The small-bites technique, endorsed by leading medical associations (eg. the European Hernia Society, the American Hernia Society and the World Society of Emergency Surgery), involves smaller, more frequent tissue bites during suturing. This method is crucial for achieving precise abdominal wall closure.
Key aspects of small-bites technique
1. Fortelny RH. Abdominal wall closure in elective midline laparotomy: the current recommendations. Front Surg. (2018) 5:34.
2. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg. 2009 Nov;144(11):1056-9. doi: 10.1001/archsurg.2009.189. PMID: 19917943.
3. Theodorou A, Banzsch M, Gök H, Deerenberg EB, Kalff JC, von Websky MW. Don't fear the (small) bite: a narrative review of the rationale and misconceptions surrounding closure of abdominal wall incisions. Front Surg 2022; 9: 1002558.
4. Conway RG, O'Neill N, Brown J, Kavic S. An educated guess - Distance estimation by surgeons. Surg Open Sci. 2020 Apr 30;2(3):113-116. doi: 10.1016/j.sopen.2020.04.001. PMID: 33981983; PMCID: PMC8083008.
5. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FPH, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. 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. Epub 2015 Jul 15. PMID: 26188742.
The small-bites technique offers numerous advantages over traditional methods:
By adopting the small-bites technique, surgeons can achieve more reliable outcomes in abdominal wall closure, leading to improved patient recovery and reduced postoperative complications.
1. Höer JJ, Junge K, Schachtrupp A, Klinge U, Schumpelick V. Influence of laparotomy closure technique on collagen synthesis in the incisional region. Hernia. 2002 Sep;6(3):93-8. doi: 10.1007/s10029-002-0070-4. Epub 2002 Jul 20. PMID: 12209295.
2. Theodorou A, Banzsch M, Gök H, Deerenberg EB, Kalff JC, von Websky MW. Don't fear the (small) bite: a narrative review of the rationale and misconceptions surrounding closure of abdominal wall incisions. Front Surg 2022; 9: 1002558.
3. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg. 2009 Nov;144(11):1056-9. doi: 10.1001/archsurg.2009.189. PMID: 19917943.
4. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FPH, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. 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. Epub 2015 Jul 15. PMID: 26188742.
5. Yii, E. Onggo J, Zii MK. Small bite versus large bite stitching technique for midline laparotomy wound closure: A systematic review and meta-analysis. Asian J Surg 2023; 46(11): 4719-4726.
6. Tolstrup MB, Watt SK, Gögenur I. Reduced Rate of DehiscenceAfter Implementation of a Standardized Fascial Closure Technique in Patients UndergoingEmergency Laparotomy. Ann Surg. 2017 Apr;265(4):821-826. doi:10.1097/SLA.0000000000001762. PMID: 28267697.
Milbourn D, Cengiz Y, Israelsson LA.
Arch Surg. 2009
Small-bites
Large-bites
P value
Surgical site infection
17/326 (5.2%)
35/343 (10.2%)
0.02
Incisional Hernia
14/250 (5.6%)
49/272 (18.0%)
<0.001
1. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg. 2009 Nov;144(11):1056-9. doi: 10.1001/archsurg.2009.189. PMID: 19917943.
Deerenberg EB, Henriksen NA, Antoniou GA, et al.
Lancet 2015
Small-bites
Large-bites
P value
Surgical site infection
58/276 (21.0%)
68/284 (24%)
NS
Incisional Hernia
35/268 (13.0%)
57/277 (21.0%)
0.02
2. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FPH, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. 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. Epub 2015 Jul 15. PMID: 26188742.
Suture length 40cm
Wound length 10cm
SL/WL= 4:1
1. Jenkins TP. The burst abdominal wound: a mechanical approach. Br J Surg. 1976 Nov;63(11):873-6. doi: 10.1002/bjs.1800631110. PMID: 137024.
2. Sekhar S, Ekka NM, Nair R, Pratap V, Mundu M, Kumar A. Effect of suture length on the incidence of incisional hernia and surgical site infection in patients undergoing midline laparotomy: a systematic review and meta-analysis. Cureus. 2023 Feb 10;15(2):e34840. doi: 10.7759/cureus.34840. eCollection
3. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FPH, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. 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. Epub 2015 Jul 15. PMID: 26188742.
Surgical societies now widely endorse the small bites technique for abdominal wall closure due to strong evidence of its benefits.
The European Hernia Society and the American Hernia Society jointly established guidelines in 2022 based on three RCTs involving 1722 patients, advocating for continuous small-bites closure with slowly resorbable sutures in both elective and emergency surgeries.1
The World Society of Emergency Surgery also supports this technique as of 2023.2
Additionally, the European Society for Vascular Surgery stresses proper closure techniques, recommending the small-bite suturing method with slowly absorbable sutures for optimal outcomes in open vascular procedures.3
Guideline
Year
Patient population
Recommendation
AHS/EHS
2022
Elective
Continuous small-bites closure technique with slowly resorbable suture
WSES
2023
Emergency
Small-bites closure technique
ESVS
2023
Vascular surgery
A continuous small bite suturing technique with a slowly absorbable suture
1. Deerenberg EB, Henriksen NA, Antoniou GA, Antoniou SA, Bramer WM, Fischer JP, Fortelny RH, Gök H, Harris HW, Hop W, Hrone CM, Jensen TK, Köckerling F, Kretschmer A, Lopez-Cano M, Malcher F, Shao JM, Slieker JC, de Smet, GHJ, Stabilini C, Torkington J, Muysoms FE. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. BJS. 2022; 109: 1239-1250.
2. Frassini S, Cobianchi L, Fugazzola P, Biffl WL, Coccolini F, Damaskos D, Moore EE, Kluger Y, Ceresoli M, Coimbra R, Davies J, Kirkpatrick A, Di Carlo I, Hardcastle TC, Isik A, Chiarugi M, Gurusamy K, Maier RV, Segovia Lohse HA, Jeekel H, Boermeester MA, Abu-Zidan F, Inaba K, Weber DG, Augustin G, Bonavina L, Velmahos G, Sartelli M, Di Saverio S, Ten Broek RPG, Granieri S, Dal Mas F, Farè CN, Peverada J, Zanghì S, Viganò J, Tomasoni M, Dominioni T, Cicuttin E, Hecker A, Tebala GD, Galante JM, Wani I, Khokha V, Sugrue M, Scalea TM, Tan E, Malangoni MA, Pararas N, Podda M, De Simone B, Ivatury R, Cui Y, Kashuk J, Peitzman A, Kim F, Pikoulis E, Sganga G, Chiara O, Kelly MD, Marzi I, Picetti E, Agnoletti V, De’Angelis N, Campanelli G, de Moya M, Litvin A, Martínez-Pérez A, Sall I, Rizoli S, Tomadze G, Sakakushev B, Stahel PF, Civil I, Shelat V, Costa D, Chichom-Mefire A, Latifi R, Chirica M, Amico F, Pardhan A, Seenarain V, Boyapati N, Hatz B, Ackermann T, Abeyasundara S, Fenton L, Plani F, Sarvepalli R, Rouhbakhshfar O, Caleo P, Ho-Ching Yau V, Clement K, Christou E, Castillo AMG, Gosal PKS, Balasubramaniam S, Hsu J, Banphawatanarak K, Pisano M, Adriana T, Michele A, Cioffi SPB, Spota A, Catena F, Ansaloni L. ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings. World J Emerg Surg. 2023 Jul 26;18(1):42.
3. Antoniou, G. A., et al. (2023). "Updated Guideline on Abdominal Wall Closure from the European and American Hernia Societies: Transferring Recommendations to Clinical Practice for Vascular Surgeons." Eur J Vasc Endovasc Surg 65(6): 774-777.
Implementation of this technique in daily surgical practice is now the most important point. The present challenge is for surgeons to acknowledge that sufficient data is available for a surgical standard to be changed, and to change their suture technique accordingly.5 Another challenge for the surgeons is to implement the technique correctly and consistenly.
1. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg. 2009 Nov;144(11):1056-9. doi: 10.1001/archsurg.2009.189. PMID: 19917943.
2. Tolstrup MB, Watt SK, Gögenur I. Reduced Rate of Dehiscence After Implementation of a Standardized Fascial Closure Technique in Patients Undergoing Emergency Laparotomy. Ann Surg. 2017 Apr;265(4):821-826. doi: 10.1097/SLA.0000000000001762. PMID: 28267697.
3. Lozada Hernández EE, Hernández Bonilla JP, Hinojosa Ugarte D, Magdaleno García M, Mayagoitía González JC, Zúñiga Vázquez LA, Obregón Moreno E, Jiménez Herevia AE, Cethorth Fonseca RK, Ramírez Guerrero P. Abdominal wound dehiscence and incisional hernia prevention in midline laparotomy: a systematic review and network meta-analysis. Langenbecks Arch Surg. 2023 Jul 7;408(1):268. doi: 10.1007/s00423-023-02954-w. PMID: 37418033.
4. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FPH, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. 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. Epub 2015 Jul 15. PMID: 26188742.
5. Israelsson LA, Jonsson T. Suture length to wound length ratio and healing of midline laparotomy incisions. Br J Surg. 1993 Oct;80(10):1284-6.
Suturing with the small-bites technique is considered best practice and recommended by EHS, AHS and WSES.1,2
However, only 24% of surgeons adhere to small-bites technique.3
1. Bloemen A, De Kleijn RJCMF, Van Steensel S, Aarts F, Schreinemacher MHF, Bouvy ND. Laparotomy closure techniques: Do surgeons follow the latest guidelines? Results of a questionnaire. Int J Surg. 2019 Nov;71:110-116. doi: 10.1016/j.ijsu.2019.09.024. Epub 2019 Sep 24. PMID: 31561005.
2. Deerenberg EB, Henriksen NA, Antoniou GA, Antoniou SA, Bramer WM, Fischer JP, Fortelny RH, Gök H, Harris HW, Hope W, Horne CM, Jensen TK, Köckerling F, Kretschmer A, López-Cano M, Malcher F, Shao JM, Slieker JC, de Smet GHJ, Stabilini C, Torkington J, Muysoms FE. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. Br J Surg. 2022 Nov 22;109(12):1239-1250.
3. Frassini S, Cobianchi L, Fugazzola P, Biffl WL, Coccolini F, Damaskos D, Moore EE, Kluger Y, Ceresoli M, Coimbra R, Davies J, Kirkpatrick A, Di Carlo I, Hardcastle TC, Isik A, Chiarugi M, Gurusamy K, Maier RV, Segovia Lohse HA, Jeekel H, Boermeester MA, Abu-Zidan F, Inaba K, Weber DG, Augustin G, Bonavina L, Velmahos G, Sartelli M, Di Saverio S, Ten Broek RPG, Granieri S, Dal Mas F, Farè CN, Peverada J, Zanghì S, Viganò J, Tomasoni M, Dominioni T, Cicuttin E, Hecker A, Tebala GD, Galante JM, Wani I, Khokha V, Sugrue M, Scalea TM, Tan E, Malangoni MA, Pararas N, Podda M, De Simone B, Ivatury R, Cui Y, Kashuk J, Peitzman A, Kim F, Pikoulis E, Sganga G, Chiara O, Kelly MD, Marzi I, Picetti E, Agnoletti V, De’Angelis N, Campanelli G, de Moya M, Litvin A, Martínez-Pérez A, Sall I, Rizoli S, Tomadze G, Sakakushev B, Stahel PF, Civil I, Shelat V, Costa D, Chichom-Mefire A, Latifi R, Chirica M, Amico F, Pardhan A, Seenarain V, Boyapati N, Hatz B, Ackermann T, Abeyasundara S, Fenton L, Plani F, Sarvepalli R, Rouhbakhshfar O, Caleo P, Ho-Ching Yau V, Clement K, Christou E, Castillo AMG, Gosal PKS, Balasubramaniam S, Hsu J, Banphawatanarak K, Pisano M, Adriana T, Michele A, Cioffi SPB, Spota A, Catena F, Ansaloni L. ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings. World J Emerg Surg. 2023 Jul 26;18(1):42. doi: 10.1186/s13017-023-00511-w. Erratum in: World J Emerg Surg. 2023 Nov 27;18(1):52. PMID: 37496068; PMCID: PMC10373269.
Even after a formal training on midline laparotomyclosure, including small-bites technique, only 31% of surgeons performed it correctly in their clinical practice.1
Estimation of the distance between stitches is difficult. The 5-mm mark placement estimated by surgeons ranged from 2.01 mm to 11.69 mm.2
1. Pereira Rodríguez JA, Amador-Gil S, Bravo-Salva A, Montcusí-Ventura B, Sancho-Insenser JJ, Pera-Román M, et al. Small bites technique for midline laparotomy closure: from theory to practice: still a long way to go. Surgery.(2021) 170(1):140–5. doi: 10.1016/j.surg.2020.12.007.
2. Conway RG, O’Neill N, Brown J, Kavic S. An educated guess – Distance estimation by surgeons. Surg Open Sci. 2020; 2(3): 113-116.
Using a slowly absorbable suture for abdominal wound closure offers several key benefits:
Sustained wound strength:
Continuous suture line:
Improved healing:
Polydioxanone (PDO) suture:
Optimal collagen formation:
Comfort and reduced complications:
Choosing a slowly absorbable suture ensures better support and healing for abdominal wall closures.
1. Wissing J, van Vroonhoven TJ, Schattenkerk ME, Veen HF, Ponsen RJ, Jeekel J. Fascia closure after midline laparotomy: results of a randomized trial. Br J Surg. (1987) 74(8):738–41.
2. Deerenberg EB, Henriksen NA, Antoniou GA, Antoniou SA, Bramer WM, Fischer JP, Fortelny RH, Gök H, Harris HW, Hope W, Horne CM, Jensen TK, Köckerling F, Kretschmer A, López-Cano M, Malcher F, Shao JM, Slieker JC, de Smet GHJ, Stabilini C, Torkington J, Muysoms FE. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. Br J Surg. 2022 Nov 22;109(12):1239-1250.
3. Höer JJ, Junge K, Schachtrupp A, Klinge U, Schumpelick V. Influence of laparotomy closure technique on collagen synthesis in the incisional region. Hernia 2002; 6(3): 93-8.
4. Dart AJ, Dart CM. Biomaterials and clinical use. In: Comprehensive Biomaterials. Ducheyne P (Ed). Elsevier Science. 2011.
5. Sajid MS, Parampalli U, Baig MK, McFall MR. A systematic review on the effectiveness of slowly-absorbable versus non-absorbable sutures for abdominal fascia closure following laparotomy. Int J Surg 2011; 9(8): 615-25.
1. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, Wijnhoven BP, Schouten WR, Cense HA, Stockmann HB, Berends FJ, Dijkhuizen FPH, Dwarkasing RS, Jairam AP, van Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange JF. 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. Epub 2015 Jul 15. PMID: 26188742.
2. HART Collaborative. Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART). Br J Surg. 2022 Sep 9;109(10):943 950. doi: 10.1093/bjs/znac198. Erratum in: Br J Surg. 2022 Dec 13;110(1):126. PMID: 35979802; PMCID: PMC10364691.
3. Swedish Institute for Health Economics, 2024.
4. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg. 2009 Nov;144(11):1056-9. doi: 10.1001/archsurg.2009.189. PMID: 19917943.
5. Tolstrup MB, Watt SK, Gögenur I. Reduced Rate of Dehiscence After Implementation of a Standardized Fascial Closure Technique in Patients Undergoing Emergency Laparotomy. Ann Surg. 2017 Apr;265(4):821-826. doi: 10.1097/SLA.0000000000001762. PMID: 28267697
6. Lozada Hernández EE, Hernández Bonilla JP, Hinojosa Ugarte D, Magdaleno García M, Mayagoitía González JC, Zúñiga Vázquez LA, Obregón Moreno E, Jiménez Herevia AE, Cethorth Fonseca RK, Ramírez Guerrero P. Abdominal wound dehiscence and incisional hernia prevention in midline laparotomy: a systematic review and network meta-analysis. Langenbecks Arch Surg. 2023 Jul 7;408(1):268. doi: 10.1007/s00423-023-02954-w. PMID: 37418033.
7. Kantar Sifo Navigare, 2021. REPORT UK, SWEDEN and GERMANY Market Mapping Unmet Needs Within Abdominal Wall Closure.
8. Bloemen A, De Kleijn RJCMF, Van Steensel S, Aarts F, Schreinemacher MHF, Bouvy ND. Laparotomy closure techniques: Do surgeons follow the latest guidelines? Results of a questionnaire. Int J Surg. 2019 Nov;71:110-116. doi: 10.1016/j.ijsu.2019.09.024. Epub 2019 Sep 24. PMID: 31561005.