Suture Techniques and Materials for Fascial Closure of Abdominal Wall Incisions: A Comprehensive Meta-Analysis

The aim of this systematic review and meta-analysis was to evaluate the effectiveness of different suture materials and techniques for laparotomy closure.

A literature search was conducted in 3 databases in April 2024. All randomized controlled trials (RCTs) and prospective cohort studies on laparotomy closure were included. The quality of the studies was evaluated using critical appraisal checklists (ROB2 and ROBINS-I). The primary outcome was incisional hernia (IH) formation, and secondary outcomes were fascial dehiscence (FD), combined FD+IH, and surgical site infection (SSI). Meta-analyses were performed using random effects models.

A total of 41 RCTs and 9 prospective cohort studies were included. Meta-analysis revealed no superiority of slowly absorbable sutures over fast-absorbable sutures (5 studies, 1177 patients). Furthermore, no differences between interrupted and continuous suturing were found (14 studies, 5939 patients). Small-bites technique with a slowly absorbable suture was associated with significantly less risk of IH (odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.30-0.65), combined FD+IH (OR: 0.40; 95% CI: 0.21-0.75), and SSI (OR: 0.70; 95% CI: 0.53-0.91) compared with a large-bites technique (8 studies, 2360 patients). Significant improvements were found for the continuous modified Smead-Jones suturing in the emergency setting (2 studies, 90 patients) and retention-line suturing (1 RCT, 124 patients). Layered closure (6 studies, 2660 patients) or Hughes closure (2 studies, 772 patients) revealed no superiority over mass closure.

Closure of laparotomies in the elective setting using a small-bites technique with slowly absorbable sutures is superior over a large-bites technique. More evidence is needed in the emergency setting, with promising alternatives such as the modified Smead-Jones technique and retention-line suturing.