The STITCH trial: a summary

One discussion this week mentioned the STITCH trial.

Reference: Deerenberg EB, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised control trial. Lancet. 2015 Sep 26;386(10000):1254-1260. doi: 10.1016/S0140-6736(15)60459-7.

Summary: Incisional hernia is a frequent complication of abdominal operations with an incidence of 10–23%, which can increase to 38% in specific risk groups. It is associated with pain and discomfort, resulting in a decreased quality of life. Incarceration and strangulation of abdominal contents can take place, for which emergency surgery is indicated, with associated morbidity and mortality. The authors (2015) estimate about 348,000 operations for incisional hernia are done every year in the US with $3.2 billion in annual associated costs.

This trial is registered at, number NCT01132209 and with the Nederlands Trial Register, number NTR2052.

METHODS: The STITCH trial was a prospective, multicentre, double-blind, randomised controlled trial conducted at surgical and gynaecological departments in 10 hospitals in the Netherlands between October 2009 – May 2012. The 560 patients who were scheduled to undergo elective abdominal surgery with midline laparotomy were randomly assigned to receive small tissue bites of 5 mm every 5 mm or large bites of 1 cm every 1 cm.  The primary outcome was the occurrence of incisional hernia; a reduced incidence in the small bites group was expected

RESULTS: Patients in the small bites group had fascial closures sutured with more stitches than those in the large bites group (mean number of stitches 45 [SD 12] vs 25 [10]; p<0.0001), a higher ratio of suture length to wound length (5.0 [1.5] vs 4.3 [1.4]; p<0.0001) and a longer closure time (14 [6] vs 10 [4] min; p<0.0001). At 1 year follow-up, 57 (21%) of 277 patients in the large bites group and 35 (13%) of 268 patients in the small bites group had incisional hernia (p=0.0220, covariate adjusted odds ratio 0.52, 95% CI 0.31-0.87; p=0.0131). Rates of adverse events did not differ significantly between groups.

CONCLUSIONS: In this study, the small bites suture technique is more effective than the traditional large bites technique for prevention of incisional hernia in midline incisions and is not associated with a higher rate of adverse events. The small bites technique should become the standard closure technique for midline incisions.

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