Background <p>Incisional hernia is the most common long-term complication following abdominal surgery, resulting in considerable morbidity and the need for reoperation. The effectiveness of the small-bite fascial closure technique in reducing incisional hernia rates has been demonstrated; however, outside of elective settings, evidence is scarce regarding mixed elective and emergency populations. This prospective observational cohort study aimed to evaluate factors associated with incisional hernia at 12 months and to assess the association between closure technique and hernia formation.</p> Methods <p>We prospectively enrolled consecutive adults undergoing midline laparotomy from May 2021 to June 2023. Patient information including intraoperative parameters, such as the closure technique employed, that is, small-bite versus conventional, incision and suture length, and the suture-to-wound length ratio were recorded. Occurrence of incisional hernia was confirmed clinically and ultrasonographically after 12 months. Secondary outcomes included early wound complications and hospital stay duration. Independent predictors were identified using univariate and multivariate logistic regression analyses.</p> Results <p>Of the 231 patients enrolled, 217 completed 12-month follow-up (76 small-bite, 141 conventional). Incisional hernia developed in 3 patients (3.9%) with small-bite and 31 (22.0%) with conventional closure (<i>p</i> = 0.001). Early wound complications occurred in 16.6% overall and were significantly less frequent with small-bite closure (8.6% vs. 20.9%, <i>p</i> = 0.018). In the multivariate model, emergency surgery (OR = 5.74, <i>p</i> = 0.011), comorbidities (OR = 6.03, <i>p</i> = 0.001), and early wound complications (OR = 16.59, <i>p</i> &lt; 0.001) were independent predictors for incisional hernia, whereas the protective effect of small-bite technique was not significant (OR = 0.47, <i>p</i> = 0.325). The small-bite technique independently diminished the risk of postoperative early wound complications by 74% (adjusted OR = 0.26, <i>p</i> = 0.045).</p> Conclusions <p>The major independent predictors for incisional hernia development were emergency surgery, comorbidity, and early wound complications. The small-bite closure technique significantly reduced the occurrence of early wound complications and demonstrated a favorable but not statistically significant effect regarding hernia prevention.</p> Trial registration <p>ClinicalTrials.gov NCT07340918 (Retrospectively registered).</p>