A traction suture for abdominal wall closure in large incisional hernias: a prospective analysis of the "suitcase technique" - a simple horizontal offloading z-suture for gradual myofascial approximation.

PURPOSE: Primary myofascial closure in large incisional hernia repair remains technically challenging due to excessive tension, loss of domain, and limited accessibility of costly traction devices. This study aimed to evaluate the feasibility, biomechanical effect, and short-term outcomes of a novel horizontal traction suture method—the suitcase technique—designed to facilitate gradual fascial approximation. METHODS: This prospective, single-center study included 69 patients undergoing elective open repair of large midline incisional hernias (defect width 8–20 cm) with retromuscular mesh placement. Patients were stratified into two groups based on defect width (≤ 14 cm and 14–20 cm). The ‘suitcase technique’, consisting of a centrally placed Z-suture (‘suitcase’ suture), was applied prior to definitive fascial closure. Tensile force required for fascial approximation and resting distance between fascial edges were measured before Z-suture placement and after 5 and 10 min. Primary outcome was successful primary myofascial closure. Secondary outcomes included operative parameters and postoperative complications. RESULTS: Successful primary myofascial closure was achieved in all patients with defects ≤ 14 cm and in 76.7% of patients with defects > 14 cm. Application of the ‘suitcase’ suture resulted in a progressive reduction in tensile force required for fascial approximation. After 10 min the tensile force decreased respectively by 8.2 N (34.3%) in Group 1 and 8.1 N (27.7%) in Group 2 (p = 0.001). After 10 min of sustained ‘suitcase’ suture application, the resting fascial edge distance was reduced by 4.6 cm (43.8%) in Group 1 and by 4.6 cm (28.8%) in Group 2 (p = 0.019).Transversus abdominis release was performed in 75.4% of patients to ensure adequate mesh overlap. No reoperations were required. Postoperative complications were infrequent and manageable, with no early hernia recurrences observed at 12-month follow-up. CONCLUSION: The suitcase technique is a simple, cost-effective, and reproducible method that facilitates gradual myofascial approximation and enables primary fascial closure using the small bites technique with low morbidity. It represents a valuable alternative to dedicated intraoperative traction devices, particularly in resource-limited settings.