Small bites for fascial closure

[DoctwoB]

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60459-7/fulltext?rss=yes

It's great to see good studies in areas of surgical technique, when so much of what we are taught is dogmatic. I was always taught that fascial bites should be 1cm and 1 cm in travel to avoid strangulating the fascia. Consider that debunked.

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[ThoracicGuy]

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60459-7/fulltext?rss=yes

It's great to see good studies in areas of surgical technique, when so much of what we are taught is dogmatic. I was always taught that fascial bites should be 1cm and 1 cm in travel to avoid strangulating the fascia. Consider that debunked.

Never had concern for fascia strangulation, the concern was also hernia formation. We were taught the 1 cm/1 cm rule, but never told to make it even closer together because of that worry. It would make sense that you would have less hernia with a tighter closure.

 

[thedrjojo]

A well designed study, albeit I find their hernia rate in the large bite group a little high, and their rate in the small bite group is higher than what they predicted in the power calculation (they powered for 15% in the large bite and 7.5% in the small bite group), and most of these hernias were diagnosed radiologically only (upwards of 50%) and we're close to significantly smaller (2cm vs 4cm, p was like 0.065, so likely a type 2 error). Still, if I get to make the decision on suture type (which I will next year as a chief, and maybe on a rare occasion this year) I may use a 2-0 pds and do small bits instead of the large bites with #2 looped pds which is our programs standard (the paper used #1 looped pds, tied it to itself and then possibly to each other. We just tie them to each other and not to itself, which somewhat defeats the looped part).

 

[vhawk]

Using ultrasound to diagnose is weird but I suppose the idea was to sort of substitute that for longer follow up. Timely thread as we reviewed this paper in journal club last night. I think if you combine this paper with the Israelsson paper the preponderance of evidence seems to be on the side of small bites though. As painful as that may be.