Midline laparotomy remains one of the most common surgical approaches for accessing the abdominal cavity, particularly in emergency settings [1]. Despite its widespread use, this approach is associated with significant postoperative complications, including wound dehiscence, surgical site infections (SSIs), and incisional hernias, which occur in approximately 1-3%, 15%, and 20% of patients, respectively [2,3]. These complications not only increase morbidity and mortality but also contribute to prolonged hospitalization, increased healthcare costs, and reduced quality of life [4].

The pathophysiology of these complications is multifactorial, involving patient-related factors such as obesity, malnutrition, and immunosuppression, as well as technical factors related to the surgical approach and closure technique [5]. Among the technical factors, the method of fascial closure has emerged as a critical determinant of postoperative outcomes. Traditional closure techniques using large tissue bites (typically 10mm) have been associated with higher complication rates due to increased tissue ischemia and impaired wound healing [6].

In recent years, the small bite suturing technique, characterized by smaller tissue bites (5-8mm) taken at closer intervals, has gained attention as a potentially superior approach for abdominal wall closure [7]. This technique is based on the principle that taking smaller bites of the fascia, while maintaining an adequate suture length to wound length ratio (at least 4:1), distributes tension more evenly across the wound and reduces tissue strangulation [8]. Several studies have demonstrated the benefits of this technique in reducing the incidence of incisional hernias and SSIs [9,10].

The landmark STITCH trial by Deerenberg et al. [11] provided robust evidence supporting the small bite technique, showing a significant reduction in incisional hernia rates at 1 year (13% vs. 21%) compared to the large bite technique. Similarly, Millbourn et al. [12] reported that the small bite technique nearly quartered the rate of incisional hernias and halved the rate of SSIs compared to the large bite technique. These findings have been supported by subsequent studies, leading to increasing adoption of the small bite technique in clinical practice [13].

Despite this growing evidence base, most studies have been conducted in elective surgical settings or mixed populations, with limited data specifically focusing on emergency laparotomies, which carry a higher risk of complications due to factors such as hemodynamic instability, contamination, and physiological stress [14]. Furthermore, there is a paucity of data from Indian populations, where unique patient characteristics and healthcare settings may influence outcomes.

This study aimed to compare the efficacy of small bite versus large bite suturing techniques for midline laparotomy wound closure in an emergency setting, with a focus on postoperative complications and technical parameters. We hypothesized that the small bite technique would be associated with lower rates of incisional hernia, wound sepsis, and wound dehiscence compared to the large bite technique, despite requiring longer sutures and more time for closure.

Study Design and Setting

A randomized comparative parallel study was conducted at the Department of General Surgery, Deen Dayal Upadhyay Hospital, New Delhi, between July 2022 and June 2024.

Sample Size Calculation

The sample size was calculated based on the study by Millbourn et al. [12], which reported incisional hernia rates of 4.7% in the small bite group and 17.2% in the large bite group. Using a two-sided alpha error of 5% and power of 80%, the minimum sample size required was 97 patients per group. Accounting for a 5-10% loss to follow-up, the final sample size was set at 100 patients per group (total 200 patients).

Patient Selection

All adult patients (age >18 years) undergoing emergency laparotomy with midline incision were considered for inclusion. Exclusion criteria included: previous incisional hernia after midline incision, previous surgery through a midline incision within 3 months, pregnancy, current immunosuppressive therapy (more than 40 mg of corticosteroid per day or azathioprine), chemotherapy within 2 weeks before operation, and severe neurologic or psychiatric disease.

Randomization and Blinding

Computer-generated block randomization was used to allocate patients to either the small bite technique group (Group A) or the large bite technique group (Group B). The randomization sequence was concealed in sealed opaque envelopes, which were opened just before fascial closure. Due to the nature of the intervention, surgeons could not be blinded to the allocated technique; however, outcome assessors and data analysts were blinded to the group assignment.

Surgical Technique

All procedures were performed by experienced surgeons. After completing the intra-abdominal procedure, fascial closure was performed using polypropylene No. 1 suture material in both groups.

Small bite technique (Group A): Tissue bites of 5mm were taken from the wound edge, with inter-suture spacing of 5mm. The suture was placed in the aponeurosis only, avoiding incorporation of the rectus muscle. The principle was to place at least twice as many stitches as the incision length in centimeters.

Large bite technique (Group B): Tissue bites of at least 10mm were taken from the wound edge, with inter-suture spacing of 10mm. This technique incorporated both the aponeurosis and underlying muscle tissue.

In both groups, suturing was performed from both ends of the incision toward the center, creating an overlap of at least 2cm where the sutures met. Both sutures were then separately knotted. The length of suture used and the time taken for fascial closure were recorded for each patient.

Outcome Measures

Primary outcome: Incidence of incisional hernia at 12 months, defined as "any abdominal wall gap with or without a bulge in the area of a postoperative scar, palpable or perceptible by clinical examination or imaging."

Secondary outcomes:

1. Wound sepsis: Defined according to Centers for Disease Control and Prevention (CDC) criteria as infection occurring within 30 days after surgery involving skin and subcutaneous tissue of the incision, with at least one of the following: purulent drainage; organisms isolated from an aseptically obtained culture; at least one sign or symptom of infection (pain, tenderness, localized swelling, redness, or heat) with deliberate opening by the surgeon; or diagnosis by the surgeon.
2. Wound dehiscence: Defined as postoperative separation of the abdominal musculoaponeurotic layers.
3. Mean suture length: Total length of suture material used for fascial closure.
4. Mean operative time for closure: Time from start of fascial closure to completion of knot tying.

Follow-up Protocol

Patients were followed up on postoperative days 3, 7, and 15, then at 1 month, 6 months, and 12 months after surgery. At each follow-up visit, clinical examination was performed to assess for wound complications. From the 1-month follow-up onward, ultrasonography was also performed to detect subclinical incisional hernias.

Statistical Analysis

Data were analyzed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and compared using the Wilcoxon-Mann-Whitney U test for non-normally distributed data. Categorical variables were expressed as frequencies and percentages and compared using the chi-square test or Fisher's exact test as appropriate. A p-value <0.05 was considered statistically significant.

Baseline Characteristics

A total of 215 patients were assessed for eligibility, of which 15 were excluded (1 did not meet inclusion criteria, 1 refused to participate, and 13 had other reasons). The remaining 200 patients were randomized to either the small bite technique group (n=100) or the large bite technique group (n=100). All patients received the allocated intervention and were included in the final analysis.

The baseline characteristics of the study population are presented in Table 1. The mean age was 37.77±16.34 years in the small bite group and 35.59±14.00 years in the large bite group, with no significant difference between groups (p=0.627). The small bite group had a higher proportion of males (85% vs. 76%), although this difference was not statistically significant (p=0.108).

Primary Outcome: Incisional Hernia

The incidence of incisional hernia at 12 months was significantly lower in the small bite technique group (0%) compared to the large bite technique group (8%) (p=0.007). All cases of incisional hernia in the large bite group were detected at the 6-month follow-up, with no new cases identified at 12 months (Table 2).

Secondary Outcomes

Wound Sepsis: The overall incidence of wound sepsis was significantly lower in the small bite technique group (23%) compared to the large bite technique group (58%) (p<0.001). This difference was particularly evident in the early postoperative period, with wound sepsis on postoperative day 3 occurring in 1% of patients in the small bite group versus 34% in the large bite group (p<0.001). However, there was no significant difference in wound sepsis rates between groups at postoperative day 7 (22% vs. 24%, p=0.737) (Table 2).

Wound Dehiscence: The overall incidence of wound dehiscence was significantly lower in the small bite technique group (1%) compared to the large bite technique group (32%) (p<0.001). Wound dehiscence on postoperative day 7 occurred in 1% of patients in the small bite group versus 23% in the large bite group (p<0.001). Similarly, wound dehiscence on postoperative day 15 occurred in 0% of patients in the small bite group versus 9% in the large bite group (p=0.003) (Table 2).

Technical Parameters: The small bite technique required significantly longer suture length (109.30±6.68cm) compared to the large bite technique (88.40±4.91cm) (p<0.001). Similarly, the mean operative time for closure was significantly longer in the small bite technique group (16.02±3.05 minutes) compared to the large bite technique group (10.19±1.50 minutes) (p<0.001) (Table 3).

Table 1: Baseline Characteristics of Study Population

Table 2: Comparison of Postoperative Complications

Table 3: Comparison of Technical Parameters

This randomized controlled trial demonstrates that the small bite suturing technique significantly reduces postoperative complications following emergency midline laparotomy compared to the traditional large bite technique. The small bite technique was associated with an 8% absolute reduction in incisional hernia rates, a 35% absolute reduction in wound sepsis rates, and a 31% absolute reduction in wound dehiscence rates. These findings are consistent with previous studies and provide further evidence supporting the adoption of the small bite technique in emergency surgical settings.

The reduction in incisional hernia rates observed in our study (0% vs. 8%) is particularly noteworthy. While our absolute reduction is smaller than that reported in the STITCH trial (8% vs. 13%) [11], the relative risk reduction is comparable. This difference may be attributed to several factors, including our focus on emergency laparotomies, which carry a higher baseline risk of complications, and our relatively shorter follow-up period (12 months vs. longer follow-up in other studies). It is possible that with extended follow-up, additional cases of incisional hernia might have been detected in both groups, potentially widening the absolute difference.

The significant reduction in wound sepsis rates with the small bite technique (23% vs. 58%) is consistent with the findings of Millbourn et al. [12], who reported a halving of SSI rates with the small bite technique. The early postoperative period appears to be particularly critical, with the most significant difference observed on postoperative day 3 (1% vs. 34%). This early difference may be explained by the reduced tissue ischemia associated with the small bite technique, which allows for better perfusion and oxygen delivery to the wound edges, enhancing resistance to infection [15]. The smaller bites also create a more secure closure that is less prone to disruption during coughing or straining, common occurrences in the early postoperative period.

Similarly, the marked reduction in wound dehiscence rates with the small bite technique (1% vs. 32%) highlights the superior mechanical stability of this closure method. This finding is consistent with experimental studies demonstrating that small bites with small suture distances increase laparotomy closure strength by distributing tension more evenly across the wound [16]. The large bite technique, which incorporates more muscle tissue, may create areas of focal stress concentration that are prone to disruption, particularly in emergency settings where patients may have increased intra-abdominal pressure due to pain, coughing, or physiological stress.

Despite these clinical benefits, the small bite technique required significantly longer suture length (109.30±6.68cm vs. 88.40±4.91cm) and more time for closure (16.02±3.05 minutes vs. 10.19±1.50 minutes). These technical differences are expected given that the small bite technique requires more individual stitches to achieve the same wound length. However, the additional 6 minutes required for closure and the modest increase in suture material usage seem reasonable trade-offs for the substantial reduction in postoperative complications. From a healthcare economics perspective, the cost of additional suture material and operating room time is likely offset by the reduced costs associated with managing complications such as SSIs, wound dehiscence, and incisional hernias [17].

The mechanisms underlying the superiority of the small bite technique are multifactorial. First, by taking smaller bites of the fascia, the technique minimizes tissue strangulation and ischemia, which are known to impair wound healing and increase infection risk [18]. Second, the increased number of stitches distributes tension more evenly across the wound, reducing the risk of focal failure and subsequent dehiscence or hernia formation [19]. Third, by avoiding incorporation of the rectus muscle, the small bite technique may reduce postoperative pain and muscle dysfunction, further promoting optimal wound healing [20].

Our study has several strengths, including its randomized design, adequate sample size, and focus on emergency laparotomies, a population at high risk of complications. However, several limitations should be acknowledged. First, the relatively short follow-up period (12 months) may have underestimated the true incidence of incisional hernias, which can develop years after surgery. Second, our study was conducted at a single center, which may limit the generalizability of our findings to other settings. Third, we did not assess patient-reported outcomes such as pain, cosmesis, or quality of life, which are important considerations when evaluating surgical techniques. Finally, while we attempted to control for known confounders through randomization, unmeasured factors such as nutritional status, comorbidities, and surgical expertise may have influenced our results.

In conclusion, our study provides robust evidence that the small bite suturing technique significantly reduces postoperative complications following emergency midline laparotomy compared to the traditional large bite technique. Despite requiring longer sutures and more time for closure, the clinical benefits of the small bite technique make it the preferred approach for emergency abdominal closure. Future studies with longer follow-up periods and multicenter designs are needed to further validate these findings and assess the cost-effectiveness of this technique across diverse healthcare settings.

This randomized controlled trial demonstrates that the small bite suturing technique significantly reduces postoperative complications following emergency midline laparotomy compared to the traditional large bite technique. The small bite technique was associated with lower rates of incisional hernia (0% vs. 8%), wound sepsis (23% vs. 58%), and wound dehiscence (1% vs. 32%). Although the small bite technique required longer suture length and more time for closure, these technical trade-offs are justified by the substantial clinical benefits. Based on these findings, the small bite suturing technique should be considered the standard approach for emergency midline laparotomy closure to minimize postoperative complications and improve patient outcomes.

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