A cost-utility analysis of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service

Abstract

PurposeThis study aimed to perform an economic evaluation of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service (NHS).MethodsA cost-utility analysis was conducted using data from a systematic literature review. Large bite sutures placed 10 mm from the wound edge were compared to small bite sutures 3–6 mm from the wound edge. The analysis used a 3-year time horizon in order to take into account complications including incisional hernias and surgical site infections (SSIs). Cost and benefit data were considered from the perspective of the NHS. A two-way sensitivity analysis was conducted to assess the impact of a variation in the clinical effectiveness of small bite sutures.ResultsThe incremental cost-effectiveness ratio was calculated to be −£482.61 per quality-adjusted life year (QALY) using the proposed small bite suture technique, indicating a cost saving to the NHS. Sensitivity analysis demonstrated that small bites are a cost-neutral technique provided that the cost of using small bites is less than £98 per patient. Small bites cost less than £20,000/QALY when they reduce either the rate of SSIs by more than 15% or the rate of hernias by more than 3.4%.ConclusionThis study proposes that small bite sutures should become the mainstay suturing technique in the closure of midline laparotomies, replacing large bite sutures, which dominate current practice. The financial savings accompanied by the decrease in SSI rates and herniation warrant the use of this new technique. The sensitivity analysis demonstrates that findings hold true for a wide range of levels of clinical effectiveness for small bites.

The Best Closure Technique Without Mesh in Elective Midline Laparotomy Closure

“…As can be seen from the studies, this is an investment of 5-6 min compared to the long stitch technique, which has no relation to the follow-up costs in case of complications or even the repair of a incisional hernia. The cost-benefit analyses as described by several authors (34,35,36) clearly show the advantage of the short stitch technique. Irrespective of the costs related to the treatment of incisional hernias, the personal fate of the patient must be considered and taken as an important factor.…”

Does small bite closure reduce the incidence of incisional hernia compared to standard mass closure for midline laparotomy?

“…The goal of the review was to answer the question posed at the start of the article; whether small bites can reduce the incidence of incisional hernia following midline laparotomy when compared to the conventional mass closure technique, with the latter being the regular practice of most of today's surgeons for several years if not for their entire career which makes the transition even more difficult if another technique is proven to be superior [ 11 , 12 ]. Nevertheless, we think by generating high-quality evidence of the small bite/small stitch technique in the form of best evidence topic, might help in adoption of this technique by more units.…”

A Comparison of a Small-Stitch Closure With a Standard Closure in Midline Laparotomy Incisions: A Prospective Comparative Study

“…However, midline laparotomy is associated with many postoperative complications, such as fistula formation, surgical site infection (SSI), incisional hernia, and wound dehiscence [2]. SSI is reported in 15% of patients who have undergone major surgery, like midline laparotomy, which can further lead to wound dehiscence and incisional hernia [3]. These complications associated with midline laparotomies lead to morbidity, re-operation, prolonged hospital stay, and decreased quality of life [4].…”

“…This traditional approach of long stitch suturing includes the aponeurosis, sub-cuticular fat, and muscle within the suture [13]. If force is applied, the soft tissue gets compressed, leading to a greater amount of necrotic soft tissue and delayed wound healing [3,6,8,14]. Not only this, but the compression of soft tissue also causes the suture to cut through the tissue, leading to a separation of the aponeurotic borders, impairing collagen deposition, and resulting in a higher rate of postoperative complications [8].…”