Impact of the SUture BIte TEchnique on clinical outcomes after midline laparotomy closure: SUBITE—a systematic review and meta-analysis

Abstract Background The objective of this Systematic Review and Meta-Analysis (SR/MA) was to identify the best suture technique (short or large bites) for abdominal wall closure with respect to relevant outcome parameters such as incisional hernia (IH), surgical site infection (SSI) and linea alba (aponeurotic layer of the abdominal wall) dehiscence (LAD). Methods Registration was done in PROSPERO, a systematic literature search was performed in three data bases (PubMed, Embase and Cochrane). Randomised controlled (RCT) as well as non-randomised controlled trials (n-RCT) comparing the short (SB) versus large bite (LB) technique for abdominal wall closure after midline laparotomy were eligible for inclusion. Quality assessment was performed for RCTs (ROB) & n-RCTs (ROBINS-1, MINORS). The incidence of IH, SSI, LAD as well as the length of hospital stay (LOS) and time to close the linea alba (aponeurotic layer of the abdominal wall) were analysed as outcome parameters. Odds ratio with 95% confidence intervals were chosen to determine statistical significance. Heterogeneity was explored using the I 2 -statistics and funnel plots evaluated a possible publication bias. Results This SR/MA comprised in total 5886 patients (large bite group 3339 vs. 2547 short bite group) enrolled in 7 RCTs and 5 n-RCTs. The SB-technique was associated with a significant lower IH, SSI, FD rate and a shorter LOS compared to the LB-technique (IH: Odds Ratio OR = 0.47 (95% CI 0.38–0.58; p < 0.00001; I 2 = 11%)); SSI: OR = 0.53 (95% CI 0.42–0.67; p < 0.00001; I 2 = 0%); FD: OR = 0.60 (95% CI 0.38–0.93; p = 0.02; I 2 = 0%); LOS: Mean difference in days MD = -1.04 (95% CI -1.70, -0.37; p = 0.002; I 2 = 13%), respectively). Furthermore, pooled effect estimates derived from RCTs were comparable to n-RCTs. No statistical relevant publication bias was detected, and the confidence of resulting evidence was high according to the validated GRADE tool. Conclusion This systematic review and meta-analysis demonstrate consistent reductions in incisional hernia and surgical site infection with the small bites technique for midline laparotomy closure. The direction of effect is stable across randomized and comparative studies and supported by available long-term data. The clinical relevance and consistency of these findings support preferential use of the small bites technique in routine practice. The present evidence provides a robust basis for consideration in future updates of EHS abdominal wall closure guidelines. Registration PROSPERO, registration number: CRD420251033244, registration date: 16th April 2025.