13 - SMALL AIM, SMALL MISS - TAKING SMALL BITES IMPROVES CONSISTENCY IN FASCIAL CLOSURE SIMULATION

Objectives: Several studies including the STITCH trial have suggested utilizing small bite (5 mm) closure technique improves outcomes. At our institution we created a felt model to simulate fascial closure and educate residents regarding small bite technique. Despite common knowledge that small bite closure is beneficial, it is not well documented how accurately and consistently surgeons employ this technique. The aim of this study is to gauge accuracy and consistency of bite size in fascial closure and assess if utilizing a templated model could improve technique.

Methods: Two 10 cm incisions were made in different pieces of felt. Residents were instructed to suture the incisions to simulate fascial closure by running the incisions closed with 1 cm and 5 mm bites respectively. The process was then repeated with templated pieces of felt marked with 1 and 0.5 cm to guide bite size. Residents were timed for each closure (Fig 1). The travel and distance from the midline for each bite was measured and statistical analysis performed.

Results: 14 residents participated. Each closure was timed. Paired T test was utilized to compare means and standard deviations of bite size and travel. Taking 5 mm bites took 89 seconds longer than 1 cm bites (p=0.001). Standard deviation of travel (0.539, p< 0.001) and right sided distance from midline (0.508, p< 0.001) were significantly smaller when a template was utilized. Standard deviation of travel (0.294, p=0.01) and right sided distance (0.359, p=0.001) from midline were significantly larger in the 1 cm compared to 5mm groups.

Conclusion: There is much discussion about utilizing a small bite technique to close fascia and reasons why this seems to decrease incisional hernia rate are speculated but not proven. In this study, we demonstrated that utilizing a small-bite technique results in a more consistent and uniform closure and that the standard deviation between bites is improved when residents are instructed to take smaller bites. The riflery adage, “aim small, miss small,” seems to hold true in fascial closure and may be one reason why small bite technique improves hernia recurrence after laparotomy. This study also suggests that the use of a template improves accuracy and consistency of closure regardless of bite size intention. This raises the question of should we be templating fascial closure.