Design: Systematic review and meta-analysis of randomised trials with trial sequential analysis
Population: 2617 patients undergoing midline laparotomy, ten RCTs
Primary outcome: Incisional hernia
Effect: RR 0.48 (95% CI 0.33 to 0.70) at >12 months; RR 0.56 (0.36 to 0.89) at ≥24 months

This meta-analysis pooled ten randomised trials (2617 patients) comparing small-bite closure of midline laparotomy, with 5 mm bites and 5 mm spacing, against large-bite closure at 10 mm. Published in October, it included trial sequential analysis to test whether the evidence was conclusive.

Across trials with more than 12 months' follow-up, small-bite closure reduced incisional hernia (RR 0.48, 95% CI 0.33 to 0.70). The benefit held in trials following patients beyond 24 months (RR 0.56, 0.36 to 0.89). In the five trials that used both clinical and imaging assessment, the reduction was RR 0.57 (0.39 to 0.82; I² = 44%). Surgical site infection (RR 0.72) and total complications (RR 0.76) were also lower. Closure took about 4.8 minutes longer, and pain scores did not differ.

Incisional hernia after laparotomy is common and expensive to repair, and closure technique is something every surgeon controls. The evidence now consistently favours small bites, and trial sequential analysis suggested the benefit is firm. Most of the gain needs only technique and a suitable needle and suture, so it applies in any operating theatre, including those without subspecialty support.

Close elective midline laparotomies with small bites: about 5 mm from the fascial edge and 5 mm apart.
Take bites of the aponeurosis only, avoiding fat and muscle.
Use a continuous slowly absorbable monofilament suture on a small needle suited to the technique.
Allow about five extra minutes for closure in theatre planning.
Teach and audit the technique across the team, including trainees who close.

Why it matters

Closure is often handed to the most junior person in theatre, yet it determines one of the commonest long-term complications of abdominal surgery.

The statistics, in plain English

An RR of 0.48 means about half the hernia risk with small bites. The benefit is smaller in trials that also used imaging (RR 0.57), which catch more hernias, and that figure is probably the more realistic one. Heterogeneity of 44% in that group means trials varied somewhat, but all pointed the same way.