Modified Smead–Jones versus conventional continuous rectus closure for midline laparotomy: a prospective randomized controlled trial assessing early and late wound outcomes

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Abstract

Background: Incisional hernia remains a prevalent complication following midline laparotomy, affecting 10- 20% of patients at one-year follow-up. The optimal fascial closure technique remains debated. The study compared conventional continuous closure with the modified Smead–Jones closure technique. Objective: To evaluate the efficacy of the modified Smead–Jones double-loop closure versus conventional continuous closure in reducing post-operative complications and incisional hernia formation following midline laparotomy. Materials and Methods: A prospective randomized controlled trial was conducted over 24 months enrolling 40 patients (20 per group) undergoing elective or emergency midline laparotomy. Patients were randomized to either conventional continuous rectus fascia closure (single- layer running suture) or modified Smead–Jones closure (double-loop far-near near-far technique). Primary outcome was incisional hernia at one-year follow-up. Secondary outcomes included early wound complications (seroma, surgical site infection, and burst abdomen), hospital stay duration, and quality of life at one-year follow-up. Results: Overall complication rate was significantly lower in the modified Smead–Jones group (15% vs 60%, p = 0.018). One-week seroma formation was reduced in the modified Smead–Jones group (10% vs 30%, p = 0.113). Burst abdomen was completely eliminated in the modified Smead–Jones group (0% vs 10%, p = 0.146). At one-year follow-up, the incisional hernia rate was 0% in the modified Smead–Jones group compared to 15% in the conventional group (p = 0.071). Fascial integrity assessment by ultrasound showed 95% normal fascia in the modified Smead–Jones group versus 80% in the conventional group. No re-operations were required in the modified Smead–Jones group versus two re-operations for hernia repair in the conventional group (p = 0.154). At one-year follow-up, the pain scores were significantly lower with modified Smead–Jones closure (0.6 ± 0.6 vs 1.3 ± 1.1, p = 0.008). Mean closure time was longer with modified Smead–Jones technique (41.0 ± 6.6 minutes vs 22.3 ± 4.4 minutes, p < 0.001), requiring more sutures (2.5 ± 0.3 vs 1.5 ± 0.3, p < 0.001), but total operative time and hospital stay remained comparable between the groups. Conclusion: The modified Smead–Jones closure technique significantly reduces post-operative complications, prevents incisional hernia formation, and improves long-term pain outcomes compared to conventional continuous closure. Despite increased operative closure time and suture usage, the technique is cost-effective with a cost per complication avoided of approximately USD 295. The modified Smead–Jones technique is recommended for patients undergoing midline laparotomy, particularly in emergency and high-risk settings.