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Small-bites versus large-bites closure of midline laparotomies: A systematic review and meta-analysis
Stefan Morarasu1,2, Sorinel Lunca1,2, Luke O'Brien3
12nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania.
Aim:
Surgical site infection (SSI) and incisional hernia (IH) are common complications following midline laparotomy. The small-bites technique for closing a midline laparotomy has been suggested to improve SSI and IH rates compared with the classic mass closure. The aim of this work was to perform a systematic review, meta-analysis and fragility assessment of existing evidence comparing small-bites and conventional closure.
Method:
The study was registered with PROSPERO. A systematic search of PubMed and EMBASE databases was performed for all comparative studies examining small-bites versus conventional closure for midline laparotomy. The fragility index for randomized controlled trials (RCTs) was assessed and the number of outcomes required to render results insignificant using the Fisher exact test was calculated.
Results:
Seven studies were included, with a total of 3807 patients. Small bites was performed in 1768 and large bites in 2039. Follow-up ranged from 12 to 52 months. On meta-analysis of all studies, small bites is associated with a lower risk of IH (p < 0.00001), SSI (p = 0.0002) and wound dehiscence (p = 0.02). On meta-analysis of RCTs there is a lower risk of IH (p = 0.01) but no difference in SSI (p = 0.06) or wound dehiscence (p = 0.73). Fragility is evident among RCTs reporting differences in IH rates.
Conclusion:
There is evidence to suggest that small-bites closure provides a decreased likelihood of IH over varying follow-up in RCTs but significant fragility exists among studies.
Insights
The small-bites technique for midline laparotomy closure may reduce incisional hernias (IH) and surgical site infections (SSI). However, evidence from randomized controlled trials (RCTs) shows fragility, particularly for IH rates.
Area of Science:
- Abdominal Surgery
- Surgical Complications
- Evidence-Based Medicine
Background:
- Surgical site infection (SSI) and incisional hernia (IH) are frequent complications after midline laparotomy.
- The small-bites technique is proposed as an alternative to conventional mass closure to reduce these complications.
Purpose of the Study:
- To systematically review, meta-analyze, and assess the fragility of evidence comparing the small-bites technique with conventional mass closure for midline laparotomy.
Main Methods:
- A systematic search of PubMed and EMBASE was conducted for comparative studies.
- Meta-analysis was performed on data from seven studies (3807 patients).
- Fragility index and Fisher exact test were used to assess the robustness of findings in randomized controlled trials (RCTs).
Main Results:
- Overall meta-analysis showed small-bites closure was associated with lower risks of IH, SSI, and wound dehiscence.
- Meta-analysis of RCTs indicated a lower risk of IH but no significant difference in SSI or wound dehiscence.
- Fragility was identified in RCTs reporting differences in IH rates.
Conclusions:
- Evidence suggests the small-bites technique may decrease the likelihood of incisional hernias (IH) compared to conventional closure.
- The robustness of this evidence, particularly from RCTs, is limited due to study fragility.
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