Surgeon perspectives on the STITCH trial: a mixed methods study

Background: Incisional hernia prevention strategies related to fascial closure technique during laparotomy are well described yet poorly implemented in practice. The factors hindering the surgeon’s adoption of evidence-based techniques for fascial closure are poorly understood and characterized. Methods: Using an exploratory sequential mixed methods design, we first collected 139 responses to a validated quantitative survey based on a Theoretical Domain Framework for adoption of healthcare practices. Mean scores from survey responses were tabulated, and the findings were used to develop an interview guide for subsequent qualitative individual semi-structured phone interviews. Fourteen practicing surgeons were purposively sampled from social media outlets and our institution. The interviews were recorded and transcribed verbatim for coding and thematic analysis using NVivo 12 Plus. Data from the surveys and interviews were integrated using joint displays. Results: Quantitative and qualitative analyses from surveys and semi-structured interviews revealed various themes related to surgeon decision-making related to fascial closure technique. Surgeons cited limitations of prior studies, applicability of findings, anecdotal experiences, and situation-specific environments that influence their decision-making. Peer influence and lack of training also affected surgeons’ perspectives on integrating small bite technique into practice. Conclusion: Trial design limitations, peer influence, and patient-specific factors impacted surgeon decision-making in the choice of fascial closure technique. Future clinical trials in diverse patient populations may improve surgeons’ confidence in implementing technique for fascial closure.