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

The survey, which ran from November 20, 2024, to January 7, 2025, was distributed by email to 15,112 physician members of the JSGS aged 65 or younger. Responses were collected anonymously through a web-based questionnaire, and 1,967 surgeons completed the survey, a response rate of 13.0 percent. Respondents were asked about their experiences of and exposure to harassment over the preceding ten years, a deliberately broad recall window chosen because this was the first nationwide survey of its kind conducted by the society and was intended to establish a baseline for future repeated measurements. The cohort skewed heavily male, with 87.0 percent of respondents being men, mirroring the composition of the specialty itself. The median time since medical school graduation was 21 years, meaning that the sample captured surgeons well beyond the training years, from residents and research fellows to department chiefs, professors, and hospital directors.

The study assessed five distinct categories of harassment, defined with reference to guidance from Japan’s Ministry of Health, Labour and Welfare and adapted to the surgical context. These included power harassment, sexual harassment, maternity and paternity harassment, academic harassment, and a newly formulated category called surgery-related harassment, designed to capture inappropriate behavior occurring in intraoperative and perioperative settings that exceeds what is necessary and appropriate for work. All categories were assessed on the basis of each respondent’s subjective perception, and the categories were not treated as mutually exclusive.

Overall, 66 percent of respondents reported experiencing at least one type of harassment during the preceding decade. The figure was dramatically higher among women: 87 percent of female surgeons reported harassment compared with 63 percent of male surgeons. Power harassment and surgery-related harassment were the most common forms, each affecting slightly more than half of all respondents, at 52 percent and 51 percent respectively. Academic harassment was reported by 27 percent, sexual harassment by 11 percent, and maternity or paternity harassment by 6 percent. The seemingly low prevalence of the latter two categories reflects the overwhelmingly male sample; among female surgeons, 55 percent reported sexual harassment and 24 percent reported maternity or paternity harassment, compared with just 8 percent and 4 percent of men respectively. Even for surgery-related harassment, prevalence among women exceeded that among men by 16 percentage points.

Perhaps the most striking finding concerns witnessing rather than experiencing. Eighty-eight percent of respondents reported having seen or heard about at least one type of harassment in their workplace over the past ten years, including 87 percent of men and 94 percent of women. Power harassment was the most frequently witnessed category at 78 percent, followed by surgery-related harassment at 69 percent and sexual harassment at 52 percent. For every single type of harassment, the proportion who had witnessed it exceeded the proportion who had personally experienced it. The researchers interpret this pattern as evidence that harassment is embedded in, and normalized by, the culture of surgical workplaces rather than being confined to individual perpetrator-victim dyads. When abusive conduct is visible across an entire community, they argue, the problem must be treated as organizational rather than purely interpersonal.

The career consequences were equally alarming. Among surgeons who experienced harassment, 56 percent reported that it had driven them to consider leaving the profession, with nearly identical rates among men and women. For power harassment and surgery-related harassment specifically, 57 percent of affected surgeons had contemplated exit. The corresponding figures were 46 percent for maternity or paternity harassment, 37 percent for academic harassment, and 18 percent for sexual harassment. Timing mattered: surgeons who experienced power harassment within ten years of graduation were more likely to consider leaving than those harassed later in their careers, at 61 percent versus 50 percent. Most troubling of all, respondents who reported harassment across multiple career periods were the most likely of all to consider abandoning surgery, regardless of harassment type, suggesting that cumulative exposure compounds the damage.

These results land on a specialty already under demographic strain. Despite an overall increase in the number of medical interns in Japan, applications to surgical training programs have been declining, and the JSGS has documented year-by-year decreases in its own membership even as an aging society sustains demand for operations. A 2023 Health Labour Sciences Research report found that among residents who had originally intended to pursue surgery, one reason for ultimately choosing another path was the perception that harassment was likely to be common, alongside work-life balance concerns and the image of surgery as excessively demanding. An earlier nationwide survey by the Japan Surgical Society found that roughly 40 percent of young surgeons had experienced harassment from supervising surgeons and nearly 30 percent had considered leaving their training program, with harassment accounting for more than half of the reasons for contemplating withdrawal. The new data extend this concern beyond trainees to surgeons at every career stage, indicating that harassment persists throughout professional life rather than ending with residency.

The comparison with the general workforce is stark. In a recent nationwide survey of Japanese workers commissioned by the Ministry of Health, Labour and Welfare, 19.3 percent reported power harassment and 6.3 percent reported sexual harassment. Among gastroenterological surgeons, the corresponding figures were 51 percent and 11 percent. The authors attribute this elevated prevalence to the traditional hierarchical structure of surgical training, long working hours, high clinical demands, and strongly hierarchical organizational cultures, conditions that also make harassment less visible and more likely to persist implicitly. They note that while surgical education sometimes requires strict guidance and tension-filled situations, educational quality and a healthy work environment should not be regarded as mutually exclusive, and that behaviors presented as instruction or supervision may still be perceived as harassment by younger surgeons.

Demand for institutional action proved overwhelming. Fifty-eight percent of respondents strongly agreed and 34 percent agreed that the JSGS should implement countermeasures against harassment, meaning 92 percent supported society-level intervention, while only 5 percent disagreed. The authors argue that professional societies are uniquely positioned to act in hierarchical specialties such as surgery, where institutional responses within hospitals may be constrained by power structures and conflicts of interest. Potential initiatives include structured anti-harassment education for trainers and department leaders, periodic nationwide monitoring, video-based and simulation-based training programs of the kind being explored internationally, and systems to recognize and promote institutions that maintain healthy educational environments. Japan’s Japanese Medical Specialty Board has already established a consultation pathway for trainees who suspect harassment, and international bodies have developed formal professional-society resources addressing harassment-related behaviors, although evidence for real-world effectiveness in surgery remains limited.

The researchers acknowledge limitations, including the possibility of self-selection bias among voluntary respondents, the reliance on subjective perception rather than legal determination, the unavoidable recall bias of a ten-year window, the cross-sectional design that precludes causal inference, and the exclusion of surgeons who had already left practice or the society, including those who may have departed because of harassment. Nevertheless, the large nationwide sample and the inclusion of surgeons across career stages provide an unusually comprehensive view. The survey has already fed into policy: on July 17, 2025, the JSGS issued a formal Declaration for the Eradication of Harassment, and the study’s authors say the findings underscore the importance of translating that declaration into concrete action rather than leaving it as a statement of principle. With the future of the surgical workforce at stake, they argue, harassment must be recognized not merely as an ethical failing but as a workforce policy problem that threatens the sustainability of surgical care in Japan.

Subject of Research: Prevalence and consequences of workplace harassment among gastroenterological surgeons in Japan

Article Title: Workplace Harassment and Consideration of Leaving Surgical Practice: A Nationwide Survey by the Japanese Society of Gastroenterological Surgery

Article References: Kurimoto, K., Fujii, T., Shirai, Y., Fujinaga, A., Fukumoto, M., Ishida, S., Hida, K., Tanaka, C., Mizushima, T., Nomura, S., & Shirabe, K. (2026). Workplace Harassment and Consideration of Leaving Surgical Practice: A Nationwide Survey by the Japanese Society of Gastroenterological Surgery. Annals of Gastroenterological Surgery, Article ags3.70274. https://doi.org/10.1002/ags3.70274

Image Credits: AI Generated

DOI: 10.1002/ags3.70274

Keywords: workplace harassment, gastroenterological surgery, power harassment, sexual harassment, surgeon burnout, workforce sustainability, gender disparity, surgical training, Japan, professional societies, physician attrition, organizational culture