Small-bites technique: Precision in abdominal wall closure

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

Bite size and interval: Refers to suture bites sized between 5-8mm, with a stitch interval of 5mm.¹
Focused application: Targets only the fascia (aponeurosis)², avoiding sensitive fatty tissue and muscle fibers within the bite.³
Even tension distribution: Ensures better tension distribution across the wound.^3,4
Challenges and precision: Achieving accurate small-bites is challenging with manual needle driver suturing when the step interval is estimated by eye.⁴ Moreover, it is time-consuming.^3,5

Show references

Advantages with small bites technique

The small-bites technique offers numerous advantages over traditional methods:

Improved wound healing: Even tension distribution promotes better tissue healing.^1,2
Enhanced wound strength: 5mm step interval enhances initial wound strength.^1,2
Reduced infection and hernia risk: Lowers incidence of surgical site infections and incisional hernias.^3,5
Reduced wound dehiscence: Precise suturing minimizes wound separation.⁶
Enhanced recovery: Shorter recovery times and fewer complications

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.

Show references

Clinical trials showed lower rates of wound infection and incisional hernia with small-bites

Effect of Stitch Length on Wound Complications After Closure of Midline Incisions¹

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

Show references

Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial²

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%)

Incisional Hernia

35/268 (13.0%)

57/277 (21.0%)

0.02

Show references

Suture length to wound length ratio

The suture to wound (SL/WL) ratio is the relationship between the length of the suture and the length of the wound
After abdominal surgery, fascial layers may lengthen by 30% as abdomen distends causing a rise in suture tension¹
SL/WL ratio of ≥4:1 has been demonstrated to significantly reduce the risk of incisional hernia^2,3

Suture length 40cm
Wound length 10cm

→

SL/WL= 4:1

Show references

Guidelines and recommendations

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

Guideline

AHS/EHS

Year

2022

Patient population

Elective

Recommendation

Continuous small-bites closure technique with slowly resorbable suture

Guideline

WSES

Year

2023

Patient population

Emergency

Recommendation

Small-bites closure technique

Guideline

ESVS

Year

2023

Patient population

Vascular surgery

Recommendation

A continuous small bite suturing technique with a slowly absorbable suture

Show references

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.

To summarize the small-bites technique

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.

Show references

Only 24% of surgeons adhere to small-bites technique¹

Suturing with the small-bites technique is considered best practice and recommended by EHS, AHS and WSES.^2,3
However, only 24% of surgeons adhere to small-bites technique.¹

Show references

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.

The perception that the small-bites technique is performed correctly is often misconceived

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

Show references

Slowly absorbable suture optimal for abdominal wound closure

Using a slowly absorbable suture for abdominal wound closure offers several key benefits:

Sustained wound strength:

Provides crucial support during the first 4 weeks when the wound strength depends solely on the suture.
Fascia retains only 70% of its original strength even a year after surgery.¹

Continuous suture line:

Recommended by EHS for consistent support throughout the healing process.²

Improved healing:

Proper tension distribution boosts collagen accumulation, essential for healing and scar formation.³
Promotes transition from weaker collagen type III to stronger collagen type.³

Polydioxanone (PDO) suture: ‍

Retains 74% of tensile strength at 2 weeks and 25% after 6 weeks, taking 180-210 days to be absorbed. This allows the fascia to reach approximately 50% strength even in delayed healing scenarios.⁴

Optimal collagen formation:

Using a continuous suture with an SL/WL ratio >4:1 enhances collagen strength and wound integrity.³

Comfort and reduced complications:

Absorbable sutures are linked to a lower incidence of fascia sinus and less post-operative pain compared to non-absorbable sutures.⁵

Choosing a slowly absorbable suture ensures better support and healing for abdominal wall closures.

Show references

Summarizing the clinical challenge in laparotomy closure

Show references

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.

Small-bites technique: Precision in abdominal wall closure

Advantages with small bites technique

Clinical trials showed lower rates of wound infection and incisional hernia with small-bites

Effect of Stitch Length on Wound Complications After Closure of Midline Incisions1

Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial2

Suture length to wound length ratio

Guidelines and recommendations

To summarize the small-bites technique

Only 24% of surgeons adhere to small-bites technique1

The perception that the small-bites technique is performed correctly is often misconceived

Slowly absorbable suture optimal for abdominal wound closure

Summarizing the clinical challenge in laparotomy closure

Sign up to be contacted

Effect of Stitch Length on Wound Complications After Closure of Midline Incisions¹

Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial²

Only 24% of surgeons adhere to small-bites technique¹