Midline laparotomy remains one of the most employed abdominal incisions due to its rapid accessibility, minimal blood loss, and wide exposure across upper and lower abdominal quadrants. [1,2] Despite these advantages, abdominal wound dehiscence continues to be a major postoperative complication, particularly in resource-limited settings. The incidence in Asian countries exceeds 10%, largely attributable to malnutrition and delayed emergency surgical intervention. [3] In contrast, the Veterans Affairs National Quality Program in the United States reports a dehiscence rate of 3.2%. [4] Indian data indicate wound disruption rates as high as 10–30% in emergency operations and 0–5% in elective cases. [4] Delayed presentation and prolonged peritonitis may result in necrosis of the linea alba and an amplified systemic inflammatory response, which interfere with collagen synthesis and impair wound healing. [5,6] The Smead-Jones “Far-Near-Near-Far” interrupted technique has historically been used to reduce fascial cut-through by distributing tension more effectively. However, the choice between continuous and interrupted suturing remains debated. Some studies favour interrupted closure for reduced dehiscence [7], while others report advantages with continuous techniques [8]. Still others found no clear superiority [9]. A meta-analysis by Gupta et al. reported significantly less dehiscence with interrupted closure [10]. Recent studies show favourable outcomes with modified continuous Smead-Jones techniques, particularly in contaminated and emergency settings [11,12]. The anatomical basis for improved outcomes in such techniques is supported by Rizk’s description of the linea alba as a decussation of multiple aponeurotic laminae [13]. Risk factors for dehiscence include emergency surgery, advanced age, malnutrition, intra-abdominal sepsis, diabetes, and elevated intra-abdominal pressure [14-23]. Given these complexities, and the absence of consensus on the optimal closure method, this study compares a modified continuous “Far-Near-Near-Far” closure technique with the standard continuous interlocking method to evaluate wound outcomes after midline laparotomy.

Study Design and Setting A prospective randomized comparative study was conducted in the Department of General Surgery, Sir Sayajirao General Hospital and Medical College, Vadodara, Gujarat, India from May 2018 to July 2019. Sample Size and Randomization A total of 106 patients undergoing midline laparotomy were enrolled; 6 patients died before wound healing and were excluded. Thus, 100 patients were analysed. Patients were randomized using sealed envelopes: • Odd numbers → Continuous Interlocking (Control) • Even numbers → Modified Far-Near-Near-Far (Study) Inclusion Criteria 1. Age >18 years 2. Midline laparotomy incision 3. Consent for participation Exclusion Criteria • Prior laparotomy • Existing incisional hernia or burst abdomen • Declined consent Surgical Techniques 1. Continuous Interlocking Closure (Control Group) Closure of the rectus sheath using polypropylene No.1 in a continuous interlocking pattern, with each bite 2 cm from the fascial edge and 1 cm between stitches. 2. Modified Continuous Far-Near-Near-Far Closure (Study Group) A continuous, interlocking adaptation of the traditional Smead-Jones method: • Far: 2 cm from the edge • Near: 1 cm from the edge • Near (opposite side): 1 cm • Far (opposite side): 2 cm Approximately 3 cm between suture units was maintained. Postoperative Care Dressings were performed on postoperative days 3, 6, 9, and 12. Follow-up continued weekly until suture removal, then at 3 and 6 months for assessment of incisional hernia. Outcome Measures • Primary: Wound dehiscence • Secondary: Surgical site infection (SSI), operative closure time, hospital stay, incisional hernia at 6 months

Table 1. Age-wise Distribution of Patients and Wound Dehiscence Age Group (Years) Control Group (n=50) Wound Dehiscence (Control) Study Group (n=50) Wound Dehiscence (Study) 18–20 7 3 4 0 21–30 8 2 9 0 31–40 7 0 8 0 41–50 10 0 16 1 51–60 7 3 8 0 61–70 4 0 9 0 >70 2 1 1 1 Total 50 9 50 2 The age-wise distribution of patients was comparable between the two groups, with most participants aged 21–60 years and no statistically significant difference in age profiles. The 41–50 years category was most common in both groups. Wound dehiscence in the control group occurred mainly in the 18–20 and 51–60 years ranges (three cases each), whereas the study group showed only two isolated cases (one each in the 41–50 and >70 years groups). Overall, dehiscence was higher in the control group (18%) compared to the study group (4%), indicating that age was not a confounding factor in postoperative outcomes. The mean age of patients in the continuous interlocking technique group was 42 years, while the mean age in the modified Smead-Jones “Far-Near-Near-Far” technique group was 43 years. The comparison of age distribution between the two groups yielded a p-value >0.05, indicating no statistically significant difference. Table 2. Gender-wise Distribution of Patients and Wound Dehiscence Gender Control Group Study Group Total Wound Dehiscence (%) Male 8/42 1/41 9/83 (10.8%) Female 1/8 1/9 2/17 (11.7%) Total 9/50 (18%) 2/50 (4%) 11/100 (11%) The gender-wise distribution showed that most patients were male (n=83) compared to female (n=17). In the control group, wound dehiscence occurred in 8 out of 42 males and 1 out of 8 females, whereas in the study group only one male and one female developed dehiscence. Overall, the incidence of wound dehiscence was similar between males (10.8%) and females (11.7%), and the difference was not statistically significant, indicating that gender did not influence the occurrence of wound dehiscence in either technique. Table 3. Wound Infection Distribution in Control and Study Groups Parameter Control Group (n = 50) Study Group (n = 50) Total (N = 100) P value Wound infection 18 (36%) 10 (20%) 28 (28%) 0.07 No wound infection 32 (64%) 40 (80%) 72 (72%) Total 50 50 100 In the present study, wound infection occurred in 18 patients (36%) in the control group compared with 10 patients (20%) in the study group. Although the infection rate was lower in the modified Smead-Jones “Far-Near-Near-Far” group, the difference did not reach statistical significance (p = 0.07). Overall, 28% of the total study population developed wound infection, indicating a trend toward better outcomes with the modified technique, though without significant intergroup variation. Table 4. Operative Time and Hospital Stay in Control and Study Groups Parameter Control Group (n = 50) Study Group (n = 50) Inference Operative time (per 10 cm closure) 6.5 minutes 5.8 minutes Faster in study group Hospital stays (days) 16 days 13 days Shorter in study group The mean operative time required for rectus sheath closure was shorter in the study group (5.8 minutes per 10 cm) compared with the control group (6.5 minutes), indicating greater efficiency with the modified Smead-Jones technique. Similarly, the mean duration of hospital stay was reduced in the study group (13 days) compared to the control group (16 days). Although not assessed for statistical significance, these findings suggest that the modified closure method may contribute to faster recovery and reduced postoperative hospitalization. Table 5. Incisional Hernia Incidence in Control and Study Groups Parameter Control Group Study Group Total Incisional hernia present 5 (10%) 4 (8%) 9 (9%) No incisional hernia 45 (90%) 46 (92%) 91 (91%) Total 50 50 100 At six months of follow-up, incisional hernia developed in 10% of patients in the control group compared to 8% in the study group. Although the incidence was slightly lower with the modified Smead-Jones technique, the difference was not statistically significant. Overall, incisional hernia occurred in 9% of the total study population, indicating comparable long-term wound integrity between the two closure techniques.

This randomized prospective study included 100 patients who underwent midline laparotomy. These patients were evaluated to compare continuous interlocking fascial closure with the modified Smead-Jones “Far-Near-Near-Far” technique in terms of wound dehiscence, operative time, surgical site infection, hospital stay, and incisional hernia. With respect to sex distribution, wound dehiscence in males (n = 83) occurred in 6 patients in the control group and 1 patient in the study group. Among females (n = 17), 1 patient in each group developed dehiscence. The calculated relative risk was 0.92, demonstrating no significant sex-related difference in the occurrence of wound dehiscence. This finding contrasts with earlier studies by Keil RH (1973) [24] and Mayo CW (1951) [25], which reported a higher prevalence of dehiscence among males, independent of the closure technique used. In the present study, 9 out of 50 patients (18%) in the control group developed wound dehiscence, compared with only 2 out of 50 patients (4%) in the modified Smead-Jones group. This difference was statistically significant (χ² = 5.0, p = 0.025). Comparable findings have been reported in randomized trials. Sringeri R et al. (2017) [14] observed a wound dehiscence rate of 1% with the re-modified Smead-Jones technique versus 14.9% with conventional continuous closure (p = 0.01). Similarly, Dhamnaskar SS et al. (2016) [15] reported 8% dehiscence using the modified continuous Smead-Jones method compared with 24% using the interrupted mass closure technique (p < 0.05). These findings consistently demonstrate that the modified Smead-Jones “Far-Near-Near-Far” technique offers superior tensile strength and more effective distribution of fascial tension, significantly reducing the risk of postoperative wound dehiscence. Wound infection occurred in 18 out of 50 patients (36%) in the control group and 10 out of 50 patients (20%) in the study group. Although the infection rate was lower in the modified Smead-Jones group, the difference was not statistically significant (p = 0.07). Sringeri R et al. (2017) [14] reported significantly lower wound infection rates with the re-modified Smead-Jones technique (12.3%) compared to conventional closure (32.4%; p = 0.03). Dhamnaskar SS et al. (2016) [15] also observed a lower infection rate (32%) in the modified technique group compared with the interrupted closure group (38%), although this difference was not statistically significant. Overall, although the present study did not show statistical significance, the trend toward fewer infections with the modified technique suggests improved wound stability and reduced tissue trauma. The mean time required for closure of a 10 cm fascial segment was 6.5 minutes in the control group and 5.8 minutes in the modified Smead-Jones group. This demonstrates that the modified technique allows faster closure. Supporting evidence is provided by Dhamnaskar SS et al. (2016) [15], who reported closure times of 4.8 minutes with the modified continuous technique versus 6.4 minutes with interrupted suturing (p < 0.05). Thus, the modified Smead-Jones technique not only strengthens fascial closure but also reduces operative time, an important consideration in emergency or prolonged surgeries. The mean duration of hospitalization was shorter in the study group (13 days) compared with the control group (16 days). Sringeri R et al. (2017) [14] similarly reported shorter hospital stays with the modified continuous Smead-Jones technique. In the present study, the reduced hospital stay likely reflects lower rates of wound complications and faster postoperative recovery in the study group. During six months of follow-up, incisional hernia developed in 5 patients (10%) in the control group and 4 patients (8%) in the study group. The difference was not statistically significant (χ² = 0.12, p = 0.72). Sringeri R et al. (2017) [14] reported no hernias within the same follow-up period. However, incisional hernias commonly develop after 1–2 years; therefore, the six-month follow-up in the present study is insufficient to determine the true long-term incidence. The trend, however, suggests that the modified technique does not increase hernia risk and may even offer a modest protective effect. This study is limited by its relatively small sample size of 100 patients and the short follow-up duration of six months. Since most incisional hernias develop beyond this period, longer follow-up is essential to accurately assess long-term outcomes. Larger multicentric studies are also recommended to validate these findings.

The modified continuous Far-Near-Near-Far closure technique significantly reduces wound dehiscence, operative time, and hospital stay compared with the continuous interlocking technique, without increasing incisional hernia rates. It is recommended as an effective alternative for midline laparotomy fascial closure.

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