STITCH

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Deerenberg, Eva. "Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised". The Lancet. 2015. 386(10000):1254-1260.
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Clinical Question

Among adult patients undergoing midline laparotomy, does small (5mm) bites of fascia decrease the incidence of incisional hernia compared with traditional large (10mm) bites?

Bottom Line

Small bite suture technique for midline abdominal fascial closure decreases the incidence of postoperative hernia.

Major Points

The most common complication following midline laparotomy is incisional hernia, with rates estimated as high as 20% in healthy patients, and up to 35% in patients with risk factors (obesity, AAA, and diseases impacting wound healing). Incisional hernias decrease quality of life, and furthermore can require reoperation if symptomatic or involve incarcerated/strangulated bowel.

Previously identified technical considerations in preventing incisional hernia during laparotomy closure are single-layer running technique “mass closure” (involving all layers from a small amount of subcutaneous fat superficially to the parietal peritoneum deep) with a slowly resorbable suture material and a suture length to wound length ratio of 4 or more [1], [2]. Historically, it was thought that a larger “bite” (lateral distance from wound edge) of 10mm with an advancement (superior/inferior distance between stitches) of 10mm would result in a larger incorporation of fascia, thereby increasing tensile strength and decreasing dehiscence rates. Recent evidence challenged this perception, as long stitches have been associated with both wound infection (a risk factor for dehiscence) and incisional hernia[3]. The purported mechanism of failure is the long stitch method cuts through tissue, causing greater necrosis of the wound, which causes the stitch to slacken and increases risk of hernia.

The STITCH trial compared closure of elective midline laparotomy using large-bite methods (mass closure as described above, 10mm distance) to a small-bite approach (aponeurosis layer only without muscle/fat, 5mm distance), and reported a significant decrease in radiographic and clinically diagnosed incisional hernias at one year follow-up. This is a landmark trial due to the technical implications of improving surgical closure in order to reduce rates of incisional hernia.

Guidelines

European Hernia Society Guidelines on the Closure of Abdominal Wall Incisions [4]

  • The small bites technique is suggested

Design

  • Multicenter, prospective, double-blind randomized study
  • N= 560 (248 large bite, 286 small bite)
  • Setting: Inpatient and ORs in the Netherlands
  • Enrollment: October 2009 to March 2012
  • Mean follow-up: 1 month, 12-15 months after surgery
  • Analysis: t-tests for continuous variables, chi-squared for categorical variables
    • censored at reoperation, death, lost to follow-up
  • Primary outcome: radiographic/clinically evident incisional hernia at one year
    • European hernia society definition: any abdominal wall gap in a postoperative scar detectable by clinical palpation or imaging

Population

Inclusion Criteria

  • aged 18 or older
  • Elective abdominal surgery via midline incision


Exclusion Criteria

  • History of incisional hernia/fascial dehiscence
  • Midline abdominal surgery within 3 months
  • Pregnancy
  • Alternative interventional trial
  • emergent laparotomy

Baseline Characteristics

Small bites group

  • N=276
  • Male 50%
  • Age 62 years
  • BMI 24
  • Smoking 28%
  • Diabetes 11%
  • COPD 16%
  • Cardiovascular disease 37%
  • Corticosteroid use 10%
  • Non-incisional hernias 13%
  • Abdominal aorta aneurysm 5%
  • Previous laparotomy 18%
  • ASA classification
    • 1 22%
    • 2 59%
    • 3 19%
  • Preoperative chemotherapy 22%
  • Preoperative radiotherapy 21%
  • Type of surgery
    • Gynecologic 15%
    • Upper GI 27%
    • Lower GI 51%
    • Vascular 8%

Interventions

“Large bite technique”

  • 10mm distance from incision (horizontal), 10mm distance between bites (vertical distance)
  • “mass closure” (involving all layers from a small amount of subcutaneous fat superficially to the parietal peritoneum deep)
  • USP 2-0 PDS Plus II, 31mm needle

“Short bite technique”

  • 5mm distance from incision (horizontal), 5mm distance between bites (vertical distance)
  • fused midline aponeurosis (contributory aponeurosis from external abdominal oblique, internal abdominal oblique, and transversus abdominis). Does not include fat or muscle tissue
  • USP 2-0 PDS Plus II, 31mm needle
  • In both cases, suturing was performed starting both superior and inferior, run towards the center, with at least 2cm, separately knotted

Outcomes

Comparisons are large bite vs. small bite fascial closure’’

Primary Outcomes

Incisional hernia 1 year post-operative
21% vs. 13% (OR 0.52; 95% CI 0.31-0.87; P=0.02)

Secondary Outcomes

Postoperative complications
45% vs. 45% (P = 1.0)
Ileus
12% vs. 10% (P= 0.59)
Pneumonia
14% vs. 13% (P= 0.71)
Cardiac event
11% vs. 9% (P= 0..57)
Surgical Site Infection
Overall 24% vs. 21% (P=.42)
Superficial: 12% vs. 8% (P= 0.21)
Deep 4% vs. 3% (P=.50)
Organ/space 8% vs. 10% (P=.55)
Burst abdomen
1% vs. 1% (P= 0.44)
Length of stay
24 days vs. 35 days(P= 0.44):


Subgroup Analysis

  • Patients who developed incisional hernias reported lower general health SF-36 scores, and greater difficulty in EQ-5D dimension of mobility
  • No subgroup effects were identified

Adverse Events

  • Death and burst abdomen rates did not differ between the two groups

Criticisms

  • Short follow-up may underestimate incidence of incisional hernias
  • Significant proportion of hernias (approximately half) were diagnosed by radiographic evidence alone, with unclear clinical implications. The size of radiographic hernias were notably not smaller
  • Different suture materials were used between the two groups, and it may therefore be that a smaller needle and thinner suture material (used in the small bite group) contributes to decreased hernia recurrence independent of closure tecnique
  • Unclear extrapolation to emergency laparotomies

Funding

  • Funding by Ethicon
  • Funding by Erasmus University Medical Center Research Grant
  • The authors disclose no conflicts of interest

Further Reading

  1. van 't Riet M et al. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg 2002. 89:1350-6.
  2. Weiland DE et al. Choosing the best abdominal closure by meta-analysis. Am. J. Surg. 1998. 176:666-70.
  3. Millbourn D et al. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg 2009. 144:1056-9.
  4. Muysoms FE et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 2015. 19:1-24.