Abdominal surgeries account for a significant proportion of operative procedures worldwide, and the midline abdominal incision remains one of the most commonly used approaches to access the abdominal cavity [1]. Its popularity is due to its technical simplicity, rapid entry, minimal bleeding, and excellent exposure. However, proper closure of the midline incision is a critical surgical step, as inadequate closure can lead to severe complications, including surgical site infection (SSI), wound dehiscence, and incisional hernia [2]. Fascial closure is the most critical component of abdominal wound closure because the fascia provides the primary tensile strength of the abdominal wall. Conventional principles recommend the use of a continuous, slowly absorbable monofilament suture with an adequate suture length-to-wound length ratio (at least 4:1) [3]. Conventional monofilament sutures such as polydioxanone are widely used due to their high tensile strength and minimal tissue reactivity. However, these sutures rely on knots to maintain wound approximation. Knots represent the weakest point in a suture line and contribute to increased foreign body reaction, bulkiness, and potential loosening [4]. Barbed sutures represent a relatively recent advancement. They contain unidirectional or bidirectional barbs along their length, allowing them to anchor into tissue without the need for knots. The barbs engage the tissue at multiple points, preventing backsliding and enabling more uniform distribution of tension along the suture line [5]. This concept of knotless suturing is particularly advantageous in long abdominal fascial closures. The present study aimed to compare intraoperative and postoperative outcomes between barbed sutures and conventional monofilament sutures for midline abdominal incision closure in emergency exploratory laparotomy.

2.1 Study Design and Setting This prospective comparative observational study was conducted in the Department of General Surgery, Jorhat Medical College and Hospital (JMCH), Jorhat, Assam, over a period of one year (November 2024 to November 2025). Ethical approval was obtained from the Institutional Ethics Committee prior to commencement, and written informed consent was acquired from all participants. 2.2 Participants and Allocation Patients undergoing emergency exploratory laparotomy through a midline abdominal incision were enrolled. Exclusion criteria included pregnant females, children below 14 years of age, known cases of malignancy on active treatment, re-exploration cases, chronic steroid use, and surgeries involving stoma formation. Using systematic sampling (odd-even allocation based on admission serial numbers), 94 patients were divided into two equal groups: • Group A (Barbed Suture Group, n = 47): Fascial closure performed using barbed sutures. • Group B (Conventional Monofilament Suture Group, n = 47): Fascial closure performed using conventional monofilament sutures. 2.3 Data Collection and Parameters Intraoperative parameters recorded included total operative time and fascial closure time. Postoperative evaluations included pain (assessed via Visual Analogue Scale [VAS] on days 1, 3, and 7), length of hospital stay, and surgical complications (SSI, wound dehiscence, hematoma, and requirement for secondary suturing). Surgeon feedback regarding the ease of use and requirement of assistance was collected using a 5-point Likert scale (1 = Strongly Agree to 5 = Strongly Disagree). 2.4 Statistical Analysis Data were analyzed using descriptive and inferential statistics. Continuous variables were presented as mean ± standard deviation (SD) and compared using independent t-tests. Categorical variables were expressed as frequencies and percentages and compared using the Chi-square (χ2) test. A p-value of < 0.05 was considered statistically significant.

Baseline Demographics and Clinical Characteristics The mean age in the barbed suture group was 41.21 ± 14.83 years and 46.00 ± 14.99 years in the conventional monofilament group (p = 0.123). The cohort was predominantly male (85.1%), with an exactly equal sex distribution across both groups (40 males, 7 females each; p = 1.000). The most common surgical indication was hollow viscus perforation (HVP), accounting for 59 cases (62.8%), followed by appendicular abscess and trauma hemoperitoneum (10 cases each, 10.6%). The distribution of surgical indications (p = 0.338) and wound classifications (Dirty: 76.6%; Clean-Contaminated: 16.0%; Contaminated: 7.4%; p = 0.495) showed no significant differences between the two groups, ensuring baseline comparability. Intraoperative Outcomes The mean total operative time was 107.62 ± 6.02 minutes in the barbed group and 108.87 ± 5.63 minutes in the conventional group (p = 0.299). However, a highly significant difference was observed in fascial closure time. The barbed suture group required a mean of 13.81 ± 1.57 minutes for closure compared to 19.62 ± 1.58 minutes for the conventional group (t = -17.871, p < 0.001) (Table 1). Operative Parameter Barbed Suture (n=47) Mean ± SD Conventional Mono (n=47) Mean ± SD Statistical Value Total Operative Time (min) 1 07.62 ± 6.02 1 08.87 ± 5.63 t = -1 .044, p = 0.299 Fascial Closure Time (min) 1 3.81 ± 1 .57 1 9.62 ± 1 .58 t = -1 7.871 , p < 0.001 Postoperative Outcomes and Complications Postoperative pain scores evaluated via VAS showed no significant variations between the groups at day 1 (p = 0.840), day 3 (p = 0.627), or day 7 (p = 0.464). The mean postoperative hospital stay was 8.94 ± 2.54 days for the barbed group and 8.74 ± 2.10 days for the conventional group (p = 0.691). As detailed in Table 2, the occurrence of SSI, wound dehiscence, and postoperative hematoma did not differ significantly between the two techniques. However, the requirement for secondary suturing was significantly lower in the barbed suture group (2 cases, 4.3%) compared to the conventional monofilament group (8 cases, 17.0%; p = 0.045). Surgeon Perspectives Evaluation of surgeon feedback demonstrated that both suturing techniques were comparably manageable. The mean ease of suturing score was 2.17 ± 1.07 for the barbed group versus 2.13 ± 0.88 for the conventional group (p = 0.833). The requirement for assistance was also comparable (2.26 ± 1.11 vs. 2.34 ± 0.98; p = 0.695). Complication Barbed Suture n (%) Conventional Mono n (%) p-value Surgical Site Infection (SSI) 9 (1 9.1 %) 1 4 (29.8%) 0.354 Wound Dehiscence 6 (1 2.8%) 9 (1 9.1 %) 0.398 Hematoma 1 (2.1 %) 3 (6.4%) 0.307 Requirement of Secondary Suturing 2 (4.3%) 8 (1 7.0%) 0.045

The integrity of midline fascial closure is a critical determinant of postoperative recovery. The present study demonstrates a highly significant reduction in fascial closure time (13.81 ± 1.57 min vs. 19.62 ± 1.58 min; p < 0.001) utilizing barbed sutures. This aligns with findings by Abhilash et al., who emphasized that continuous and simpler closure methods reduce operative duration [6], and Agarwal et al., who reported substantial time reductions with barbed sutures in caesarean sections . The knotless, self-anchoring mechanism of barbed sutures eliminates repeated knot tying, streamlining the closure process without altering the total surgical duration (p = 0.299), which is largely dictated by the complexity of the intra-abdominal pathology.[7] Both groups experienced comparable postoperative pain, hospital stays, and overall wound complications (SSI, hematoma, and dehiscence). Given that 76.6% of procedures involved dirty wounds, primarily due to perforative peritonitis, the comparable rates of SSI (p = 0.354) and dehiscence (p = 0.398) confirm that barbed sutures maintain robust fascial integrity even in highly contaminated environments. This observation is supported by Guadalajara et al. and Fortelny et al., who highlighted that proper tension distribution is vital for preventing abdominal wall complications [8]. A notable clinical advantage identified in this cohort was the significantly lower requirement for secondary suturing in the barbed suture group (4.3% vs. 17.0%; p = 0.045). This likely reflects the even distribution of tension along the fascial plane afforded by the multiple anchoring points of the barbed suture, mitigating the risk of localized tissue ischemia or suture cut-through typically associated with overtightened knots.

Barbed sutures present a highly effective and safe alternative to conventional monofilament sutures for midline abdominal incision closure in emergency laparotomies. Their primary advantage lies in significantly reducing fascial closure time and minimizing the need for secondary postoperative suturing. These benefits are realized without compromising wound integrity or increasing postoperative complications, supporting their routine integration into abdominal surgical practice.

1. Ajao OG. Abdominal incisions in general surgery: a review. Annals ofIbadan Postgraduate Medicine. 2007;5(2):59-63. 2. Veljkovic R, Protic M, Gluhovic A, et al. Prospective clinical trial of factors predicting the early development of incisional hernia after midline laparotomy. Journal ofthe American College ofSurgeons. 2010;210(2):210-219. 3. Deerenberg EB, Henriksen NA, Antoniou GA, et al. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. Br JSurg. 2022;109:1239-1250. 4. Wong YR, McGrouther DA. Biomechanics of surgical knot security: a systematic review. International Journal of Surgery. 2023;109(3):481-490. 5. Villa MT, White LE, Alam M, et al. Barbed sutures: a review of the literature. Plast Reconstr Surg. 2008;121:102e-e108. 6. Abhilash SB. A Comparative Study Between Continuous and X-Interrupted Sutures in Preventing Burst Abdomen in Emergency Midline Laparotomy Incisions. Rajiv Gandhi University of Health Sciences, 2018. 7. Agarwal S, D'Souza R, Ryu M, Maxwell C. Barbed vs conventional suture at cesarean delivery: A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2021;100(6):1010-1018. 8. Fortelny RH. The best closure technique without mesh in elective midline laparotomy closure. Journal of Abdominal Wall Surgery. 2022;1:10962