A suture length to wound length (SL:WL) ratio of ≥4:1 when closing laparotomy incisions seems to help prevent incisional hernias. However, this practice is often not followed. Our prospective study of 140 patients assessed emergency midline laparotomy wound closure by surgical residents; and compared wound outcomes between those with and without a SL:WL ratio of ≥4:1. The latter was achieved in only one patient. While the incidence of wound dehiscence and of incisional hernia at six months was similar in those with a SL:WL ratio of <3 and ≥3 (p = 0.73 and p = 0.32 respectively), it was significantly higher in those with a SL:WL ratio <2.5 than ≥2.5 (p = 0.005 and p = 0.02 respectively). Even if an ideal SL:WL ratio of ≥4:1 cannot be achieved, a SL:WL ratio of ≥3 would be adequate to prevent surgeon-related wound dehiscence and incisional hernias.
Le Huu NhoRMegeDOuaïssiM, et al.Incidence and prevention of ventral incisional hernia. J Visc Surg2012; 149: e3–e14.
2.
Yahchouchy-ChouillardEAuraTPiconeO, et al.Incisional hernias. I. Related risk factors. Dig Surg2003; 20: 3–9.
3.
IsraelssonLA. Abdominal closure and incisional hernia. European Surg2003; 35: 5–10.
4.
MuysomsFEAntoniouSABuryK, et al.European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia2015; 19: 1–24.
5.
IsraelssonLA. The surgeon as a risk factor for complications of midline incisions. Eur J Surg1998; 164: 353–359.
6.
IsraelssonLA. Bias in clinical trials: the importance of suture technique. Eur J Surg1999; 165: 3–7.
7.
MishraASharmaDRainaVK. A simplified prognostic scoring system for peptic ulcer perforation in developing countries. Indian J Gastroenterol2003; 22: 49–53.
8.
DeerenbergEBHenriksenNAAntoniouGA, et al.Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. Br J Surg2022; 109: 1239–1250.
9.
JenkinsTPN. The burst abdominal wound: a mechanical approach. Br J Surg1976; 63: 873–876.
10.
IsraelssonLAJonssonTKnutssonA. Suture technique and wound healing in midline laparotomy incisions. Eur J Surg1996; 162: 605–609.
11.
IsraelssonLAJonssonT. Suture length to wound length ratio and healing of midline laparotomy incisions. Br J Surg1993; 80: 1284–1286.
12.
VarshneySManekPJohnsonCD. Six-fold suture: wound length ratio for abdominal closure. Ann R Coll Surg Engl1999; 81: 333–336.
13.
WilliamsZFTenzelPHooksWB3rd, et al.Suture to wound length ratio in abdominal wall closure: how well are we doing?Hernia2017; 21: 869–872.
14.
CeydeliARucinskiJWiseL. Finding the best abdominal closure: an evidence-based review of the literature. Curr Surg2005; 62: 220–225.
15.
HenriksenNADeerenbergEBVenclauskasL, et al.Meta-analysis on materials and techniques for laparotomy closure: the MATCH review. World J Surg2018; 42: 1666–1678.
16.
SekharSEkkaNMNairR, et al.Effect of suture length on the incidence of incisional hernia and surgical site infection in patients undergoing midline laparotomy: a systematic review and meta-analysis. Cureus2023; 15: e34840.
17.
BeesonSFaulknerJAcquistaE, et al.Decreasing incisional hernia by teaching 4:1 suture to wound length ratio early in surgical education. J Surg Educ2021; 78: e169–e173.
18.
BloemenADe KleijnRJCMFVan SteenselS, et al.Laparotomy closure techniques: do surgeons follow the latest guidelines? Results of a questionnaire. Int J Surg2019; 71: 110–116.
19.
FischerJPHarrisHWLópez-CanoM, et al.Hernia prevention: practice patterns and surgeons’ attitudes about abdominal wall closure and the use of prophylactic mesh. Hernia2019; 23: 329–334.
20.
Pereira RodríguezJAAmador-GilSBravo-SalvaA, et al.Small bites technique for midline laparotomy closure: from theory to practice: still a long way to go. Surgery2021; 170: 140–145.
21.
BörnerGToftLRogmarkP, et al.A feasibility and safety trial investigating a device for swift and standardized median laparotomy closure. Hernia2025; 29: 196.
22.
MillbournDCengizYIsraelssonLA. Effect of stitch length on wound complications after closure of midline incisions. A randomized controlled trial. Arch Surg2009; 144: 1056–1059.
23.
FrassiniSCobianchiLFugazzolaP, et al.ECLAPTE: effective closure of LAParoTomy in emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings. World J Emerg Surg2023; 18: 42.
24.
YiiEOnggoJYiiMK. Small bite versus large bite stitching technique for midline laparotomy wound closure: a systematic review and meta-analysis. Asian J Surg2023; 46: 4719–4726.
25.
FortelnyRHHofmannABaumannP, et al.Three-year follow-up analysis of the short-stitch versus long-stitch technique for elective midline abdominal closure randomized-controlled (ESTOIH) trial. Hernia2024; 28: 1283–1291.
26.
FortelnyRHBaumannPHofmannA, et al.5-year Clinical outcome of the ESTOIH trial comparing the short-bite versus large-bite technique for elective midline abdominal closure. Hernia2025; 29: 263.
