Small bites versus large bites during fascial closure of midline laparotomies: a systematic review and meta-analysis

Ana Caroline Dias Rasador, Sergio Mazzola Poli de Figueiredo, Miguel Godeiro Fernandez, Yasmin Jardim Meirelles Dias, Rafael Ribeiro Hernandez Martin, Carlos André Balthazar da Silveira, Richard Lu

Research output: Contribution to journalReview articlepeer-review


Purpose: Incisional ventral hernias (IVH) are common after laparotomies, with up to 20% incidence in 12 months, increasing up to 60% at 3–5 years. Although Small Bites (SB) is the standard technique for fascial closure in laparotomies, its adoption in the United States is limited, and Large Bites (LB) is still commonly performed. We aim to assess the effectiveness of SB regarding IVH. Methods: We searched for RCTs and observational studies on Cochrane, EMBASE, and PubMed from inception to May 2023. We selected patients ≥ 18 years old, undergoing midline laparotomies, comparing SB and LB for IVH, surgical site infections (SSI), fascial dehiscence, hospital stay, and closure duration. We used RevMan 5.4. and RStudio for statistics. Heterogeneity was assessed with I2 statistics, and random effect was used if I2 > 25%. Results: 1687 studies were screened, 45 reviewed, and 6 studies selected, including 3 RCTs and 3351 patients (49% received SB and 51% LB). SB showed fewer IVH (RR 0.54; 95% CI 0.39–0.74; P < 0.001) and SSI (RR 0.68; 95% CI 0.53–0.86; P = 0.002), shorter hospital stay (MD -1.36 days; 95% CI -2.35, -0.38; P = 0.007), and longer closure duration (MD 4.78 min; 95% CI 3.21–6.35; P < 0.001). No differences were seen regarding fascial dehiscence. Conclusion: SB technique has lower incidence of IVH at 1-year follow-up, less SSI, shorter hospital stay, and longer fascial closure duration when compared to the LB. SB should be the technique of choice during midline laparotomies.

Original languageEnglish (US)
Article number104
JournalLangenbeck's Archives of Surgery
Issue number1
StatePublished - Dec 2024


  • Incisional Hernia
  • Large Bites Fascial Closure
  • Midline Laparotomy
  • Small Bites Fascial Closure

ASJC Scopus subject areas

  • Surgery


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