Background <p>Acute abdominal wall dehiscence is a rare but life-threatening complication after laparotomy. The optimal suture technique for fascial closure remains debated. Barbed sutures may improve tissue distribution of tension and efficiency, but evidence on their impact on dehiscence is limited.</p> Methods <p>We conducted a multicenter retrospective cohort study (Project SUTURA) across four university-affiliated hospitals to compare midline laparotomy closure with barbed absorbable sutures (Stratafix™ Symmetric) versus conventional loop monofilament sutures (PDS™). Adult patients undergoing laparotomy between 2019 and 2022 were identified from electronic health records and operative registries. The primary outcome was acute abdominal wall dehiscence within 30 days. Multivariable Firth logistic regression and propensity score weighting (overlap weighting, IPTW) were used to adjust for baseline imbalances.</p> Results <p>A total of 1,522 patients were included (737 PDS; 785 Stratafix). Overall, 13 patients (0.85%) developed acute dehiscence: 8 in the PDS group (1.1%) and 5 in the Stratafix group (0.6%). In adjusted analyses, barbed closure was consistently associated with lower odds of dehiscence (Firth OR 0.48, 95% CI 0.17–1.37; overlap-weighted OR 0.45, 95% CI 0.07–2.78), although none reached statistical significance. Patient-related factors—particularly low preoperative hemoglobin, hypoalbuminemia, prior chemotherapy, and unplanned reoperation—were the strongest predictors of dehiscence.</p> Conclusions <p>Barbed fascial closure was safe, including in complex contexts such as oncologic resections, stoma creation, and reoperations. Adjusted models did not demonstrate statistically significant differences, although point estimates suggested a protective association. Given the very low event rate, statistical power was limited, precluding definitive conclusions.</p>