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
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 SSIs 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.
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
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%)
NS
Incisional Hernia
35/268 (13.0%)
57/277 (21.0%)
0.02
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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
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
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.
Only 24% of surgeons adhere to small-bites technique 3
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
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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
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.
