cm): 22 ± 5 vs 22 ± 5; P = 0.982
• Suture length–to–wound length ratio: 4.3 ± 1.4 vs 5.0 ± 1.5; P < 0.0001
• Time of fascial closure (min): 10 ± 4 vs 14 ± 6; P < 0.0001
• Mean fascial defect (both groups): 3.4 ± 4.4 cm
• Hernias detected by both physical exam and imaging: 49%
• Hernias detected by imaging only: 47%
• Hernias detected by physical exam only: 3%
• Size of imaging-only hernia vs exam + imaging hernia: 2.4 ± 4.0 cm vs 4.2 ± 0.5 cm; P = 0.0650
• Pain (VAS), quality of life (EQ-5D), and overall health (SF-36) data were not included.

Subgroup Analysis

• No subgroup effects were identified.

Adverse Events

• Any post-operative complication: 45% vs 45%; P = 1.000
• Ileus: 12% vs 10%; P = 0.590
• Pneumonia: 14% vs 13%; P = 0.710
• Cardiac event: 11% vs 9%; P = 0.573
• Any surgical-site infection: 24% vs 21%; P = 0.419
• Superficial SSI: 12% vs 8%; P = 0.207
• Deep SSI: 4% vs 3%; P = 0.496
• Organ/space SSI: 8% vs 10%; P = 0.554
• Burst abdomen: 1% vs 1%; P = 0.444
• Length of hospital stay (days): 14 ± 24 vs 15 ± 35; P = 0.585

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Criticisms

• Follow-up limited to 1 year. Incisional hernia continues to develop well beyond 12 months, and longer follow-up would likely raise the overall rate in both arms.
• High radiological-only detection rate. 47% of hernias were found only by imaging; the clinical significance of these small hernias is unclear and likely inflates the reported incidence above historical rates.
• Suture material was not controlled for. The small-bites arm used USP 2-0 on a 31 mm needle while the large-bites arm used USP #1 double-loop on a 48 mm needle, so the observed benefit cannot be cleanly separated from effects of the different suture gauge and needle size.
• Emergency laparotomy not addressed. Data are not necessarily applicable to patients undergoing emergency abdominal surgery, where the highest-risk hernia population lives.

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Funding

• Erasmus University Medical Center and Ethicon.
• Funders played no role in the study design, data collection, analysis, interpretation, or creation of the manuscript.
• The authors had full access to the data and were responsible for the decision to submit for publication.

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Quick-Reference Card

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Related Topic Reviews

• Hernias — incisional hernia epidemiology, risk factors, repair options.

Related Case Prep

• Exploratory Laparotomy — technique considerations for midline opening and closure.

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Source

• Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet. 2015 Sep 26; 386(10000): 1254–1260. doi:10.1016/S0140-6736(15)60459-7. PMID 26188742
• WikiJournalClub STITCH Trial summary