{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T07:39:35Z","timestamp":1792136375700,"version":"4.4.0"},"reference-count":27,"publisher":"American Medical Association (AMA)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Surg"],"published-print":{"date-parts":[[2026,6,1]]},"abstract":"<jats:sec>\n                    <jats:title>Importance<\/jats:title>\n                    <jats:p>Incisional hernia after midline laparotomy causes long-term morbidity and reduced quality of life; closure technique may affect long-term risk. Superiority of the small-bites fascial closure technique in reducing incisional hernia rate at 1 year after midline laparotomy was previously demonstrated in the STITCH trial.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To evaluate incisional hernia incidence 13 years after accrual ended.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design, Setting, and Participants<\/jats:title>\n                    <jats:p>This multicenter, double-blind randomized clinical trial took place between October 2009 and March 2012 at 10 participating centers in the Netherlands, including surgical and gynecological departments. The study included 559 patients undergoing elective midline laparotomy. These data were analyzed from January 2025 through June 2025.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions<\/jats:title>\n                    <jats:p>Continuous small-bites fascial closure (5 mm\u2009\u00d7\u20095 mm, polydioxanone 2-0 on 31-mm needle) vs large bites (10 mm\u2009\u00d7\u200910 mm, looped polydioxanone on 48-mm needle) in the control group.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main Outcomes and Measures<\/jats:title>\n                    <jats:p>Primary outcome was cumulative incidence of incisional hernia (clinical and radiologic) analyzed with time-to-event methods accounting for competing risks. Secondary outcomes included hernia width, repair rates, and patient-reported quality of life.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 275 patients were randomized to small-bites fascial closure and 284 to the control group. Median time to censoring was 8 (IQR, 2-13) years. At final follow-up, 170 patients were alive without evidence of incisional hernia. Of these, 122 (72%) underwent additional abdominal ultrasound. Abdominal imaging performed as part of patient care was available for 238 patients. At 13 years, cumulative incidence of incisional hernia was 34% in the small-bites group and 49% in the large-bites group (hazard ratio, 0.61; 95% CI, 0.43-0.86). Corresponding outcomes for hernia width more than 20 mm were 17% and 34%, respectively (hazard ratio, 0.36; 95%CI, 0.21-0.60). Hernias were significantly smaller after small-bites closure at final follow-up (mean, 25 mm vs 43 mm;\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u2009.02). Hernia repair rates were similar. Patients with an incisional hernia reported significantly lower quality of life.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions and Relevance<\/jats:title>\n                    <jats:p>In this study, the small-bites technique reduced the long-term risk and width of incisional hernias after elective midline laparotomy. Given its simplicity, cost neutrality, and broad applicability, it should be regarded standard practice. Further research should explore strategies to enhance adoption and assess broader patient-centered outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial Registration<\/jats:title>\n                    <jats:p>\n                      ClinicalTrials.gov Identifier:\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/clinicaltrials.gov\/study\/NCT01132209\">NCT01132209<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1001\/jamasurg.2026.0618","type":"journal-article","created":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T15:32:13Z","timestamp":1775057533000},"page":"566","source":"Crossref","is-referenced-by-count":8,"title":["Small Bites vs Large Bites for Closure of Abdominal Midline Incisions"],"prefix":"10.1001","volume":"161","author":[{"given":"Rudolf","family":"van den Berg","sequence":"first","affiliation":[{"name":"Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"van Egmond","sequence":"additional","affiliation":[{"name":"Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fokko","family":"Smits","sequence":"additional","affiliation":[{"name":"Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara J.","family":"Baart","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Theo J.","family":"Aufenacker","sequence":"additional","affiliation":[{"name":"Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huib A.","family":"Cense","sequence":"additional","affiliation":[{"name":"Department of Surgery, Rode Kruis Hospital, Beverwijk, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Esther C. J.","family":"Consten","sequence":"additional","affiliation":[{"name":"Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frederik P. H. L. J.","family":"Dijkhuizen","sequence":"additional","affiliation":[{"name":"Department of Gynecology, Rijnstate Hospital, Arnhem, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"H. (Lena) C.","family":"van Doorn","sequence":"additional","affiliation":[{"name":"Department of Gynecology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joris J.","family":"Harlaar","sequence":"additional","affiliation":[{"name":"Department of Surgery, Ziekenhuisgroep Twente, Hengelo, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gert-Jan","family":"Kleinrensink","sequence":"additional","affiliation":[{"name":"Department of Anatomy, Erasmus University Medical Center, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johan F.","family":"Lange","sequence":"additional","affiliation":[{"name":"Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harold E.","family":"Lont","sequence":"additional","affiliation":[{"name":"Department of General Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marijn M.","family":"Poelman","sequence":"additional","affiliation":[{"name":"Department of General Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hein B. A. C.","family":"Stockmann","sequence":"additional","affiliation":[{"name":"Department of Surgery, Spaarne Gasthuis, Haarlem, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hilco P.","family":"Theeuwes","sequence":"additional","affiliation":[{"name":"Department of Trauma Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pieter J.","family":"Tanis","sequence":"additional","affiliation":[{"name":"Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eva B.","family":"Deerenberg","sequence":"additional","affiliation":[{"name":"Department of General Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"11","key":"soi260013r1","doi-asserted-by":"publisher","first-page":"684","DOI":"10.1016\/j.ciresp.2021.08.004","article-title":"Incidence and risk factors for incisional hernia after open abdominal aortic aneurysm repair.","volume":"100","author":"Barranquero","year":"2022","journal-title":"Cir Esp (Engl Ed)"},{"issue":"1","key":"soi260013r2","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/s10029-014-1342-5","article-title":"European Hernia Society guidelines on the closure of abdominal wall incisions.","volume":"19","author":"Muysoms","year":"2015","journal-title":"Hernia"},{"key":"soi260013r3","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0000000000006684","article-title":"A systematic review and independent patient data meta-analysis of prophylactic mesh augmentation for incisional hernia prevention after Abdominal Aortic Aneurysm Surgery (I-PREVENT-AAA) a collaborative European Hernia Society Project.","author":"van den Berg","year":"2026","journal-title":"Ann Surg"},{"key":"soi260013r4","doi-asserted-by":"publisher","first-page":"11214","DOI":"10.3389\/jaws.2023.11214","article-title":"Quality of life with a hernia-a novel patient led study.","volume":"2","author":"Hill","year":"2023","journal-title":"J Abdom Wall Surg"},{"issue":"2","key":"soi260013r5","doi-asserted-by":"publisher","first-page":"144","DOI":"10.1016\/j.amjsurg.2012.01.012","article-title":"Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study.","volume":"204","author":"van Ramshorst","year":"2012","journal-title":"Am J Surg"},{"issue":"2","key":"soi260013r6","doi-asserted-by":"publisher","first-page":"e488","DOI":"10.1097\/SLA.0000000000003916","article-title":"The risk of incarceration during nonoperative management of incisional hernias: a population-based analysis of 30,998 patients.","volume":"275","author":"Dadashzadeh","year":"2022","journal-title":"Ann Surg"},{"issue":"5","key":"soi260013r7","doi-asserted-by":"publisher","first-page":"536","DOI":"10.1016\/j.jamcollsurg.2020.08.735","article-title":"Improved understanding of acute incisional hernia incarceration: implications for addressing the excess mortality of emergent repair.","volume":"231","author":"Huckaby","year":"2020","journal-title":"J Am Coll Surg"},{"issue":"2","key":"soi260013r8","doi-asserted-by":"publisher","first-page":"415","DOI":"10.1007\/s10029-022-02707-6","article-title":"Ventral hernia repair: an increasing burden affecting abdominal core health.","volume":"27","author":"Schlosser","year":"2023","journal-title":"Hernia"},{"issue":"11","key":"soi260013r9","doi-asserted-by":"publisher","first-page":"1056","DOI":"10.1001\/archsurg.2009.189","article-title":"Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial.","volume":"144","author":"Millbourn","year":"2009","journal-title":"Arch Surg"},{"issue":"10000","key":"soi260013r10","doi-asserted-by":"publisher","first-page":"1254","DOI":"10.1016\/S0140-6736(15)60459-7","article-title":"Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial.","volume":"386","author":"Deerenberg","year":"2015","journal-title":"Lancet"},{"issue":"1","key":"soi260013r11","doi-asserted-by":"publisher","first-page":"87","DOI":"10.1007\/s10029-021-02410-y","article-title":"Effects of the short-stitch technique for midline abdominal closure: short-term results from the randomised-controlled ESTOIH trial.","volume":"26","author":"Albertsmeier","year":"2022","journal-title":"Hernia"},{"issue":"8","key":"soi260013r12","doi-asserted-by":"publisher","first-page":"1617","DOI":"10.1111\/codi.17081","article-title":"CLosure of Abdominal MidlineS Survey (CLAMSS): a national survey investigating current practice in the closure of abdominal midline incisions in UK surgical practice.","volume":"26","author":"Messenger","year":"2024","journal-title":"Colorectal Dis"},{"key":"soi260013r13","doi-asserted-by":"publisher","DOI":"10.3389\/fsurg.2022.1002558","article-title":"Don\u2019t fear the (small) bite: a narrative review of the rationale and misconceptions surrounding closure of abdominal wall incisions.","volume":"9","author":"Theodorou","year":"2022","journal-title":"Front Surg"},{"issue":"10","key":"soi260013r14","doi-asserted-by":"publisher","first-page":"4469","DOI":"10.1007\/s00464-016-4779-z","article-title":"Incisional hernias after open versus laparoscopic surgery for colonic cancer: a nationwide cohort study.","volume":"30","author":"Jensen","year":"2016","journal-title":"Surg Endosc"},{"key":"soi260013r15","doi-asserted-by":"crossref","DOI":"10.1016\/S0140-6736(25)00672-5","article-title":"CONSORT 2025 statement: updated guideline for reporting randomised trials.","author":"Hopewell","year":"2025","journal-title":"Lancet"},{"issue":"4","key":"soi260013r16","doi-asserted-by":"publisher","first-page":"407","DOI":"10.1007\/s10029-009-0518-x","article-title":"Classification of primary and incisional abdominal wall hernias.","volume":"13","author":"Muysoms","year":"2009","journal-title":"Hernia"},{"issue":"4","key":"soi260013r17","doi-asserted-by":"publisher","first-page":"343","DOI":"10.1016\/0197-2456(96)00075-X","article-title":"A note on quantifying follow-up in studies of failure time.","volume":"17","author":"Schemper","year":"1996","journal-title":"Control Clin Trials"},{"issue":"12","key":"soi260013r18","doi-asserted-by":"publisher","first-page":"2967","DOI":"10.1080\/03610929908832460","article-title":"The analysis of repeated measurements: a comparison of mixed-model Satterthwaite F tests and a nonpooled adjusted degrees of freedom multivariate test.","volume":"28","author":"Keselman","year":"1999","journal-title":"Commun Stat Theory Methods"},{"issue":"1","key":"soi260013r19","doi-asserted-by":"publisher","first-page":"263","DOI":"10.1007\/s10029-025-03459-9","article-title":"5-year clinical outcome of the ESTOIH trial comparing the short-bite versus large-bite technique for elective midline abdominal closure.","volume":"29","author":"Fortelny","year":"2025","journal-title":"Hernia"},{"issue":"10","key":"soi260013r20","doi-asserted-by":"publisher","first-page":"943","DOI":"10.1093\/bjs\/znac198","article-title":"Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART).","volume":"109","author":"Collaborative","year":"2022","journal-title":"Br J Surg"},{"issue":"2","key":"soi260013r21","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1002\/bjs.9364","article-title":"Incisional hernia rate 3 years after midline laparotomy.","volume":"101","author":"Fink","year":"2014","journal-title":"Br J Surg"},{"issue":"9","key":"soi260013r22","doi-asserted-by":"publisher","first-page":"2109","DOI":"10.1002\/wjs.12294","article-title":"Long-term follow-up after incisional hernia repair: dynamics of recurrence and patient-reported outcome.","volume":"48","author":"Karlsson","year":"2024","journal-title":"World J Surg"},{"issue":"4","key":"soi260013r23","doi-asserted-by":"publisher","first-page":"578","DOI":"10.1097\/01.sla.0000141193.08524.e7","article-title":"Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia.","volume":"240","author":"Burger","year":"2004","journal-title":"Ann Surg"},{"issue":"1","key":"soi260013r25","doi-asserted-by":"publisher","first-page":"42","DOI":"10.1186\/s13017-023-00511-w","article-title":"ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings.","volume":"18","author":"Frassini","year":"2023","journal-title":"World J Emerg Surg"},{"issue":"1","key":"soi260013r26","doi-asserted-by":"publisher","first-page":"141","DOI":"10.1007\/s00068-025-02804-y","article-title":"Variable use of modern abdominal wall closure techniques at emergency laparotomy\u2014an international, cross-sectional survey of surgical practice.","volume":"51","author":"Stephens","year":"2025","journal-title":"Eur J Trauma Emerg Surg"},{"key":"soi260013r27","volume-title":"Global guidelines for the prevention of surgical site infection","author":"WHO","year":"2018"},{"key":"soi260013r24","unstructured":"Sameh? E. Small versus large bite closure of emergency midline laparotomy (E-STITCH). Accessed February 23, 2026. https:\/\/clinicaltrials.gov\/study\/NCT04098380"}],"container-title":["JAMA Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/articlepdf\/2847017\/jamasurgery_van_den_berg_2026_oi_260013_1780929725.66245.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,10]],"date-time":"2026-06-10T15:01:00Z","timestamp":1781103660000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/fullarticle\/2847017"}},"subtitle":["A Randomized Clinical Trial"],"short-title":[],"issued":{"date-parts":[[2026,6,1]]},"references-count":27,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2026,6,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamasurg.2026.0618","relation":{},"ISSN":["2168-6254"],"issn-type":[{"value":"2168-6254","type":"print"}],"subject":[],"published":{"date-parts":[[2026,6,1]]}}}