STITCH: Small Bites versus Large Bites for Closure of Abdominal Midline Incisions
STITCH was a double-blind, multicenter randomized trial in 560 adults having elective midline laparotomy at ten Dutch hospitals that compared continuous small-bites fascial closure (5 mm bites and spacing, 2-0 polydioxanone on a 31 mm needle) with continuous large-bites closure (1 cm bites and spacing, looped size 1 polydioxanone on a 48 mm needle). Incisional hernia at the 1-year visit occurred in 35 of 268 patients (13%) after small bites and 57 of 277 (21%) after large bites (adjusted OR 0.52, 95% CI 0.31–0.87), with similar complication rates and 4 minutes longer closure.[1]
- Design and population
- Multicenter, double-blind randomized superiority trial. 560 adults scheduled for elective abdominal surgery through a midline laparotomy at surgical and gynecological departments of ten Dutch hospitals.
- Arms
- Continuous small-bites fascial closure (5 mm bites and spacing, 2-0 polydioxanone on a 31 mm needle) versus continuous large-bites fascial closure (1 cm bites and spacing, looped size 1 polydioxanone on a 48 mm needle)
- Report and follow-up
- 2015 · 1-year visit, defined as a visit up to month 15 after surgery; follow-up ended Aug 30, 2013
| Endpoint | Results | Effect | Finding |
|---|---|---|---|
| Incisional hernia at the 1-year visit (clinical examination, ultrasonography or CT; EHS definition), 545 of 560 analyzed | 35/268 (13%) vs 57/277 (21%) | OR 0.52; CI 0.31–0.87; P 0.0131 | Met |
Harms: Patients with postoperative complications: 125/276 (45%) vs 129/284 (45%); Surgical site infection: 58/276 (21%) vs 68/284 (24%); Burst abdomen: 4/276 (1%) vs 2/284 (1%)
Design
Patients 18 or older scheduled for elective abdominal surgery through a midline incision were enrolled from October 20, 2009 to March 12, 2012 in surgical and gynecological departments. Exclusions were a history of incisional hernia or fascial dehiscence after midline laparotomy, midline laparotomy within the previous 3 months, pregnancy and participation in another intervention trial. Most operations were gastrointestinal: lower gastrointestinal in 47% and 51% of the large-bites and small-bites groups, upper gastrointestinal in 31% and 27%, gynecological in 14% and 15%, and vascular in 7% and 8%. Median age was 63 and 62 years.[1]
Randomization took place in the operating room about 15 minutes before closure, 1:1 by a computer-generated sequence, stratified by centre and by surgeon versus resident with minimization. Patients and study investigators were masked; the examiners who performed the follow-up physical examination and ultrasonography were also masked.[1]
The primary outcome was incisional hernia during follow-up, defined by the European Hernia Society as any abdominal wall gap with or without bulge in the area of a postoperative scar that is perceptible or palpable by clinical examination or imaging. Patients were seen at 1 month and 1 year (a visit up to month 15), with physical examination and abdominal ultrasonography; any postoperative abdominal CT was also used, and imaging was decisive when findings conflicted. The trial was sized for 259 patients per group to detect a fall from 15% to 7.5% with 80% power at a two-sided alpha of 0.05, and planned 576 patients (288 per group) to allow for 10% loss to follow-up; 560 were randomized. The protocol's Cox regression was replaced by a binary endpoint at up to 15 months, analyzed by chi-squared test and covariate-adjusted logistic regression.[1]
Results
Of 560 randomized patients (284 large bites, 276 small bites), 545 (97%) completed follow-up and were analyzed. At the 1-year visit, incisional hernia was present in 35 of 268 patients (13%) in the small-bites group and 57 of 277 (21%) in the large-bites group (unadjusted p = 0.0220; covariate-adjusted OR 0.52, 95% CI 0.31–0.87; p = 0.0131), which met the primary hypothesis of a lower incidence with small bites. Tests of interaction showed no subgroup effects (all p > 0.20). The mean fascial defect among hernias was 3.4 cm (SD 4.4) and did not differ between groups.[1]
Follow-up was by clinical and radiological examination in 338 patients (62%), radiological examination alone in 76 (14%) and physical examination alone in 131 (24%). Among 87 patients with incisional hernia assessed by both methods, 43 hernias (49%) were found by both, 41 (47%) by imaging alone and 3 (3%) by physical examination alone.[1]
At 13 years postoperatively, in an analysis of 275 patients in the small-bites group and 284 in the control group with a median time to censoring of 8 years (IQR 2–13), the cumulative incidence of incisional hernia was 34% versus 49% (HR 0.61, 95% CI 0.43–0.86), accounting for competing risks. Hernias wider than 20 mm occurred in 17% versus 34% (HR 0.36, 95% CI 0.21–0.60), and mean hernia width at final follow-up was 25 mm versus 43 mm (p = 0.02). Hernia repair rates were reported as similar. Of 170 patients alive without hernia at final follow-up, 122 (72%) had additional ultrasound, and imaging done during routine care was available for 238 patients.[2]
Surgery and treatment delivery
In the small-bites group the surgeon placed at least twice as many stitches as the incision length in centimetres, with USP 2-0 PDS Plus II on a 31 mm needle, bites of 5 mm and spacing of 5 mm; every stitch took aponeurosis only, avoiding fat and muscle. The large-bites group had mass closure with bites of at least 1 cm and spacing of 1 cm, using USP 1 double-loop PDS Plus II on a 48 mm needle. In both groups suturing started at the two ends of the incision and ran toward the centre, where the cranial and caudal sutures overlapped by at least 2 cm and were knotted separately; an extra knot was allowed. Both techniques aimed for a suture length to wound length ratio of 4:1 or higher.[1]
Small-bites closure used a mean of 45 stitches (SD 12) versus 25 (SD 10), a suture length to wound length ratio of 5.0 (SD 1.5) versus 4.3 (SD 1.4), and 110 cm (SD 39) versus 95 cm (SD 34) of suture for a mean wound length of 22 cm in both groups. Mean closure time was 14 minutes (SD 6) versus 10 minutes (SD 4) (p < 0.0001). Two small-bites patients did not receive the allocated closure because of fragile fascia.[1]
Adverse events
Postoperative complications occurred in 125 of 276 patients (45%) after small bites and 129 of 284 (45%) after large bites (p = 1.000). Surgical site infection occurred in 58 of 276 (21%) versus 68 of 284 (24%) (p = 0.419): superficial incisional 8% versus 12%, deep incisional 3% versus 4%, and organ or space 10% versus 8%. Burst abdomen occurred in 4 of 276 (1%) versus 2 of 284 (1%) (p = 0.444). Ileus (10% versus 12%), pneumonia (13% versus 14%) and cardiac events (9% versus 11%) did not differ significantly. Mean hospital stay was 15 days (SD 35) versus 14 days (SD 24). First-week pain scores and 12-month SF-36 and EQ-5D results did not differ between groups, with the data not shown; patients who developed incisional hernia had lower SF-36 general health scores at 12 months (mean 60.16 versus 64.84; p = 0.0326).[1]
Limitations
The two arms differed in bite size, spacing, suture caliber (2-0 versus size 1 looped) and needle length (31 versus 48 mm), so the effect of smaller bites cannot be separated from that of the finer suture and smaller needle. The primary analysis was at 1 year, imaging was done in roughly three-quarters of patients, and the remaining 131 analyzed patients (24%) were assessed by physical examination alone. Only elective operations were included. Ethicon, the manufacturer of the suture, co-funded the trial; the report states that the funders had no role in design, data collection, analysis or reporting.[1]
In conversation
STITCH followed a single-centre Swedish trial of small versus large stitches that allocated patients by alternating calendar week and did not use radiological examination; STITCH randomized by computer sequence and examined roughly three-quarters of patients with ultrasonography or CT.[1]
Guidelines and approvals
The European and American Hernia Societies' updated guideline (2022) suggests a continuous small-bites suturing technique with a slowly absorbable suture for closure of elective midline incisions . The guideline cites STITCH among the trials of the small-bites technique and defines the technique as tissue bites of 5–9 mm from the wound edges that incorporate aponeurosis only, with stitches placed 5 mm apart in a continuous suture; it states that the technique implies a ratio of suture length to wound length of at least 4:1.[3]
Report history
| Published | Report | Cutoff | Headline results | Citation |
|---|---|---|---|---|
| 2015-07-16 | 1-year randomized comparison · primary | — | Incisional hernia at the 1-year visit (clinical examination, ultrasonography or CT; EHS definition), 545 of 560 analyzed: 35/268 (13%) vs 57/277 (21%); OR 0.52; CI 0.31–0.87; P 0.0131 Met Mean time of fascial closure, minutes (SD): 14 (SD 6) min vs 10 (SD 4) min; difference 4; P <0.0001 Mean length of hospital stay, days (SD): 15 (SD 35) days vs 14 (SD 24) days; P 0.585 First-week visual analogue pain scores; SF-36 and EQ-5D at 12 months (452 of 483 patients completed the questionnaires): The report states that pain scores and SF-36 and EQ-5D results did not differ significantly between groups; the data are not shown. Patients who developed incisional hernia had lower SF-36 general health scores than those without (mean 60.16 versus 64.84; p=0.0326).; — | Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. *Lancet.* 2015;386(10000):1254-1260. DOI |
| 2026 | 13-year follow-up · updated | — | Cumulative incidence of incisional hernia (clinical and radiologic) at 13 years, time-to-event analysis accounting for competing risks: 34% vs 49%; HR 0.61; CI 0.43–0.86 Cumulative incidence of incisional hernia wider than 20 mm at 13 years: 17% vs 34%; HR 0.36; CI 0.21–0.6 Mean hernia width at final follow-up: 25 mm vs 43 mm; P 0.02 Hernia repair rates: The abstract reports the repair rates as similar and gives no counts.; — | van den Berg R, van Egmond S, Smits F, et al. Small bites vs large bites for closure of abdominal midline incisions: a randomized clinical trial. *JAMA Surg.* 2026;161(6):566-573. DOI |
References
1. Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. "Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial." Lancet. 2015;386(10000):1254-1260. doi:10.1016/S0140-6736(15)60459-7
2. van den Berg R, van Egmond S, Smits F, et al. "Small bites vs large bites for closure of abdominal midline incisions: a randomized clinical trial." JAMA Surg. 2026;161(6):566-573. doi:10.1001/jamasurg.2026.0618
3. Deerenberg EB, Henriksen NA, Antoniou GA, et al. "Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies." Br J Surg. 2022;109(12):1239-1250. doi:10.1093/bjs/znac302