Small-bite compared with large-bite closure of midline laparotomy: meta-analysis of short- and long-term outcomes with trial sequential analysis
Sameh Hany Emile, Asmaa Elhadad, Ahmed Hossam ElsayedAbstract
Background
Fascial closure after a midline laparotomy (ML) is a crucial step to avoid incisional hernia. This meta-analysis aimed to compare short- and long-term outcomes, including incisional hernia, of the small-bite versus large-bite closure techniques in ML.
Methods
A PRISMA-compliant systematic review of RCTs comparing small-bite (5-mm bites/spacing) and large-bite (10-mm bites/spacing) techniques in ML closure was conducted. PubMed, Scopus, Web of Science, and Cochrane Central were searched from inception through April 2026 for eligible RCTs. The primary outcome was incisional hernia. Secondary outcomes included total complications, surgical-site infection (SSI), seroma, fascial dehiscence, closure time, and pain. Pairwise meta-analyses and trial sequential analyses (TSA) were performed.
Results
Ten unique RCTs reported in 12 publications (2617 patients) were included. Among the five studies using standardized clinical and imaging assessment, small-bite closure reduced incisional hernia by 43% (risk ratio (RR) of 0.57 (95% c.i. 0.39 to 0.82) (P = 0.003, I2 = 44.1%), compared with an RR of 0.31 (95% c.i. 0.18 to 0.53) (P < 0.001, I2 = 0) when clinical assessment only was used). Across all eligible studies with follow-up >12 months, the pooled RR was 0.48 (95% c.i. 0.33 to 0.70). This benefit persisted on the analysis of studies with ≥24 months of follow-up (RR 0.56 (95% c.i. 0.36 to 0.89)). TSA demonstrated firm evidence for benefit despite not reaching the required information size. Small-bite closure was also associated with reduced SSI (RR 0.72) and total complications (RR 0.76), with no differences in seroma or fascial dehiscence. Closure time was slightly longer with small-bite closure (weighted mean difference 4.82 min), while pain scores were comparable.
Conclusion
The small-bite technique significantly reduced incisional hernia and postoperative complications after ML, with durable benefit extending beyond 2 years.