The study, led by researchers at the University of Edinburgh, set out to characterize contemporary global practice in lower abdominal transverse incisions, or LATIs. These are the horizontal cuts made just above the pubic bone, used almost universally for caesarean sections and increasingly adopted by general surgeons and urologists for other abdomino-pelvic procedures. Using an anonymised online questionnaire distributed through professional networks, the team collected responses over a ten-month period from January to October 2025. After removing duplicates and ineligible respondents, 231 surgeons from 31 countries across six continents were included in the final analysis.

The respondent pool was dominated by general surgeons, who accounted for 68.4 percent of the sample, followed by obstetricians and gynaecologists at 26.4 percent and urologists at 5.2 percent. This distribution matters because the three groups bring very different levels of experience with the incision type. Obstetricians and gynaecologists performed a dramatically higher annual volume of LATI procedures, with 60.7 percent reporting more than fifty cases per year, compared with just 6.5 percent of general and urological surgeons. The median consultant experience also differed, with general and urological surgeons reporting a median of sixteen years in independent practice versus nine years for obstetricians and gynaecologists.

The first major divergence appeared at the point of entry into the abdominal wall. General surgeons and urologists predominantly used diathermy, an electrosurgical tool that cuts tissue while simultaneously coagulating blood vessels, to open the fascia, the tough fibrous layer enveloping the rectus muscles. In contrast, most obstetricians and gynaecologists favoured a combination of dissection modalities, blending blunt and sharp techniques. The differences extended deeper into the wound. When it came to opening the peritoneum, the thin serous membrane lining the abdominal cavity, 62.3 percent of obstetricians and gynaecologists used blunt dissection, compared with just 7.6 percent of the other group, who more commonly relied on sharp dissection with scissors or a blade.

The direction of the peritoneal opening also split along specialty lines. Obstetricians and gynaecologists most frequently opened the peritoneum transversely, in line with the modified Joel-Cohen technique popularised for caesarean sections roughly three decades ago, an approach designed to avoid injury to the bladder. General surgeons and urologists, by contrast, most commonly opened the peritoneum longitudinally, a practice more consistent with the traditional Pfannenstiel incision described in 1900 or with abdominal entry through a midline incision. These differences in technique likely reflect the distinct operative exposures required by each specialty, as well as the underlying pathology being treated and the potential need for more urgent access in obstetric surgery.

The second major divergence emerged at closure. Obstetricians and gynaecologists left the peritoneum unsutured in 77.0 percent of cases, whereas 75.9 percent of general and urological surgeons routinely closed it. This non-closure practice aligns with current guidelines from the UK’s National Institute for Health and Care Excellence and the PROSPECT recommendations, which suggest that leaving the peritoneum open reduces operating time and postoperative analgesic requirements. The two largest randomised controlled trials addressing this question, CAESAR and CORONIS, demonstrated equivalence between closure and non-closure across most considered outcomes, including infection, bleeding and pain. However, some potentially important outcomes such as adhesion and hernia formation remain under-explored, and a systematic review has suggested that non-closure may be associated with an increased risk of adhesions.

Re-approximation of the rectus muscles also differed between groups. Obstetricians and gynaecologists were less likely to bring the muscles back together, with only 36.1 percent doing so, compared with 58.2 percent of general and urological surgeons. Urologists had the highest rates of muscle re-approximation across all groups at 83.3 percent. Interestingly, country income status appeared to influence this practice as well, with surgeons in upper-middle and lower-middle income countries more likely to re-approximate the rectus muscles than their counterparts in high-income countries. The reasons for this geographic variation are unclear but may relate to differences in training traditions, suture availability or perceived risk of wound complications.

Fascial closure technique revealed perhaps the most striking inter-specialty difference. The small bites technique, which involves placing sutures closer together with smaller tissue bites, has been recommended by the European and American Hernia Societies for closure of midline abdominal incisions based on evidence that it reduces hernia rates. General surgeons and urologists overwhelmingly adopted this approach, with 85.3 percent using it, while only 42.6 percent of obstetricians and gynaecologists did so. More than half of the obstetric group employed large bites instead. Across all groups, continuous rather than interrupted closure was predominant, and slowly absorbable sutures were the preferred suture material, with no significant difference between specialties in this regard.

The survey also explored surgeons’ experience with hernias related to these incisions. General surgeons were far more likely to have encountered a LATI hernia, with 85.4 percent reporting at least one, compared with 41.7 percent of urologists and 42.6 percent of obstetricians and gynaecologists. The types of hernias seen also differed. General surgeons commonly encountered a mix of total and partial inter-parietal hernias, the latter remaining clinically occult within the abdominal wall layers, while urologists and obstetricians predominantly reported partial hernias. Most general surgeons also reported finding LATI hernias incidentally during laparoscopy, at 62.0 percent, whereas far fewer urologists and obstetricians reported this finding.

Perhaps most tellingly, 84.0 percent of all respondents agreed that LATI hernias are underreported, with the proportion rising to 91.1 percent among general surgeons. This consensus suggests that the true prevalence of hernias following these incisions may be substantially higher than current clinical recognition implies. The authors caution that the survey’s open, network-based dissemination means no response rate could be calculated and that voluntary participation may have introduced selection bias. The questionnaire also did not distinguish between elective and emergency contexts, which may obscure clinically relevant differences within specialties. Nevertheless, the findings highlight a clear need for further outcome-focused research and standardisation of LATI techniques, particularly regarding the relationship between entry and closure methods and the development of incisional hernias, which could ultimately inform guidelines that currently rest almost exclusively on evidence from obstetric populations.

Subject of Research: International survey of surgical practice in lower abdominal transverse incision entry and closure techniques across specialties

Article Title: Contemporary global practice in dissection and closure techniques for lower abdominal transverse incisions: a cross-sectional survey

Article References: Brown, L. R., Adegoke, H., Gardner, E., Drake, T. M., Lucocq, J., & Zanellato, A. (2026). Contemporary global practice in dissection and closure techniques for lower abdominal transverse incisions: a cross-sectional survey. Journal of Abdominal Wall Surgery, 5, Article 17006. https://doi.org/10.3389/jaws.2026.17006

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.17006

Keywords: lower abdominal transverse incision, LATI, surgical technique, incisional hernia, caesarean section, peritoneal closure, fascial closure, small bites technique, cross-sectional survey, abdominal wall surgery, inter-specialty variation, Joel-Cohen technique

Incisional hernias occur when tissue pushes through a weakness in the abdominal wall at the site of a surgical scar. They are among the most frequent postoperative complications, causing pain and cosmetic concerns and, more seriously, carrying the risk of small bowel incarceration—a situation in which a loop of intestine becomes trapped in the defect and requires emergency surgery. Even without such emergencies, definitive repair usually demands another operation, imposing additional physical and economic burdens on patients. While minimally invasive approaches such as conventional multiport, robot-assisted, or single-incision laparoscopic surgery reduce hernia risk compared with open surgery, the problem persists. In minimally invasive colorectal surgery, particularly when the specimen extraction site sits on the midline, previous reports put the incidence at roughly 16 percent.

Barbed sutures were developed as an advancement in wound-closure surgery, and they bring several mechanical advantages. Because the barbs anchor tissue directly, surgeons do not need to tie knots or rely on an assistant to hold tension, which shortens closure time. More importantly, the barbs distribute tension more evenly along the wound rather than concentrating it at knot points. Earlier studies have linked barbed sutures to a lower risk of evisceration after abdominal fascial closure in emergency surgery, and other research found reduced hernia rates compared with interrupted slowly absorbable sutures after minimally invasive colorectal operations. What remained unclear was whether barbed sutures could outperform the continuous non-barbed slowly absorbable sutures that guidelines currently favor.

To answer that question, the research team reviewed the records of patients who underwent elective minimally invasive gastroenterological surgery requiring a midline incision, including the umbilical region for specimen extraction, between January 2021 and January 2025. After applying exclusion criteria—such as preoperative hernia, conversion to open surgery, or missing imaging data—255 patients entered the analysis: 142 whose extraction sites were closed with continuous triclosan-coated polydioxanone suture, a standard slowly absorbable monofilament, and 113 closed with a triclosan-coated barbed suture of the same absorbable material. The choice of suture was left to the operating surgeon’s discretion, but the fascial closure technique itself was standardized across the institution.

Because surgeons did not assign sutures randomly, the researchers used a statistical technique called inverse probability of treatment weighting, built on propensity scores that accounted for known hernia risk factors. These included age, sex, body mass index, smoking status, nutritional status measured by the prognostic nutritional index, comorbidities such as diabetes and chronic obstructive pulmonary disease, prior midline abdominal surgery, rectus diastasis—a separation of the abdominal muscles of two centimeters or more—and primary umbilical hernia. After weighting, the two groups were well balanced, with standardized mean differences below 0.1 for nearly all baseline characteristics. Hernia status one year after surgery was assessed uniformly by abdominal computed tomography, and four surgeons blinded to the closure method made the diagnoses according to European Hernia Society criteria.

The results were striking. One year after surgery, incisional hernia was detected in 20.6 percent of the weighted conventional suture group but only 10.7 percent of the barbed suture group. Weighted logistic regression showed that barbed sutures were associated with a reduced risk of hernia, with an odds ratio of 0.46 and a 95 percent confidence interval of 0.22 to 0.99, a statistically significant result. Short-term outcomes were comparable between the groups: operative time, serious postoperative complications graded by the Clavien–Dindo classification, and surgical site infection rates showed no significant differences. Subgroup analyses across age, diabetes, rectus diastasis, body mass index, prior abdominal surgery, and surgical approach showed a generally consistent benefit, with no significant interactions.

The mechanical explanation may lie in how barbs interact with healing tissue. The authors propose three mechanisms. First, barbed sutures distribute tension homogeneously along the suture line, which may reduce segmental ischemia and tissue necrosis, promoting more stable fascial healing. Second, the barbs create multiple fixation points that keep tissue edges securely approximated even under increased intra-abdominal pressure, preventing the suture line from loosening. Third, previous work has shown that barbed sutures induce greater fibrous tissue formation around the barbs than smooth sutures, potentially reinforcing the strength of the repair. Because both groups used continuous antimicrobial-coated absorbable sutures, the presence or absence of barbs stands out as the most plausible driver of the difference.

The study also carries important caveats. When the surgical approach—robot-assisted versus laparoscopic—was added to the statistical model, the association remained in favor of barbed sutures but was attenuated and no longer statistically significant, with an odds ratio of 0.53. The researchers note that robotic surgery and barbed suture adoption both increased during the later study period, making the two strongly correlated with calendar time, so the surgical approach may have partly captured secular changes rather than a true causal factor. The retrospective, single-center design limits generalizability, particularly for hepato-biliary-pancreatic procedures, which made up only a small fraction of cases. Surgeon-specific technical details such as the suture-to-wound length ratio and bite width were unavailable, and follow-up beyond one year was limited, even though hernia rates are known to keep rising between one and three years after surgery.

An additional competing-risks analysis using all available follow-up data, with death without prior hernia treated as a competing event, reinforced the primary finding: the cumulative incidence of hernia remained lower in the barbed suture group, with a subdistribution hazard ratio of 0.48. At 12, 24, and 36 months, weighted cumulative incidence was 19.6, 24.6, and 26.8 percent in the conventional group versus 9.0, 15.7, and 15.7 percent in the barbed group. Notably, among patients who developed hernias, all eight symptomatic cases—and all seven who underwent elective repair—occurred in the conventional suture group, although defect sizes did not differ significantly between groups, suggesting symptoms may not track directly with defect dimensions.

The authors caution that even with barbed sutures, additional preventive strategies remain important for high-risk patients, including the small-bite technique—tissue bites of five to nine millimeters with stitches placed roughly five millimeters apart—a suture-to-wound length ratio of at least four to one, and avoiding midline incisions for specimen extraction where possible. As barbed sutures such as STRATAFIX become more widely adopted, the findings suggest that the choice of closure material, combined with careful technique and attention to patient risk factors, could meaningfully reduce the burden of incisional hernia. Larger, longer-term studies will be needed to confirm the benefit and establish whether this simple change in thread can deliver lasting protection.

Subject of Research: Barbed versus non-barbed suture closure for preventing incisional hernia after minimally invasive gastroenterological surgery

Article Title: Barbed Sutures Are Associated With a Lower Incidence of Incisional Hernia Compared With Continuous Non‐Barbed Monofilament Sutures After Minimally Invasive Gastroenterological Surgery

Article References: Honma, S., Takashima, T., Ushikubo, T., Ishikawa, K., Kumode, T., Suzuki, T., Murakami, T., Hosokawa, S., & Nakajima, S. (2026). Barbed Sutures Are Associated With a Lower Incidence of Incisional Hernia Compared With Continuous Non‐Barbed Monofilament Sutures After Minimally Invasive Gastroenterological Surgery. Annals of Gastroenterological Surgery, Article ags3.70294. https://doi.org/10.1002/ags3.70294

Image Credits: AI Generated

DOI: 10.1002/ags3.70294

Keywords: barbed sutures, incisional hernia, minimally invasive surgery, fascial closure, laparoscopic surgery, robot-assisted surgery, surgical site infection, rectus diastasis, propensity score analysis, abdominal wall closure, gastroenterological surgery, STRATAFIX