How to close a midline laparotomy - The STITCH trial

A lot, maybe even the majority, of things we do in medicine in general and in surgery in particular, are not evidence based. One of those things, no being supported by good data, is one of the most commonly performed procedures in surgery - closing of the abdominal midline incision.

There is some data supporting the 10mm/10mm running closure with PDS 1 suture. However this data is quite weak and now finally somebody decided to challenge that.

Even before this trial, there was evidence that smaller stitches with a more gentle suture would achieve better results in terms of preventing hernias. However, this paper describes the first double-blind, multicentre, randomised controlled trial addressing this question:

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

Here I'm sharing some thoughts about the trial and its critics.

The question which the authors attempted to answer with this study is which surgical technique would achieve better results in terms of incisional hernia incidence one year after surgery in elective cases. Secondary outcomes were short-term postoperative complications like surgical site infection, fascia dehiscence, cardiac events, length of hospital stay, and health-related quality of life.

They compared the traditional 1cm/1cm bites with looped PDS 1 (large bites group) vs. 5mm/5mm bites with 2-0 PDS (small bites group) for the fascial closure.

It turned out that the small bites group had a lower rate of incisional hernia recurrence (21% vs. 13%) while there was no difference in terms of secondary outcomes.

Let's take a look at the critics!
I don't really like to discuss the partially shockingly weak (and disappointing) comments to the study in The Lancet.

Here is something substantial: the BMI. The average Dutch BMI is 24 while the average BMI in the USA is > 26. Most US surgeons conclude therefore that the small suture (2-0 PDS) would not be appropriate for the US population. Let's think about couple of things here:

• The suture strength may play a role in the rate of fascial dehiscence but nobody considers it as a factor when we talk about incisional hernia. It's an absorbable suture after all. The fascial dehiscence rate was found to be 1% in both groups.
  Hernias don't occur because the suture broke. That's why dehiscence occurs. Hernias occur because the fascial edge becomes necrotic. And using smaller bites is what tries to prevent that.
• There are more approximation points in the small bites group. Twice as many! Why should this be not good for high BMI patients?
• The Dutch maybe thinner but smokes more than the average American. BMI is not the only factor! And the comparison is not necessarily one way only.

I had the privilege to work with the president elect of the American Hernia Society and his partners (who are no smaller names in hernia surgery both on a national and international level) for couple of years. We had some interesting discussions about this trial. It changed my practice. I use now 2-0 PDS sutures in a 5mm/5mm fashion, regardless of the BMI or any other factors.

In my humble opinion this study is a big deal. It changes our understanding about the optimal way to close the abdominal midline. Paradigms are hard to change. And surgeons have been indeed indoctrinated with a particular way of closure the abdominal midline for decades. However, if we continue to pretend that our approach is evidence based, we can not afford ignoring a Level I evidence about a question which has never been addressed this way before.