Midline Laparotomy Closure Research Articles

Small bites versus large bites during fascial closure of midline laparotomies: a systematic review and meta-analysis.

Incisional ventral hernias (IVH) are common after laparotomies, with up to 20% incidence in 12months, increasing up to 60% at 3-5years. Although Small Bites (SB) is the standard technique for fascial closure in laparotomies, its adoption in the United States is limited, and Large Bites (LB) is still commonly performed. We aim to assess the effectiveness of SB regarding IVH. We searched for RCTs and observational studies on Cochrane, EMBASE, and PubMed from inception to May 2023. We selected patients ≥ 18years old, undergoing midline laparotomies, comparing SB and LB for IVH, surgical site infections (SSI), fascial dehiscence, hospital stay, and closure duration. We used RevMan 5.4. and RStudio for statistics. Heterogeneity was assessed with I2 statistics, and random effect was used if I2 > 25%. 1687 studies were screened, 45 reviewed, and 6 studies selected, including 3 RCTs and 3351 patients (49% received SB and 51% LB). SB showed fewer IVH (RR 0.54; 95% CI 0.39-0.74; P < 0.001) and SSI (RR 0.68; 95% CI 0.53-0.86; P = 0.002), shorter hospital stay (MD -1.36days; 95% CI -2.35, -0.38; P = 0.007), and longer closure duration (MD 4.78min; 95% CI 3.21-6.35; P < 0.001). No differences were seen regarding fascial dehiscence. SB technique has lower incidence of IVH at 1-year follow-up, less SSI, shorter hospital stay, and longer fascial closure duration when compared to the LB. SB should be the technique of choice during midline laparotomies.

OC-109 ONE-YEAR FOLLOW-UP ANALYSIS OF WOUND VS SUTURE LENGTH RATIO AS A PREDICTOR OF INCISIONAL HERNIA - A COHORT STUDY (WISER)

Abstract Background The purpose of the study was to determine if the recommended wound to suture length ratios of 1:4 and 1:6 were followed during midline laparotomy closure with loop PDS and 2–0 PDS, respectively, and whether this affected the development of an incisional hernia three years following the procedure. Methods This prospective study included eighty-six patients operated by the midline incision. The closures were performed as per the surgeon's choice. The length of the incision, types and length of suture used were noted. The one-year follow-up data was analyzed. Results In thirty cases, loop PDS was used for the closure, and in 56 patients, 2-0 PDS was used. Adherence to the recommendation was better with the loop PDS (13/30,43.33%) vs 2-0 PDS (8/56,14.28%). Eighteen patients were excluded(10-death-,5-loss to follow-up,3-reoperation).46.1%(12/26) developed incisional hernia in the loop PDS group vs 7.14%(3/42) with 2-0 PDS; total 22.05%(15/68). If the recommendations were followed or not, there were 20% (2/10) hernias in the loop PDS group compared to 62.5% (10/16); and 28.57% (2/7) compared to 2.8% (1/35) in the 2-0 PDS group. The loop PDS group had more malignancies (40% vs 20%, p=0.04). Conclusion The adherence to the recommendation of wound vs suture length was low. The incidence of incisional hernia was significantly low with 2-0 PDS, at one year, however the results should be interpreted with caution considering many patients closed with loop PDS had malignancies, a risk factor for incisional hernia, and low sample size due to death and loss to follow-up.

Patient-specific computational simulations of wound healing following midline laparotomy closure.

In the current study, we developed a new computational methodology to simulate wound healing in soft tissues. We assumed that the injured tissue recovers partially its mechanical strength and stiffness by gradually increasing the volume fraction of collagen fibers. Following the principles of the constrained mixture theory, we assumed that new collagen fibers are deposited at homeostatic tension while the already existing tissue undergoes a permanent deformation due to the effects of remodeling. The model was implemented in the finite-element software Abaqus® through a VUMAT subroutine and applied to a complex and realistic case: simulating wound healing following midline laparotomy closure. The incidence of incisional hernia is still quite significant clinically, and our goal was to investigate different conditions hampering the success of these procedures. We simulated wound healing over periods of 6months on a patient-specific geometry. One of the outcomes of the finite-element simulations was the width of the wound tissue, which was found to be clinically correlated with the development of incisional hernia after midline laparotomy closure. We studied the impact of different suturing modalities and the effects of situations inducing increased intra-abdominal pressure or its intermittent variations such as coughing. Eventually, the results showed that the main risks of developing an incisional hernia mostly depend on the elastic strains reached in the wound tissue after degradation of the suturing wires. Despite the need for clinical validation, these results are promising for establishing a digital twin of wound healing in midline laparotomy incision.

The Best Closure Technique Without Mesh in Elective Midline Laparotomy Closure.

Introduction: The risk of developing an incisional hernia after primary elective median laparotomy is reported in the literature as being between 5 and 20 percent. The basic of an optimal outcome after midline incision is the appropriate closure technique with or without a prophylactic mesh. The objective of this paper is to critically examine the various closure techniques and, in particular, to present a detailed comparison of the long stitch and short stitch techniques. Method: Based on the available literature, the characteristics of the different closure techniques are described in detail, advantages and disadvantages are compared, and the current status of a practicable recommendation is discussed. Special attention is paid to the criteria of the short stitch technique, such as the suture to incision length ratio, number of stitches and distances, as well as suture material. Results: For elective midline closures, the use of a continuous closure using a slowly absorbable suture material in the small-bites technique with suture to wound ratio of at least 5:1 result in significantly lower risk of complications such as bursting abdomen and less incisional hernia rates compared to the large-bites technique. Conclusion: Based on the present evidence in midline closure after elective laparotomy the small bites technique can be recommended to significantly reduce the rate of incisional hernia.

Closure of Iterative Laparotomy in Patients With Previous Mesh Reinforcement a Cohorts' Study. Short-Term Results.

Purpose: Due to extension of prophylactic mesh indications use will become more common to find patients receiving an iterative laparotomy (IL) over a previous reinforced abdominal wall. The aim of this study was to analyze outcomes after IL in patients with previous mesh reinforcement. Methods: This study was a prospective secondary analysis of midline laparotomy closure performed from July 2017 to July 2018 registered in PHACPA study (NCT02658955). IL were included and surgery characteristics and outcomes analyzed. We compared two groups: with (PreM) or without previous prophylactic onlay mesh reinforcement (PreS) Subgroups' analysis, risk factors for complications and survival free hernia analysis were performed. Results: 121 IL were analyzed. Only obesity was associated with higher SSO (OR 2.6; CI 95% 1.02-6.90; p = 0.04) There were 15 incisional hernias (IH) (14.4%). Group with previous mesh reinforcement (pre M) had a higher statistically significative incidence of IH (OR = 1.21; CI 95% 1.05-1.39; p = 0.015). Use of slowly absorbable suture (OR = 0.74; CI 95% 0.60-0.91; p = 0.001), USP 2/0 suture (OR, 0.31; 95% CI, 0.10-0.94; p = 0.033), and small bites technique (OR = 0.81; CI 95% 0.72-0.90; p = 0.011) were associated with less IH. Conclusion: IL has a high percentage of complications and IH. In case of IL without previous reinforcement, a mesh can help to reduce IH. Our data cannot clearly support any technique to close an IL with previous mesh.

Evaluation of the results of midline laparotomy closure in emergency surgery after the introduction of the fascial closure with small bites technique

Revista monográfica de cirugía de la pared abdominal, digital y en lengua española. Artículos originales de investigación, editoriales, imágenes clínicas, cartas al director, reseñas de publicaciones, etc.

Small bite closure in midline laparotomy; A practice to reduce the surgical site infection, wound dehiscence, and incisional hernia

Background: Postoperative wound site complications are a significant source of morbidity after midline laparotomy. The study's objectives were to compare the two suture patterns for fascial closure in midline abdominal wounds and their effect on postoperative wound site complications. Materials and Methods: Over 4 years, the prospective comparative study was conducted at the Government Medical College Hospital, Srinagar. All the patients ≥18 years and ≤70 years of age underwent midline laparotomy for various indications were included. Patients were randomized to two groups using computer-generated numbers based on closure techniques. Group A; Large Tissue Bite closure (10 mm from the wound edge and 10 mm apart and Group B; Small Tissue Bite closure (5–7 mm from the wound edge and 5–7 mm apart). Effect of age, sex, body mass index (BMI), albumin, and suture bite on postoperative complications were analyzed. Results: Among 324 patients who met the inclusion criteria, the mean age was 39.17 years, 84.56% were male with a Male: Female ratio of 5.48. Two hundred and two (62.35%) patients had large tissue bite closure, and 122 (37.75%) had small bite closure. There was no statistically significant difference between the two groups concerning age, sex, albumin levels, BMI, and type of surgery. About 35.64% of patients in the large tissue bite closure group and 19.67% patients in small bite closure developed surgical site infection (SSI) (P = 0.002). The difference in wound dehiscence between the two groups (15.84% vs. 7.38%) was statistically insignificant (P = 0.29). In midline laparotomy closure, the small bites technique results in significantly less incisional hernias than the large bites technique (P = 0.00001). None of our patients expired during the study period. Conclusion: The small bite technique substantially reduces SSIs, wound dehiscence, and incisional hernia. The accident-emergency and general surgery residents, in particular, should be made familiar with this technique to avoid postoperative wound site complications and improve the quality of postoperative life.

P100 EARLY POSTOPERATIVE WOUND COMPLICATIONS AFTER MIDLINE LAPAROTOMY CLOSURE WITH SMALL BITES TECHNIQUE: EXPERIENCE FROM A TERTIARY REFERRAL CENTRE

Abstract Aim To analyze the incidence and risk factors of surgical site infections (SSI) and wound dehiscence (WD) after closure of primary midline laparotomies with small-bites (SB) technique. Material and Methods Retrospective analysis using hospital prospective database of all midline abdominal wall closures (AWC) with SB technique performed in a University Hospital between December 2019 and February 2021. To achieve a proper protocol of AWC with SB technique, it is advised to have suture/wound length (SL/WL) – ratio of more than 4:1. Statistical analysis of the incidence of SSI and AWD, comparing the results when the protocol was properly used (A group) or not (B group), was performed. Between groups, no relevant differences were observed for patient characteristics. Results A total of 108 midline laparotomies were included for analysis. 55.5% of patients were male. The mean age was 62.8 years, mean body mass index was 24.3 kg/m2. 78.7% (85/108) were operated electively. SSI and WD have been recorded in 7 (6.5%) and 8 (7,4%) cases respectively. In 65 (60,2%) patients abdominal wall closure after primary laparotomy was achieved with proper protocol (group A). Median SL/WL in A and B group was 4.57 and 3.43 respectively. The rate of WD in A group (n = 1, 1,5%) was significantly (P=.006) lower than in B group (n = 7, 16,3%). Incidence of SSI was 7,7% (n = 5, A group) vs. 4,7% (n = 2; B group) (P=.420). Conclusions Using a proper AWC protocol has been effective to prevent WD in midline laparotomy.

O03 SMALL BITES AND PROPHYLACTIC MESH TO PREVENT INCISIONAL HERNIA IN HIGH-RISK PATIENTS. A MESH IS THE MOST POWERFUL TOOL

Abstract Aim Small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by guidelines to prevent incisional hernias (IHs) and burst abdomen (BA). Our aim was to implement a protocol combining both and to analyze its outcomes. Material and Methods Prospective data collection of all EMLs for one year. Results were analyzed at one month and during follow-up. The incidence of IH and BA was compared by groups depending on the use of a PM (M Group) or not (S Group), and in subgroups related to the closure technique: SB (Subgroups MSB and SSB) or not (Subgroups MLB and MSB). Results A lower number of BA was diagnosed in the M group (OR 0.0692; CI95% 0.008-0.56; P = 0.01) in 197 operations. 163 patients completed a mean follow-up of 29.23 months, with a lower frequency of IH in M group patients (OR = 0.769; CI 95% 0.65 - 0.91; P &amp;lt; 0.0001). Same differences persisted after a propensity matching score: BA (OR = 0.355; CI 95% 0.255 - 0.494; P &amp;lt; 0.0001) and IH (OR = 0.394; CI 95% 0.24 - 0.61; P &amp;lt; 0.0001). Comparing suturing techniques by subgroups any difference in IH and BA appeared. PM was the main factor related to reduction of IH (HR 11.794; CI 95% 4.29 - 32.39; P &amp;lt; 0.0001). Conclusions A PM is the most powerful tool for prevention both IH and BA after EMLs, regardless of the closure technique in patients at high-risk for IHs.

Implementing a protocol to prevent incisional hernia in high-risk patients: a mesh is a powerful tool

PurposeThe small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes.MethodsProspective data of all EMLs were collected for 2 years. Results were analyzed at 1 month and during follow-up. The incidence of HI and FD was compared by groups (M = Mesh vs. S = suture) and by subgroups depending on using SB.ResultsA lower number of FD appeared in the M group (OR 0.0692; 95% CI 0.008–0.56; P = 0.01) in 197 operations. After a mean follow-up of 29.23 months (N = 163; min. 6 months), with a lower frequency of IH in M group (OR 0.769; 95% CI 0.65–0.91; P < 0.0001). (33) The observed differences persisted after a propensity matching score: FD (OR 0.355; 95% CI 0.255–0.494; P < 0.0001) and IH (OR 0.394; 95% CI 0.24–0.61; P < 0.0001). On comparing suturing techniques by subgroups, both mesh subgroups had better outcomes. PM was the main factor related to the reduction of IH (HR 11.794; 95% CI 4.29–32.39; P < 0.0001).ConclusionFollowing the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.

Use of a bioabsorbable mesh in midline laparotomy closure to prevent incisional hernia: randomized controlled trial.

The objective was to assess the effectiveness and safety of a bioabsorbable mesh at the time of closure of a midline laparotomy for IH prevention. A multicenter, randomized clinical trial including patients undergoing abdominal surgical procedures through a midline laparotomy incision was designed. In the group of mesh (n=167) the incision was closed using a continuous polydioxanone suture (PDS) plus a bioabsorbable mesh. In the control group (n=165) a continuous PDS single layer suture was only used. Patients were randomly assigned (1:1) to the two groups. The primary outcome was the incidence of IH at 6, 12 and 24 months. Assessment of IH was done using a CT scan. At 6 months, the rates of IH were 15.2% and 24.8% in the experimental and control groups, respectively (relative risk [RR] 0.66, 95% confidence interval [CI] 0.38-0.98, P = 0.042). At 12 months, the rate of IH continued to be significantly lower in the experimental group (21.4% vs. 33.1%, P = 0.033), but at 24 months, there were no significant differences between the study groups with a follow-up rate of only 37.5%. The number needed to treat (NNT) was 11 and 9 at 6 and 12 months, respectively. The bioabsorbable mesh significantly prevented IH during the first year. Not reliable conclusions can be drawn across the second year. This may suggest that the any of the closing technique assessed in this study would have a "palliative" transient effect for preventing IH in the long-term.

Effects of the short-stitch technique for midline abdominal closure: short-term results from the randomised-controlled ESTOIH trial

PurposeThe short-stitch technique for midline laparotomy closure has been shown to reduce hernia rates, but long stitches remain the standard of care and the effect of the short-stitch technique on short-term results is not well known. The aim of this study was to compare the two techniques, using an ultra-long-term absorbable elastic suture material.MethodsFollowing elective midline laparotomy, 425 patients in 9 centres were randomised to receive wound closure using the short-stitch (USP 2-0 single thread, n = 215) or long-stitch (USP 1 double loop, n = 210) technique with a poly-4-hydroxybutyrate-based suture material (Monomax®). Here, we report short-term surgical outcomes.ResultsAt 30 (+10) days postoperatively, 3 (1.40%) of 215 patients in the short-stitch group and 10 (4.76%) of 210 patients in the long-stitch group had developed burst abdomen [OR 0.2830 (0.0768–1.0433), p = 0.0513]. Ruptured suture, seroma and hematoma and other wound healing disorders occurred in small numbers without differences between groups. In a planned Cox proportional hazard model for burst abdomen, the short-stitch group had a significantly lower risk [HR 0.1783 (0.0379–0.6617), p = 0.0115].ConclusionsAlthough this trial revealed no significant difference in short-term results between the short-stitch and long-stitch techniques for closure of midline laparotomy, a trend towards a lower rate of burst abdomen in the short-stitch group suggests a possible advantage of the short-stitch technique.Trial registryNCT01965249, registered October 18, 2013.

Small bites technique for midline laparotomy closure: From theory to practice: Still a long way to go

BackgroundThe closure technique of the abdominal wall is a key factor in the development of incisional hernia. Our aim was to implement a protocol for closure of median laparotomy, to evaluate the grade of implementation, as well as to assess the results and safety of the technique. MethodsA series of formative activities to implement the small bites technique for closure of median laparotomy in elective operations were designed. After 1 year, a survey was conducted on knowledge and use of the technique. Prospective compilation of data of all median laparotomy in elective operations and their follow-up was done for 1 year. The incidence of incisional hernia depending on the fulfilment of the protocol was compared. ResultsA total of 74 surgeons participated in the activities. All the participants accomplished the technique perceiving low difficulty (1.9/10). After 1 year, 44 surgeons answered the survey; 95% stated that they knew the small bites technique and used it always or almost always, but only 52% performed the calculation of the suture length and the incision length ratio. A total of 114 median laparotomy in elective operations were analyzed; among them, 30.7% were closed with small bites presenting a lower frequency of incisional hernia and burst abdomen (small bites 3.6% vs large bites 12.1%; odds ratio 1.30; confidence interval, 0.992--1.711; P = .20). ConclusionThe measures were effective for learning, but education alone was not enough to implement the technique in the real scenario. Small bites technique is reproducible, has no risks, and provides low incidence of incisional hernia. More incentives and actions are needed to improve laparotomy closure.

A Cost-utility Analysis of Small versus Large bite sutures in the closure of midline laparotomies in the UK NHS

Peer reviewed by Sunil Daga PhD MRCP &amp; Subarna Chakravorty PhD FRCP

Suture length to wound length ratio in 175 small animal abdominal midline closures.

Experimental and human studies have reported the advantages of a suture length to wound length (SL:WL) ratio greater than 4:1 in midline abdominal closure. This is achieved when the tissue bite (TB) is equal to or larger than the stitch interval (SI). Although TB and SI values are recommended in some textbooks, SL:WL ratios are rarely reported in veterinary textbooks. Additionally, no clinical data regarding these parameters could be found in small animals. Therefore, the aim of this study was to evaluate the SL:WL ratio of midline laparotomy closure in dogs and cats performed by surgeons with different levels of expertise and to compare the findings with current textbook recommendations. Midline laparotomy incisions of 100 dogs and 75 cats were closed in continuous pattern by diplomates and residents of both the European College of Veterinary Surgeons (ECVS) and the European College of Animal Reproduction (ECAR). The mean SL:WL ratio was 2.5 ± 0.7:1. The surgeons´ level of experience and the species and body weights of the animals did not have any significant influence on the SL:WL ratio. A moderate negative correlation was observed between the mean SI to mean TB (SI:TB) ratio and the SL:WL ratio. In this study, the mean SI matched the textbook recommendations both in feline and canine species, whereas the TB in cats was different. In this study, the SL:WL ratio was less than 4:1 without apparent complications. Because of the low prevalence of incisional hernia in dogs and cats larger studies are necessary to evaluate clinical significance of the presented data.

Elective and Emergent Laparotomy Closure: The Importance of Protocolizing the Technique

BackgroundIncisional hernias are a frequent complication, and their prevention includes proper closure of the abdominal wall. MethodsA prospective study was conducted at a third-level hospital after the introduction of a midline laparotomy closure protocol. An objective measurement of the suture length to incision length ratio was made, and the postoperative results were analyzed. Results127 patients were included and 34 of them (26.8%) had received a technically deficient closure. Incisional hernia was described in 20.5% of cases. An improvement in the quality of the abdominal wall closure was demonstrated over time. ConclusionThe abdominal wall closure was deficient in nearly one-quarter of the laparotomies performed at a third-level medical center. A protocol improved the quality of the laparotomy closure.

Long-term results of a prospective randomized trial of midline laparotomy closure with onlay mesh.

Incisional hernia (IH) continues to be one of the most common complications of laparotomy. The short-term protective effect of the use of mesh has been demonstrated in several studies. At present, there is little evidence on the long-term results of the prophylactic use of mesh. The aim of the present study is to analyze the long-term prevention of IH 5years after a midline laparotomy during elective surgery. A prospective study was performed including all of the 160 patients that had been previously included in the prospective, randomized, controlled trial performed between May 2009 and November 2012. The protocol and results at 1year have been previously published in 2014. The patients in group A (mesh) were fitted with a polypropylene mesh to reinforce the standard abdominal wall closure. The patients in group B (non-mesh) underwent a standard abdominal wall closure and were not fitted with the mesh. All patients were followed for 5years or until the diagnosis of incisional hernia was made, further surgery was performed, or the patient died. Cases lost to follow-up were also registered. Five years after surgery, in group A (mesh) we have found 4/80 (5.1%) incisional hernias, while in group B (no mesh) 37/80 patients were diagnosed with an incisional hernia (46.8%). The Kaplan-Meier survival curves for these results show statistically significant differences (p > 0.001). The protective effect of the use of an onlay mesh in abdominal wall closure is significantly maintained in the long-term, up to 5years after surgery. International Standard Randomized Controlled Trial number: ISRCTN98336745.

Evaluation of a Monofile, Ultra-Long Absorbable Suture with High Elasticity for Abdominal Wall Closure Under Daily Clinical Routine MULTIMAC a Prospective Observational Study

Recent meta-analyses have shown that the application of a monofile, late-absorbable suture using a continuous suture technique with a suture-to-wound length ratio of at least 4:1 is the method of choice for the closure of midline laparotomies. Monomax, a new ultra-long term absorbable, high elastic monofilament suture, was approved in 2009 and its safety and efficacy were proven in a selected patient population under controlled conditions for elective midline abdominal wall closure (ISSAAC Study). The present multi-centric, international, prospective observational study is aimed at evaluating the performance of Monomax suture for transverse and midline abdominal wall closure in daily clinical practice even in high risk patients. A total of 200 patients undergoing a primary elective laparotomy using either a midline or transverse incision were examined regarding the frequency of short-term complications (e.g. reoperation due to burst abdomen, wound infection, wound healing disorders), until discharge and 1 month after surgery. Postoperative length of hospital stay was also reported. Frequency of reoperation due to burst abdomen was 2.5% and a wound infection rate of 3.5% was reported up to day of discharge. Seven patients developed a wound healing disorder (3.5%). Average length of postoperative hospital stay was 10.3 days. Our results indicate that the ultra-long term absorbable, elastic monofilament suture is safe and efficient for transverse and midline abdominal wall closure performed under daily clinical routine even in high risk patients.

Cierre de la laparotomía electiva y urgente. Importancia de protocolizar la técnica

BackgroundIncisional hernias are a frequent complication, and their prevention includes proper closure of the abdominal wall. MethodsA prospective study was conducted at a third-level hospital after the introduction of a midline laparotomy closure protocol. An objective measurement of the suture length to incision length ratio was made. and the postoperative results were analyzed. Results127 patients were included and 34 of them (26.8%) had received a technically deficient closure. Incisional hernia was described in 20.5% of cases. An improvement in the quality of the abdominal wall closure was demonstrated over time. ConclusionThe abdominal wall closure was deficient in nearly one- quarter of the laparotomies performed at a third-level medical center. A protocol improved the quality of the laparotomy closure.

Optimized wound closure using a biomechanical abdominal model.

Suturing techniques for midline abdominal wall incisions vary between surgeons. This study uses a biomechanical abdominal model to assess tissue stretch using different suturing techniques for midline laparotomy closure. Deformation tests were performed on the linea alba of 48 porcine abdominal walls. Each pattern was tested three times at pressures ranging from 0 to 20 kPa using different continuous suturing techniques and a control. There was a sevenfold improvement when the best performing bite separation and bite width ([5, 16] mm) was compared with the most poorly performing combination ([15, 4] mm). The traditional bite and width separation ([10, 10] mm) and the recently proposed combination ([5, 5] mm) may not be optimal, and substantial improvements in surgical outcome may be achieved by changing to a [5,16]-mm combination. These findings suggest using a small bite separation (5 mm) and large bite width (16 mm) during abdominal wound closure may be optimal. Surgical relevance Suturing techniques for midline abdominal wall incisions vary between surgeons. This experimental study suggests substantial potential for improved tissue apposition by changing the suturing approach from the traditional clinical recommendation of 10 mm for both bite separation and bite width to a bite separation of 5 mm and a bite width of 16 mm. These findings support recent European Hernia Society guidelines and the recent randomized STITCH (Suture Techniques to Reduce the Incidence of The inCisional Hernia) trial, which found that small separations are more effective than large separations, but suggest that they should be combined with large bite depths.