Comparison of post‐operative pain in short versus long stitch technique for abdominal wall closure after elective laparotomy: a double‐blind randomized controlled trial

Abstract

Background Conventional mass closure uses suture‐to‐wound length ratio of 4:1 (‘long stitch’, LS). ‘Short stitch’ (SS) has a suture‐to‐wound length ratio of more than 4 and incorporates only the linea alba, which may reduce tension and pain. We compared the post‐operative pain after laparotomy closure using LS and SS. Methods Patients undergoing elective midline laparotomy through standardized incisions in two tertiary hospitals from February 2017 to September 2018 were randomized to either LS or SS. The primary outcome was post‐operative patient‐controlled analgesia morphine usage at 24 h. Secondary outcomes were presence of surgical site infection and length of hospital stay (LOHS). Categorical variables were analysed using chi‐squared analysis. Outcomes of study were tested for normal distribution. Skewed data were analysed using Mann–Whitney U‐test. Results Eighty‐six patients were recruited (42 SS and 44 LS). The median age was 66 (interquartile range (IQR) 15). Majority were males (62.8%) and Chinese (50%). The median incision length was 17 cm in both groups. The median patient‐controlled analgesia morphine usage 24 h post‐operatively did not differ significantly (SS 21 mg, IQR 28.3; LS 18.5 mg, IQR 33.8, P = 0.829). The median pain score at rest (SS 1, IQR 1; LS 1, IQR 2, P = 0.426) and movement (SS 3, IQR 1; LS 3, IQR 2, P = 0.307) did not differ significantly. LOHS was shorter in the SS group (SS 6, IQR 4; LS 8, IQR 5, P = 0.034). The rate of surgical site infection trended lower in the SS group with no statistical difference. Conclusion There were no differences in post‐operative pain between SS and LS but we found that there were shorter LOHS in SS arm as secondary outcome.

The 6:1 short stitch SL-WL-ratio: short term closure results of transverse and midline incisions in elective and emergency operations

“…We know of three randomized-controlled trials investigating the effect of the short stitch suture technique using polydioxanone [PDS] as the suture material [ 6 , 15 , 24 ]. Recently the ESTIOH-trial using p-4OHB (same thread as in this study) as alternative suture material involved 425 patients showed a clear benefit by cutting in half the incisional hernia incidence (3.3% vs 6.4%) compared to conventional 4:1 SL/WL ratio [ 16 ].…”

6:1 Suture or Wound length ratio with the short stitch technique – a reality check on practicability and short term outcome

“…Since most elective even larger oncological/ abdominal procedures are nowadays at least contemplated to be performed laparoscopically, our patient clientel here is regarded as an intermediate, probably even high risk group from a diagnostic standpoint (presenting disease), but also in general (underlying diseases). We know of three randomised-controlled trials investigating the effect of the `short stitch` suture technique using polydioxanone (PDS) as the suture material [6,15,19]. Recently the ESTIOH-trial using poly-4-OH butyrate (same thread as in this study) as alternative suture material involved 425 patients showed a clear benefit by almost cutting in half the incisional hernia incidence (3.3% vs 6.4%) compared to conventional 4:1 SL/WL ratio [16].…”

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

“…According to the long stitch suture technique, the distance between the suture bite site and the wound incision should be 1 cm, and the inter-suture distance should also be 1 cm. 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].…”