Impact of Short-Stitch Technique on Midline Abdominal Closure: ESTOIH Trial Short-Term Results

Overview

The ESTOIH randomized controlled trial evaluated the effect of short-stitch versus long-stitch techniques using an elastic, extra-long-term absorbable monofilament suture for midline abdominal closure. Preliminary short-term results indicate differences in burst abdomen and surgical site infection rates between the two techniques.

Background

Incisional hernia remains a significant complication after midline abdominal wall closure, with rates ranging from 10% to 69%. Factors influencing wound healing include suture tension, collagen deposition, blood supply, and infection absence. Prior studies and guidelines have suggested that small bite (short-stitch) techniques with a high suture-to-wound length ratio reduce incisional hernia rates compared to large bite techniques. The ESTOIH trial was designed to assess the impact of stitch length using a novel elastic, extra-long-term absorbable suture material on postoperative outcomes.

Data Highlights

Key Findings

• The ESTOIH trial is a multi-centre, double-blinded RCT comparing short-stitch (5 mm intervals) versus long-stitch (10 mm intervals) techniques for midline closure.
• Both groups used an elastic, extra-long-term absorbable monofilament suture (poly-4-hydroxybutyrate, Monomax®).
• The short-stitch technique achieved a suture-to-wound length ratio ≥ 5:1, while the long-stitch technique had approximately 4:1.
• Surgeons received standardized training to ensure consistency in suture technique application.
• Short-term outcomes focused on burst abdomen and surgical site infections within 30 days postoperatively.
• Protocol amendments allowed inclusion of patients with BMI ≥ 30 kg/m2 and benign pancreatic tumors to improve recruitment and applicability.

Clinical Implications

The ESTOIH trial's preliminary findings support the feasibility of the short-stitch technique using an elastic, long-term absorbable suture for midline closure. If confirmed, this technique may reduce early postoperative complications such as burst abdomen and surgical site infections. Surgeons should consider stitch length and suture material properties when planning abdominal wall closure to optimize wound healing.

Conclusion

The ESTOIH study provides important early data on the impact of stitch length and suture material in midline abdominal closure. Further follow-up is needed to confirm long-term benefits on incisional hernia rates and wound healing outcomes.

References

1. Höer et al. 2015 -- European Hernia Society Guidelines on Abdominal Wall Closure
2. Millbourn et al. 2011 -- Randomized Trial Comparing Large and Small Bite Closure
3. Diener et al. 2010 -- INLINE Meta-Analysis on Midline Closure Techniques
4. Deerenberg et al. 2015 -- STITCH Trial on Small vs Large Bite Closure
5. Henriksen et al. 2017 -- Meta-Analysis on Small Bite Technique
6. ESTOIH Trial Protocol NCT01965249 -- Impact of Stitch Length on Hernia Development