Langenbeck's Archives of Surgery (2024) 409:104

https://doi.org/10.1007/s00423-024-03293-0

SYSTEMATIC REVIEW

Small bites versus large bites during fascial closure of midline

laparotomies: a systematic review and meta‑analysis
Ana Caroline Dias Rasador1 · Sergio Mazzola Poli de Figueiredo2 · Miguel Godeiro Fernandez1 ·
Yasmin Jardim Meirelles Dias3 · Rafael Ribeiro Hernandez Martin4 · Carlos André Balthazar da Silveira1 ·
Richard Lu5

Received: 13 November 2023 / Accepted: 20 March 2024

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2024

Abstract
Purpose Incisional ventral hernias (IVH) are common after laparotomies, with up to 20% incidence in 12 months, increasing
up to 60% at 3–5 years. Although Small Bites (SB) is the standard technique for fascial closure in laparotomies, its adoption
in the United States is limited, and Large Bites (LB) is still commonly performed. We aim to assess the effectiveness of SB
regarding IVH.
Methods We searched for RCTs and observational studies on Cochrane, EMBASE, and PubMed from inception to May
2023. We selected patients ≥ 18 years old, undergoing midline laparotomies, comparing SB and LB for IVH, surgical site
infections (SSI), fascial dehiscence, hospital stay, and closure duration. We used RevMan 5.4. and RStudio for statistics.
Heterogeneity was assessed with ­I2 statistics, and random effect was used if ­I2 > 25%.
Results 1687 studies were screened, 45 reviewed, and 6 studies selected, including 3 RCTs and 3351 patients (49% received
SB and 51% LB). SB showed fewer IVH (RR 0.54; 95% CI 0.39–0.74; P < 0.001) and SSI (RR 0.68; 95% CI 0.53–0.86;
P = 0.002), shorter hospital stay (MD -1.36 days; 95% CI -2.35, -0.38; P = 0.007), and longer closure duration (MD 4.78 min;
95% CI 3.21–6.35; P < 0.001). No differences were seen regarding fascial dehiscence.
Conclusion SB technique has lower incidence of IVH at 1-year follow-up, less SSI, shorter hospital stay, and longer fascial
closure duration when compared to the LB. SB should be the technique of choice during midline laparotomies.

Keywords Small Bites Fascial Closure · Large Bites Fascial Closure · Incisional Hernia · Midline Laparotomy

Introduction to 20% incidence reported at 20 months of follow-up [2–4].

Patients undergoing laparotomies are also at risk of develop-
Despite being the most commonly performed abdominal ing complications [5], such as surgical site infections (SSI)
incision [1], the midline laparotomy is associated with a and fascial dehiscence, which can increase the risk for IVH
high incidence of incisional ventral hernias (IVH), with up [6–8].

* Ana Caroline Dias Rasador Richard Lu

[email protected] [email protected]
Sergio Mazzola Poli de Figueiredo 1
Bahiana School of Medicine and Public Health, Dom João
[email protected]
VI Avenue, 275, Salvador, BA 40290‑000, Brazil
Miguel Godeiro Fernandez 2
Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, USA
[email protected]
3
University of Missouri, 5000 Holmes St, Kansas, MO 64110,
Yasmin Jardim Meirelles Dias
USA
[email protected]
4
Endocrine Surgery Department, Beth Israel Deaconess
Rafael Ribeiro Hernandez Martin
Medical Center, 330 Brooklin Avenue, Boston, MA, USA
[email protected]
5
University of Texas Medical Branch, 301 University Blvd,
Carlos André Balthazar da Silveira
Galveston, TX, USA
[email protected]

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104 Page 2 of 11 Langenbeck's Archives of Surgery (2024) 409:104

The Small Bites (SB) technique for fascial closure was references from each included study and previous systematic
described by Israelsson and colleagues [9] and consists of reviews and meta-analysis were also searched manually for
using 5-8 mm bites and 5 mm steps, allowing better tension additional studies. Conflicts between authors were solved
distribution along the wound and minimizing tissue damage by consensus.
and necrosis [10, 11]. This technique was further studied We searched for studies comparing the SB with the
compared to the traditional Large Bites (LB) technique, and LB techniques, reporting the following outcomes: 1)
showed lower rates of IVH and postoperative complications incisional ventral hernia (IVH), 2) surgical site infections
[12–14]. (SSI), 3) fascial dehiscence, 4) duration of fascial closure,
Although multiple randomized controlled trials (RCTs) and 5) length of hospital stay. The outcome of IVH was
state the superiority of SB regarding IVH, the adoption of evaluated in at least 12 months after the midline laparotomy.
this technique in the US is still very limited [15]. Fascial IVH was defined as a presence of a palpable defect by
closure is still performed by surgeon’s choice, lacking physical examination [10] or a defect noted either through
standardization regarding stitch length and steps [16]. radiological imaging or through physical examination [12,
Furthermore, LB is less complex and can be performed 14, 16, 17]. The secondary outcomes assessed, which were
faster [10, 14], causing it to be the technique of choice for SSI and fascial dehiscence were evaluated within 30 days
fascial closure to some surgeons, despite evidence proving postoperatively. Six of the included studies defined fascial
its inferiority [10]. In addition, no meta-analysis was dehiscence as “burst abdomen” [12–14, 18], while two
done comparing both techniques. This systematic review studies didn’t provide a specific definition for this outcome
and meta-analysis aims to assess the effectiveness of SB [10, 16]. Two reviewers performed the data extraction (AR,
compared to LB regarding the development of IVH and MF), and disagreements were solved between them by
surgical site complications after laparotomies. consensus. This study was registered on PROSPERO (ID:
CRD42023443152).

Material and methods Quality assessment

Eligibility criteria The risk of bias assessment was performed using Cochrane
Handbook of Systematic Reviews, from which the Revised
In this meta-analysis we included studies that met the Cochrane Risk of Bias Tool (Rob-2) was used for assessment
following inclusion criteria: 1) RCTs and observational of randomized controlled trials and the ROBINS-I was
studies, 2) comparing the SB and LB, 3) comprising used for observational studies [19, 20]. The Rob-2 assessed
patients ≥ 18 years old, 4) including primary laparotomies randomization, concealment, blinding, intention to treat,
or relaparotomies, 5) emergency or elective procedures, and baseline comparisons, concomitant interventions, and
6) through midline incisions only. We excluded studies that: completeness of follow-up. Two authors performed the
1) comprised patients ≤ 18 years old, 2) had overlapping risk of bias assessment independently (A.R. and C.S.) and
populations, 3) lacked comparison, 4) lacked outcomes of disagreements between them were solved by consensus.
interest, 5) included abdominal incisions other than midline, Quality of evidence was assessed using Grading
6) were feasibility studies. The intervention group assessed of Recommendations Assessment, Development and
was the Small Bites technique, which consisted in stitches Evaluation (GRADE assessment tool) [21]. Two independent
of 5 to 8 mm and steps between stitches ≤ 5 mm, and the authors (A.R. and C.S.) rated the recommendation’s
control was the conventional Large Bites technique, with strengths using the GRADEpro Guideline Development
stitches measuring ≥ 10 mm. Tool and another author resolved the disagreements.

Search strategy, data extraction, and outcomes Statistical analysis

of interest
Patient and study baseline characteristics were presented
Medline, EMBASE, and Cochrane databases were descriptively in this study. Mean difference (MD) was used
systematically searched without date or language restrictions as an effect measurement for continuous outcomes, with 95%
on studies that met the eligibility criteria from inception until confidence intervals (CI). We used the Mantel–Haenszel
May 2023. The following search strategy was performed test to compute risk ratios (RR) for dichotomous outcomes,
and conducted independently by two authors (AR and MF), and 95% CIs were calculated for intervention effect on
including the following terms: “small bites”, “short bites”, dichotomous variables. We followed the recommendations
“short stitches”, “small stitches”, “small steps”, “large of the Cochrane Collaborations and PRISMA guidelines
bites”, “mass closure”, “long stitches”, and “hernia”. The [22]. We used the Cochran Q test, I2 statistics, and visual
Langenbeck's Archives of Surgery (2024) 409:104 Page 3 of 11 104

inspection of the forest plots to assess heterogeneity. The ­I2 using the R meta package using studies comprising only
values of < 25%, 25–75%, and > 75% were classified in this patients undergoing primary midline laparotomy.
study as low, moderate, and high heterogeneity. P-values of
less than 0.05 were considered statistically significant. The
restricted maximum-likelihood estimator and DerSimonian- Results
Laird random-effects models for analyzing outcomes. The
statistical analysis was performed using Review Manager Study selection and characteristics
5.4. (Nordic Cochrane Center, The Cochrane Collaboration,
Copenhagen, Denmark) and the meta package for RStudio Our primary search generated 1687 results. After excluding
version 4.2.2. (R Foundation for Statistical Computing, the duplicates, 1159 studies remained. From these studies,
Vienna, Austria). 45 were chosen for full-text review. A total of 6 studies,
comprising 3 randomized controlled trials and 3 retrospec-
tive observational studies, met the eligibility criteria and
Subgroup analysis were included in this meta-analysis for further assessment.
The flow diagram of study screening and selection informa-
We performed subgroup analysis using only RCTs for tion is shown in Fig. 1. 3351 patients were included in total:
the following outcomes: 1) IVH, 2) SSI, and 3) fascial 1661 (49%) in the SB technique group and 1790 (51%) in
dehiscence. In addition, we performed subgroup analysis the LB technique group.

Fig. 1  PRISMA Flow Diagram

of Study Screening and Selec-
tion
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Study characteristics are demonstrated in Table 1. All rates of IVH in the SB group (5.8% vs 10.6%), favoring
studies used monofilament slowly absorbable sutures for the SB technique (RR 0.54; 95% CI 0.39–0.74; P < 0.001;
both SB and LB groups. From a total of 3351 patients, ­I2 = 33%; Fig. 2).
1643 (49%) were women, the mean age ranged from 62 to Subgroup analysis was done including only randomized
69 years old, and the mean BMI ranged from 24 to 27 kg/m2. controlled trials, comprising three studies with 1722 patients
In addition, 335 (10%) patients had diabetes mellitus type 2, in total, which also showed lower rates of IVH with SB (RR
283 (8.5%) patients were smokers, and 804 (24%) had ASA 0.48; 95% CI 0.29–0.78; P < 0.003; ­I2 = 53%). In addition,
score ≥ 3. Mean follow-up ranged from 1 to 73 months for subgroup analysis was performed for studies comprising
all outcomes included. Regarding IVH, mean follow-up was patients undergoing primary laparotomy only, with 2 studies
16 months in the SB group and 24 months in the LB group. included in this analysis and 1162 patients, which showed
favorable results for the SB technique with statistical sig-
Pooled analyses of all studies nificance (RR 0.35; 95% CI 0.22–0.58; P < 0.001; ­I2 = 0%;
Fig. 4). The test for subgroup differences between all mid-
Incisional ventral hernia (IVH) line laparotomy patients and primary midline laparotomy
was performed, which showed statistically significant results
IVH was reported in 5 studies, including 3169 patients (P = 0.04; Fig. 2). GRADE [21] assessment was performed
with a follow-up of at least one year. The IVH assessment for IVH, with high certainty of evidence, as showed in
method is shown in Table 1. Our results showed lower Fig. 3.

Table 1  Baseline characteristics of included studies

Study Millbourn 2009 De Vries 2019 STITCH 2015 ESTOIH 2022 Pérez 2022 [18] Söderbäck 2022
[10] [14] [12] [17, 59] [16]

Country Sweden Netherlands Netherlands Germany and Spain Sweden

Austria
Type of study RCT​ Observational RCT​ RCT​ Observational Observational
retrospective retrospective retrospective
Number of 356 / 381 136 / 191 276 / 284 215 / 210 110 / 72 518 / 602
patients, SB/LB
Age (years, SD), 65 (0.5) / 64 (0.5) 69 (12) / 68 (13) 62 (3) / 62.9 (3) NA 68 (16) / 66.6 (16) NA
SB/LB
Female sex (No. 43.5 / 40.2 57.3 / 51.8 50 / 51 47 / 44 45.4 / 55.6 51.3 / 53.9
%), SB/LB
BMI† (kg/m2, SD), 26 / 26 27 (5) / 27 (5) 24 (0.9) / 24 (0.9) 25.4 (4) / 25.1 (4) NA NA
SB/LB
Diabetes Mellitus 11 / 8.7 10 / 18 11 / 14 10 / 19 16.4 / 18 11 / 11
(No. %), SB/LB
Smoking (No. %), NA 16.2 / 17.3 28 / 23 17 / 15 10 / 9.7 NA
SB/LB
ASA score ≥ 3 NA NA 19 / 15 36 / 36 59 / 43 45.3 / 37.5
(No. %), SB/LB
Primary Primary Primary Primary Primary Primary Primary laparotomy
laparotomy/ laparotomy laparotomy and laparotomy and laparotomy laparotomy and and relaparotomy
relaparotomy (100%) relaparotomy relaparotomy (100%) relaparotomy
(No. %)
Follow-up† 12 / 12 16.7 (7.5) / 22.7 15 / 15 12 (1) / 12 (1) 1/1 32 / 73
(months, SD), (13.4)
SB/LB
IVH assessment PE (100%) PE (40%) / PE (24%) / RI PE + RI (100%) NA PE or RI
method (%) RI + PE (60%) (14%) / PE + RI
(62%)
Suture (SB/LB 2–0 PDS II / 1–0 2–0 PDS II / 1 2–0 PDS plus II / 2–0 P4HB / 1 0 PDS Plus / 2–0 PDS / 0 PDS
technique) PDS II PDS II 1 PDS plus II P4HB 1 Polyglyconate
†
Mean and Standard Deviation (SD); SB: Small Bites Technique; LB: Large Bites Technique; BMI: Body mass index; NA: not available;
PE: physical examination; RI: radiological imaging (none of the studies describe the specific method); PDS: Polydioxanone. P4HB: poly-4-
hydroxybutyrate; IVH: Incisional Ventral Hernia
Langenbeck's Archives of Surgery (2024) 409:104 Page 5 of 11 104

Fig. 2  Meta-analysis Of Inci-

sional Ventral Hernia Between
Small Bites and Large Bites
Techniques

Fig. 3  Grading of Recommendations Assessment, Development, and Evaluation of All Outcomes [21]

Fig. 4  Meta-analysis of Surgical

Site Infections Between Small
Bites and Large Bites Tech-
niques

Surgical site infections (SSI) Subgroup analysis was also done using only RCTs for
SSI, comprising three studies and 1722 patients, which
SSI was reported in all the 6 studies included. A total of showed no differences between both techniques (RR 0.73;
3351 patients were analyzed and SB technique was associ- 95% CI 0.51–1.03; P = 0.07; ­I2 = 27%). In contrast, sub-
ated with lower rates of SSI (RR 0.68; 95% CI 0.53–0.86; group analysis was performed for patients undergoing
P = 0.002; ­I2 = 0%; Fig. 4) when compared to the LB tech- primary laparotomy only, including 2 studies and 1162
nique (8.1% vs 11.8%). patients, which reported favorable results for the SB
 104 Page 6 of 11 Langenbeck's Archives of Surgery (2024) 409:104

technique (RR 0.55; 95% CI 0.34–0.89; P = 0.015; ­I2 = 0%; (P = 0.15; Fig. 5). GRADE [21] assessment was performed
Fig. 4). The test for subgroup differences between the for fascial dehiscence, with moderate certainty of evidence,
primary laparotomy patients and the overall analysis was as showed in Fig. 3.
performed, however, we didn’t find statistical significance
(P = 0.34; Fig. 4). GRADE [21] assessment was performed
for SSI, as showed in Fig. 3, with moderate certainty of Duration of fascial closure
evidence.
Two studies reported duration of fascial closure, with 985
Fascial dehiscence patients analyzed. Our results showed longer duration of
fascial closure for the SB group, which was 4.7 min longer,
Fascial dehiscence was reported in all 6 studies, using a favoring the LB technique (MD 4.78; 95% CI 3.21–6.35;
short-term follow-up of 4 weeks. 3351 patients were ana- P < 0.001; ­I2 = 83%; Fig. 6). GRADE [21] assessment was
lyzed, and no differences were seen between both groups performed for duration of fascial closure, with moderate
(RR 0.69; 95% CI 0.47–1.00; P = 0.055; ­I2 = 0%; Fig. 5). certainty of evidence (Fig. 3).
Subgroup analysis was done using only RCTs, compris-
ing 3 studies and 1722 patients, which showed no differ-
ence between SB and LB techniques (RR 0.62; 95% CI Length of hospital stay
0.16–2.45; P = 0.49; ­I 2 = 40%). Subgroup analysis was
also done using studies comprising primary laparotomies As for length of hospital stay, reported in three studies,
only, with 2 studies and 1162 patients, with statistically SB was associated with shorter length of hospital stay
significant results (RR 0.30; 95% CI 0.09–0.98; P = 0.047; (MD -1,36 days; 95% CI -2.35, -0.38; P = 0.007; ­I2 = 0%).
­I2 = 0%; Fig. 8). However, when the test for subgroup differ- GRADE [21] assessment was also performed, as reported
ences was performed, we didn’t find statistical significance in Fig. 5, with low certainty of evidence.

Fig. 5  Meta-analysis of Fascial

Dehiscence Between Small
Bites and Large Bites Tech-
niques

Fig. 6  Meta-analysis of Duration of Fascial Closure Between Small Bites and Large Bites Techniques
Langenbeck's Archives of Surgery (2024) 409:104 Page 7 of 11 104

Risk of bias This technique is associated with tissue necrosis and trauma
surrounding soft tissue, resulting in higher rates of IVH and
In the ROBINS-I assessment (Fig. 7), two studies showed postoperative complications [10, 12]. Kushner et al. [32]
critical risk of bias, and one of the studies was deemed as reported, by studying porcine models using Indocyanine
having moderate risk. In the Rob-2 (Fig. 8), one study was Green laser-induced fluorescence angiography (ICG-FA),
deemed as having high risk, one as having some concerns, that the LB technique is associated with lower tissue
and the other was categorized as low risk of bias. perfusion within 1 week of surgery compared to SB. This
may relate to the association of LB with worse distribution
of forces and a low proportion of collagen type I/III,
Discussion impairing strength and fascial blood flow [12, 33].
The SB technique, first described by Israelsson and
In this systematic review and meta-analysis with 6 studies colleagues [9, 11], consists of using a suture to wound length
and 3351 patients, the SB technique was associated with ratio ≥ 4:1 combined with stitches of 5-8 mm, and steps
lower IVH, and shorter length of hospital stay when between stitches of 5 mm. In the same study from Kushner
compared to the LB technique. SB may be also associated et al. [32], ICG-FA intensity was more than 5.2% higher in
with lower rates of SSI, however, after performing a the SB group compared to the LB group within 1 week of
subgroup analysis with RCTs only, there were no differences surgery, showing greater fascial blood flow and postoperative
between both techniques. No differences were seen regarding tissue perfusion in the SB technique. Furthermore, Höer
fascial dehiscence. Finally, the SB was associated with a et al. [25], by studying rodent models, described that SB
slightly longer duration of fascial closure (MD 4.7 min). promotes increased collagen type I/III relation, providing
Up to 5 million laparotomies are performed annually better strength distribution along the wound.
in the United States (US), most commonly through a The STITCH [12] RCT comprising 560 midline
midline incision [12]. Laparotomies are associated with a laparotomy patients, which compared SB to LB, reported
high incidence of IVH, varying between 9 to 20% after a lower IVH rates after a 1-year follow-up in the SB group
1-year follow-up [23–25], and up to 21.3% and 69.1% after (13% vs 21%; P = 0.02). Similarly, Millbourn et al. [10]
3 years and 5 years, respectively [26, 27]. Developing an reported lower IVH incidence in an RCT with 737 midline
IVH can significantly impact patients as it is associated laparotomy patients for the SB group (3.9% vs 12.8%). This
with lower quality of life and need for reoperations in up to highlights a possible relationship between LB and a higher
32% of patients at a 10-year follow-up [28–30]. IVH also amount of tissue necrosis and weakening of the abdominal
significantly impacts the health system as approximately wall [11, 34], and correlates with this meta-analysis, which
$3.2 billion is spent annually with its repair in the US [1, also found difference between SB and LB techniques for
31]. IVH. Our subgroup analysis comprising only primary
Traditionally, laparotomies are closed using Large Bites midline laparotomy patients showed that the SB was still
(LB), which consists in stitches and steps measuring ≥ 1 cm. superior, with significant subgroup differences (P = 0.04).

Fig. 7  Risk Of Bias Assessment of Observational Studies (ROBINS-I)

Fig. 8  Risk Of Bias Assessment of Randomized Controlled Trials (Rob-2)

104 Page 8 of 11 Langenbeck's Archives of Surgery (2024) 409:104

This correlates with previous studies, which shows that obese patients. Since all of the studies were performed in
primary laparotomy patients might be specially benefited European countries, this raises concerns regarding applying
by the SB and that relaparotomy patients are at higher risk these results to the US population, where the BMI of the
for IVH [10, 13, 35]. Probst et al. [36], in a feasibility RCT population is significantly higher when compared to these
comparing the SB and LB techniques in relaparotomy countries [41, 42].
patients, found no differences for IVH, SSI, and fascial On the other hand, despite not including obese patients,
dehiscence, but our analysis including relaparotomy patients our study included smokers, diabetics, and relaparotomy
showed lower rates of IVH for SB (P = 0.003). Further patients, who are at increased risk for IVH and surgical site
studies on relaparotomy patients to evaluate the correct SB complications [35, 37]. Especially relaparotomy patients,
efficacy in this population profile are needed. who were included in three of our studies, have an increased
In our analysis, the SB showed lower rates of SSI risk for complications, including fascial dehiscence, due to
(P = 0.002), however, in a subgroup analysis of RCTs, no weakening of the abdominal wall [43, 44]. Also, Millbourn
differences were seen. Subgroup analysis on SSI rates in et al. [10], STITCH trial [12], and ESTOIH trial [13]
primary laparotomies favored SB (4.3% vs 7.9%; P = 0.015), included smokers and diabetic patients, which have impaired
but subgroup differences were not significant (P = 0.34). wound healing and higher risk for IVH and surgical site
This suggests similar risk in primary laparotomy and occurrences, such as SSIs [45]. Although it is reasonable to
previous midline incisions [12, 37]. Millbourn et al. [10] and believe that the SB technique could apply to obese patients,
the ESTOIH trial [17] reported lower rates of SSI for the SB, further studies are needed to assess the efficacy of this
contrary to STITCH trial [12], possibly due to the divergent technique in this population.
fascial closure techniques used for LB. While the ESTOIH In addition, Pasquali et al. [46] described that surgeons
trial [17] and Millbourn et al. [10] used only the fascia for not trained in universities and academic hospitals are less
closure in the LB technique, the STITCH trial [12] used inclined to use evidence-based practices. Analogously,
the standard mass closure, impacting SSI rates. In addition, Altschuler et al. [47] showed that surgeons prioritize lessons
despite using the triclosan-coated polydioxanone suture, and techniques learned in practice rather than perceiving
Similarly as reported by Millbourn et al. [10] and the literature evidence. The dogma created during the surgeon’s
STITCH trial [12], we noted a slightly longer fascial closure training is one of the barriers to adopting the SB technique,
time for SB. Although this difference was statistically causing the fascial closure to be performed based on
significant, the MD was only 4.7 min, which is of very experience and the surgeon’s habits without evidence-based
limited clinical significance. The benefits of decreasing techniques [48–51].
IVH rates outweigh the harm of longer duration of fascial In addition to the SB technique, prophylactic mesh
closure [15, 38]. Millbourn et al. [39] performed a cost- placement (PMP) is another potential strategy to decrease
utility analysis in Sweden, which reported that the SB IVH rates. European Hernia Society (EHS) guidelines
technique is associated with reduced financial costs, provide a weak recommendation in favor of PMP in patients
taking into consideration the time away from work and at high risk of developing incisional hernias during elective
loss of productivity, as long as the duration of surgery is midline laparotomy [52]. Although RCTs report a lower
increased by a maximum of 10.3 min. Additionally, in a cox incidence of IVH and fascial dehiscence with onlay PMP
proportional hazard model performed by the ESTOIH trial compared to standard techniques for fascial closure using
[13] the rate of fascial dehiscence decreased when surgeon’s slowly absorbable suture with a 4:1 ratio, increased rates
took a longer time to perform the fascial closure. of seromas, nonhealing wound and SSI also occurred
Despite the recent evidence reporting the superiority of with PMP [53, 54]. Although other prophylactic mesh
SB regarding IVH and other postoperative complications, positions, such as in the retromuscular position, have been
the LB is still frequently used during fascial closure in studied with acceptable outcomes [55], it is important to
laparotomies, especially in the US, where the adoption of preserve the retromuscular space for definitive abdominal
SB is limited (16). Cochrun et al. [40] in a survey to assess wall reconstruction if an IVH were to develop, as redo
the adoption of the STITCH trial [12], showed that 26% retromuscular incisional hernia repair can be associated
didn’t apply the SB in daily practice due to the BMI of with significant morbidity [56]. As the EHS suggests, PMP
the US population, which is higher than that of the trials is another potential strategy for IVH prevention and can be
about this topic. On the other hand, 16% didn’t adopt the considered in very select group of patients [52]. However,
SB due to the demographics of US patients, such as higher further larger trials are necessary to establish what mesh
rate of comorbidities when compared to the STITCH type, mesh position and who are the patients that would
[12] sample. The studies included in this meta-analysis benefit from PMP.
comprised, similarly as the STITCH trial [12] and Millbourn Another important technical aspect of the included
et al. [10], patients with low BMI (≤ 27 kg/m2), lacking studies is the suture material utilized. Although all
Langenbeck's Archives of Surgery (2024) 409:104 Page 9 of 11 104

studies used slowly absorbable sutures, most commonly Author contributions -Study conception and design: A.R. and C.S.-
polydioxanone (PDS), the ESTOIH trial [36] used the Acquisition of data: A.R. and M.F.-Analysis and interpretation of data:
A.R. and Y.D.-Drafting of the manuscript: A.R. and R.M.-Critical
poly-4-hydroxybutyrate suture (P4HB), which has higher revision of the manuscript: S.F. and R.L.
elasticity, tensile strength, absorption rate, and slower
degradation when compared to the PDS [57], and could have Funding This manuscript received no funding.
influenced IVH rates. While the ESTOIH trial [17] reported
an overall IVH rate at 1 year of 4.7%, the STITCH trial Declarations
[12] reported a 16.4% overall IVH rate at 1 year. In addition Competing interests Ana Caroline Dias Rasador, Sergio Mazzola Poli
to IVH, the SSI rates could also be impacted by suture de Figueiredo, Miguel Godeiro Fernandez, Yasmin Jardim Meirelles
properties as the STITCH trial [12] utilized triclosan-coated Dias, Rafael Ribeiro Hernandez Martin, and Carlos André Balthazar
PDS. Despite utilizing suture materials with antimicrobial da Silveira declare that they have no conflicts of interest. Dr. Richard
Lu received payment/honoraria from Intuitive Surgical for lectures and
properties [58], the STITCH trial [12] overall SSI rates teaching lessons, which are not related to this specific work.
(22.5%) was higher when compared to other studies such
as the ESTOIH trial [59] (4.7%) and Millbourn et al. [10]
(7.0%).
There are additional limitations in our study. Firstly, References
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