Small Bites Versus Large Bites in Midline Incision Closure

Key Takeaways

• At 13 years, cumulative incisional hernia incidence was 34% with small bites and 49% with large bites.
• Incisional hernias wider than 20 mm were less frequent after small-bites closure, occurring in 17% versus 34% of patients.
• Hernia repair rates were similar between groups, and patients with an incisional hernia reported lower quality of life.

In a multicenter, double-blind JAMA Surgery randomized clinical trial from the Netherlands, investigators found that small-bites fascial closure after elective midline laparotomy was associated with lower long-term hernia risk than large-bites closure, with a hazard ratio of 0.61. Follow-up had a median of 8 years and extended to 15 years, with cumulative incisional hernia estimates through 13 years. The long-term difference in hernia burden persisted after standardized continuous closure techniques.

The study ran between October 2009 and March 2012 at 10 participating centers in the Netherlands. Investigators randomized 559 patients, with 275 assigned to small bites and 284 to large bites. Small-bites closure used 5 mm × 5 mm steps with polydioxanone 2-0 on a 31-mm needle, while large-bites closure used 10 mm × 10 mm steps with looped polydioxanone on a 48-mm needle. The primary outcome was cumulative incisional hernia incidence, detected clinically and radiologically and analyzed with competing-risk time-to-event methods. The protocol specified bite size, suture type, and needle choice for each group and included long-term follow-up.

For the primary endpoint, competing-risk time-to-event analyses favored small bites over large bites throughout long-term follow-up, consistent with the cumulative incidence difference. For incisional hernia width greater than 20 mm, the hazard ratio was 0.36, with a 95% CI of 0.21 to 0.60. At final follow-up, mean hernia size was 25 mm after small-bites closure and 43 mm after large-bites closure. That size difference was statistically significant, with a reported P value of .02. Small bites were also associated with smaller defects when hernias occurred.

Hernia repair rates were similar between groups, while patients with an incisional hernia reported significantly lower quality of life. At final follow-up, 170 patients were alive without evidence of incisional hernia. Of those patients, 122, or 72%, underwent additional abdominal ultrasound. Abdominal imaging obtained during routine care was available for 238 patients. These follow-up data extended the assessment of incisional hernia burden.

In this elective midline laparotomy trial, the authors concluded that small bites reduced the long-term risk and width of incisional hernias across extended follow-up. They also stated that the technique's simplicity, cost neutrality, and broad applicability support viewing it as standard practice. They called for further research on strategies to improve adoption and to assess broader patient-centered outcomes.