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Purpose The small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes. Methods Prospective data of all EMLs were collected for 2 years. Results were analyzed at 1 month and during follow-up. The incidence of HI and FD was compared by groups (M = Mesh  vs.  S = suture) and by subgroups depending on using SB. Results A lower number of FD appeared in the M group (OR 0.0692; 95% CI 0.008–0.56;  P  = 0.01) in 197 operations. After a mean follow-up of 29.23 months ( N  = 163; min. 6 months), with a lower frequency of IH in M group (OR 0.769; 95% CI 0.65–0.91;  P  &lt; 0.0001). (33) The observed differences persisted after a propensity matching score: FD (OR 0.355; 95% CI 0.255–0.494;  P  &lt; 0.0001) and IH (OR 0.394; 95% CI 0.24–0.61;  P  &lt; 0.0001). On comparing suturing techniques by subgroups, both mesh subgroups had better outcomes. PM was the main factor related to the reduction of IH (HR 11.794; 95% CI 4.29–32.39;  P  &lt; 0.0001). Conclusion Following the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.

Implementing a protocol to prevent incisional hernia in high-risk patients: a mesh is a powerful tool