ArticleLiterature Review

Techniques and materials for skin closure in caesarean section

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Abstract

Background: Caesarean section is a common operation with no agreed upon standard regarding certain operative techniques or materials to use. With regard to skin closure, the skin incision can be re-approximated by a subcuticular suture immediately below the skin layer, by an interrupted suture, or by staples. A great variety of materials and techniques are used for skin closure after caesarean section and there is a need to identify which provide the best outcomes for women. Objectives: To compare the effects of skin closure techniques and materials on maternal and operative outcomes after caesarean section. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2012). Selection criteria: All randomized trials comparing different skin closure materials in caesareans were selected. Two review authors independently abstracted the data. Data collection and analysis: We identified 19 trials and included 11, but only eight trials contributed data. Three trials were not randomized controlled trials; two were ongoing; one study was terminated and the results were not available for review; one is awaiting classification; and one did not compare skin closure materials, but rather suture to suture and drain placement. Main results: The two methods of skin closure for caesarean that have been most often compared are non-absorbable staples and absorbable subcutaneous sutures. Compared with absorbable subcutaneous sutures, non-absorbable staples are associated with similar incidences of wound infection. Other important secondary outcomes, such as wound complications, were also similar between the groups in women with Pfannenstiel incisions. However, it is important to note, that for both of these outcomes (wound infection and wound complication), staples may have a differential effect depending on the type of skin incision, i.e., Pfannenstiel or vertical. Compared with absorbable subcutaneous sutures, non-absorbable staples are associated with an increased risk of skin separation, and therefore, reclosure. However, skin separation was variably defined across trials, and most staples were removed before four days postpartum. Authors' conclusions: There is currently no conclusive evidence about how the skin should be closed after caesarean section. Staples are associated with similar outcomes in terms of wound infection, pain and cosmesis compared with sutures, and these two are the most commonly studied methods for skin closure after caesarean section. If staples are removed on day three, there is an increased incidence of skin separation and the need for reclosure compared with absorbable sutures.

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... This closure allows blood and serosanguinous tissues to drain. However, this technique is time consuming (6). ...
... Choudhary A, et al. has reported that subcuticular absorbable material offered better skin approximation and healing than interrupted suture which needed re-suturing more often (7). Makeen, et al. in their systematic review of Cochrane database on techniques and material for closure of caesarean section found that non absorbable staples were associated with increased risk of separation and resuturing than absorbable subcuticular suturing (6). ...
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Introduction: Caesarean section is the most common surgical procedure performed in the world. A vast majority of the procedures are carried out with Pfannenstiel incision. Different techniques and materials are used to approximate the skin in caesarean section. Each method has its own advantages and disadvantages. The objective of the study was to compare surgical wound outcome and satisfaction of women who underwent Pfannenstiel incision closure with interrupted vs. subcuticular suturing in caesarean sections.
... Operative techniques vary widely between surgeons [16,17]. While skin closure with staples compared with a subcuticular suture has been associated with an increased risk of postoperative wound complication in one systematic review which included observational data, [18] this difference was not observed when considering data from randomised trials only [19]. It is not known which (if any) type of skin suture is preferable [19,20]. ...
... While skin closure with staples compared with a subcuticular suture has been associated with an increased risk of postoperative wound complication in one systematic review which included observational data, [18] this difference was not observed when considering data from randomised trials only [19]. It is not known which (if any) type of skin suture is preferable [19,20]. A systematic review of 10 trials of closure or non-closure of the subcutaneous fascia found a significant reduction in wound seroma but not in wound haematoma or infection [21]. ...
Article
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Background: Wound infection is a common complication following caesarean section. Factors influencing the risk of infection may include the suture material for skin closure, and closure of the subcutaneous fascia. We assessed the effect of skin closure with absorbable versus non-absorbable suture, and closure versus non-closure of the subcutaneous fascia on risk of wound infection following Caesarean section. Methods: Women undergoing caesarean birth at an Adelaide maternity hospital were eligible for recruitment to a randomised trial using a 2 × 2 factorial design. Women were randomised to either closure or non-closure of the subcutaneous fascia and to subcuticular skin closure with an absorbable or non-absorbable suture. Participants were randomised to each of the two interventions into one of 4 possible groups: Group 1 - non-absorbable skin suture and non-closure of the subcutaneous fascia; Group 2 - absorbable skin suture and non-closure of the subcutaneous fascia; Group 3 - non-absorbable skin suture and closure of the subcutaneous fascia; and Group 4 - absorbable skin suture and closure of the subcutaneous fascia. The primary outcomes were reported wound infection and wound haematoma or seroma within the first 30 days after birth. Results: A total of 851 women were recruited and randomised, with 849 women included in the analyses (Group 1: 216 women; Group 2: 212 women; Group 3: 212 women; Group 4: 211 women). In women who underwent fascia closure, there was a statistically significant increase in risk of wound infection within 30 days post-operatively for those who had skin closure with an absorbable suture (Group 4), compared with women who had skin closure with a non-absorbable suture (Group 3) (adjusted RR 2.17; 95% CI 1.05, 4.45; p = 0.035). There was no significant difference in risk of wound infection for absorbable vs non-absorbable sutures in women who did not undergo fascia closure. Conclusion: The combination of subcutaneous fascia closure and skin closure with an absorbable suture may be associated with an increased risk of reported wound infection after caesarean section. Trial registration: Prospectively registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12608000143325 , on the 20th March, 2008.
... In primary cesarean, current knowledge supports that metal staples are faster, while suture has superior wound outcomes [3,4]. In patients undergoing repeat cesarean delivery, most surgeons are used to make the incision through the previous abdominal scar at the time of repeat operation. ...
Article
Objective To compare scar quality associated with metal staple or tissue adhesive for closure of the skin incision at repeat cesarean delivery (CD). Study Design Single-center Randomized Controlled Trial (ClinicalTrial.gov ID: NCT04302597), including women undergoing repeat CD using metal staple or 2- octylcyanoacrylate for closure of the skin incision. Patients were randomized to have skin closure following CD with either staples or tissue adhesive. Scar quality was evaluated 2 and 6 months postoperatively using the Vancouver Scar Scale, the Patient and Observer Scar Assessment Scale (POSAS), and a visual analog scale. Results Of the 66 patients who were recruited, 55 successfully completed the study. The duration of surgery was comparable in both groups. A partial wound dehiscence occurred in one patient who had tissue adhesive closure. No difference in subjective and objective scar cosmesis rating was found between tissue adhesive and staples groups at either 2 months or 6 months. Conclusions In women undergoing CD, stapled wounds and those closed with tissue adhesive result in equivalent cosmetic appearance of the scar.
... Optimizing all surgical-technical factors in closing a midline laparotomy and the increasing use of minimally invasive surgery unfortunately does not reduce incisional hernia rate to zero. Patients undergoing open surgery for abdominal aortic aneurysm and obese patients have a higher risk of incisional hernia formation [8,43]. In these high-risk patients, other interventions might be needed to further reduce the incidence of incisional hernia, such as prophylactic mesh augmentation, which has proven to be effective in the prevention of incisional hernias (RR 0.17; 95% CI 0.08-0.37) ...
Article
Background: The aim of this systematic review and meta-analysis was to evaluate closure materials and suture techniques for emergency and elective laparotomies. The primary outcome was incisional hernia after 12 months, and the secondary outcomes were burst abdomen and surgical site infection. Methods: A systematic literature search was conducted until September 2017. The quality of the RCTs was evaluated by at least 3 assessors using critical appraisal checklists. Meta-analyses were performed. Results: A total of 23 RCTs were included in the meta-analysis. There was no evidence from RCTs using the same suture technique in both study arms that any suture material (fast-absorbable/slowly absorbable/non-absorbable) is superior in reducing incisional hernias. There is no evidence that continuous suturing is superior in reducing incisional hernias compared to interrupted suturing. When using a slowly absorbable suture for continuous suturing in elective midline closure, the small bites technique results in significantly less incisional hernias than a large bites technique (OR 0.41; 95% CI 0.19, 0.86). Conclusions: There is no high-quality evidence available concerning the best suture material or technique to reduce incisional hernia rate when closing a laparotomy. When using a slowly absorbable suture and a continuous suturing technique with small tissue bites, the incisional hernia rate is significantly reduced compared with a large bites technique.
... section, a Pfannenstiel incision is selected most frequently, and achieves superior cosmetic results compared with a vertical incision [5]. With this type of incision, the skin is usually closed using subcuticular sutures or staples, both of which are known to result in similar final cosmetic outcomes, although a suture is more time-consuming and less prone to wound separation [6][7][8][9]. ...
Article
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Objective: The objective of the study was to compare cosmetic outcomes and overall satisfaction rate of cesarean section scar between conventional subcuticular suture and intradermal buried vertical mattress. Methods: Patients were enrolled to the study by chart review. A scar assessment was obtained retrospectively through a telephone survey. The patient component of the patient and observer scar assessment scale (POSAS) was utilized along with the overall satisfaction of the patient regarding their cesarean section scar and their willingness to choose the same skin closure technique when anticipating their next cesarean section. Results: A total of 303 cases of cesarean section was recruited, 102 finished telephone surveys were calculated for the analyses. Subcuticular suture was regarded as control group (n=52) and intradermal buried suture as test group (n=50). The PSAS score of the test group (mean, 21.8) was lower than that of the control group (mean, 28), with a statistical significance (P=0.02). Overall satisfaction rate did not differ between the two groups. Two parameters of the PSAS score and the level of overall satisfaction showed significant correlation (Pearson's r, -0.63; P<0.01). Conclusion: We suggested the use of intradermal buried vertical mattress as a cosmetically superior skin closure method for application in cesarean sections over subcuticular stitch.
... 6 Mackeen AD and others 7 evaluated the impact of skin closure procedures and materials following C-section on operative and maternal results and reported that today no clear evidence is present as for the ideal skin closure procedure following C-section. 7 The rationale of the study is that conflicting results are recorded regarding wound infection in patients undergoing caesarean section and skin closure done either with sutures or skin staples and no local study is done to address this issue. ...
... Only a small number of research studies evaluated the impact of various subcutaneous tissue and skin closure methods at cesarean section (CS) [1,2]. In a metaanalysis, a major decline in incision site rupture was revealed when suturing the subcutaneous tissue in women with a subcutaneous depth >2 cm [3,4]. However, the outcome of these, the research performed, are made on a small number of patients, insufficient follow-up period of time for accurate longterm assessment [5,6]. ...
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Thank you for your e-mail regarding a reply on questions regarding our published article (Effect of subcutaneous tissue closure technique in cesarean section on postoperative wound complications in obese Egyptian women). (Manuscript ID : DJMF −2017–1738) and we are pleased that our article is interesting to other physicians and took their attention.
... In a review of five randomised controlled trials and one prospective study, staple closure was associated with a two-times higher risk of wound infection or separation compared with subcuticular suture closure [66]. In contrast to this data, a Cochrane systematic review of eight studies stressed that wound complications and cosmetic outcomes were similar among both groups [67]. There is currently no conclusive evidence about how the skin should be closed after caesarean section. ...
... A Cochrane review of eight trials concluded that wound complications and cosmetic outcome are similar between the two techniques. 69 In contrast, a large meta-analysis concluded that staples closure is associated with twofold increase in wound infection and separation compared with subcuticular sutures. 70 A multicenter RCT found a significant (57%) decrease in the incidence of wound complications, including wound infection, with suture closure of the skin at cesarean delivery compared with staples (4.9% compared to 10.6%; odds ratio [OR]: 0.43; 95% CI: 0.23-0.78). ...
Article
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Sivan Zuarez-Easton,1 Noah Zafran,1,2 Gali Garmi,1,2 Raed Salim1,2 1Department of Obstetrics and Gynecology, Emek Medical Center, Afula, 2Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Abstract: Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%–15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. Moreover, SSI is associated with a maternal mortality rate of up to 3%. With the global increase in cesarean section rate, it is expected that the occurrence of SSI will increase in parallel, hence its clinical significance. Given its substantial implications, recognizing the consequences and developing strategies to diagnose, prevent, and treat SSI are essential for reducing postcesarean morbidity and mortality. Optimization of maternal comorbidities, appropriate antibiotic prophylaxis, and evidence-based surgical techniques are some of the practices proven to be effective in reducing the incidence of SSI. In this review, we describe the biological mechanism of SSI and risk factors for its occurrence and summarize recent key clinical trials investigating preoperative, intraoperative, and postoperative practices to reduce SSI incidence. It is prudent that the surgical team who perform cesarean sections be familiar with these practices and apply them as needed to minimize maternal morbidity and mortality related to SSI. Keywords: cesarean section, management, surgical site infection
... According to the systematic review by Dahlke et al, 9 staple closure was associated with a twofold greater risk of wound infection or separation compared with subcuticular closure, though a Cochrane review concluded that wound complications were similar with each technique. 19 Based on this difference, Dahlke et al concluded that a definitive recommendation is difficult due to uncertainty. 9 Two similar surveys of surgical techniques at CD conducted by Demers et al and Tully et al also demonstrated significant variation in closure techniques. ...
Article
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Objective To assess the frequency of surgical techniques at cesarean delivery (CD) among U.S. obstetricians. Methods Members of the American College of Obstetrician Gynecologists were randomly selected and e-mailed an online survey that assessed surgical closure techniques, demographics, and reasons. Data were analyzed using SPSS (IBM Corp., Armonk, New York, United States), descriptive statistics, and analysis of variance. Results Our response rate was 53%, and 247 surveys were analyzed. A similar number of respondents either “always or usually” versus “rarely or never” reapproximate the rectus muscles (38.4% versus 43.3%, p = 0.39), and close parietal peritoneum (42.5% versus 46.9%, p = 0.46). The most frequently used techniques were double-layer hysterotomy closure among women planning future children (73.3%) and suturing versus stapling skin (67.6%); the least frequent technique was closure of visceral peritoneum (12.2%). Surgeons who perform double-layer hysterotomy closure had fewer years in practice (15.0 versus 18.7 years, p = 0.021); surgeons who close visceral peritoneum were older (55.5 versus 46.4 years old, p < 0.001) and had more years in practice (23.8 versus 13.8 years practice; p < 0.001). Conclusion Similar numbers of obstetricians either reapproximate or leave open the rectus muscles and parietal peritoneum at CD, suggesting that wide variation in practice exists. Surgeon demographics and safety concerns play a role in some techniques.
... Several studies reported variable post operation day of removal of staples [1,6]. A 2012 Cochrane review reported a higher incidence of wound dehiscence with early (<4 days) removal of staples in women with pfannenstiel incisions [21]. In this study, staples were removed on the 6 th post operation day and this may have contributed to the low incidence of wound separation. ...
... In 2011, Tuuli et al. reported a meta-analysis of 6 studies and showed that an increased risk of wound infection or wound separation with staples (n = 803) compared with suture skin closure (n = 684) (OR 2.06; 95% CI 1.43, 2.98) [58]. A 2012 Cochrane Review of 18 trials by Mackeen et al. showed no increased risk of wound infection with staple skin closure [59]. Subsequently in 2014, a randomized controlled study of 746 women by the same group showed a lower risk of wound complications (wound infection, hematoma, seroma, or separation of 1 cm or longer) with suture skin closure compared with staple skin closure (adjusted OR 0.43; 95% CI 0.23, 0.78) [6]. ...
Article
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Cesarean delivery (CD) is one of the most common procedures performed in the United States, accounting for 32% of all deliveries. Postpartum surgical site infection (SSI), wound infection and endometritis is a major cause of prolonged hospital stay and poses a burden to the health care system. SSIs complicate a significant number of patients who undergo CD – 2-7% will experience sound infections and 2-16% will develop endometritis. Many risk factors for SSI have been described. These include maternal factors (such as tobacco use; limited prenatal care; obesity; corticosteroid use; nulliparity; twin gestations; and previous CD), intrapartum and operative factors (such as chorioamnionitis; premature rupture of membranes; prolonged rupture of membranes; prolonged labor, particularly prolonged second stage; large incision length; subcutaneous tissue thickness > 3 cm; subcutaneous hematoma; lack of antibiotic prophylaxis; emergency delivery; and excessive blood loss), and obstetrical care on the teaching service of an academic institution. Effective interventions to decrease surgical site infection include prophylactic antibiotic use (preoperative first generation cephalosporin and intravenous azithromycin), chlorhexidine skin preparation instead of iodine, hair removal using clippers instead of razors, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples. Implementation of surgical bundles in non-obstetric patients has been promising., Creating a similar patient care bundle comprised evidence-based elements in patients who undergo CD may decrease the incidence of this major complication. Each hospital has the opportunity to create its own CD surgical bundle to decrease surgical site infection.
... C esarean deliveries comprise more than 25% of deliveries in many industrialized countries and more than 30% of deliveries in the United States. 1 Although as many as 1.3 million women undergo this surgery annually in the United States, 2 guidance regarding best practices for skin closure is limited. 3 Generally, a cesarean delivery is performed through a suprapubic low transverse skin incision. At the end of the operation, the skin incision is typically closed with the placement of either a continuous absorbable suture or interrupted staples that are removed at a later date. ...
... 14,15 Tissue adhesive systems have been used in dentistry, [16][17][18] orthopedics, [19][20][21] cardiovascular 22,23 as well as in ophthalmology, 24 traumatology, and otorhinolaryngology and also for plastic and maxillofacial surgical applications. 25,26 The advantages of hard tissue (e.g. bone or dent) gluing as compared to nailing or plating includes good xation of small fragments, more homogenous weight bearing distribution within the fracture site. ...
Article
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Tissue adhesives have been introduced as a promising alternative for the traditional wound closure method of suturing. Design and development of tissue adhesives for biomedical applications has been inspired by outstanding examples in nature. This review covers the adhesive mechanisms, applications and characterizations of various biomimetic tissue adhesives reported during the past decade, with a focus on the mussel-inspired dopamine-based adhesives, which have attracted extensive interest due to their promising adhesive performance in a wet environment.
... Formal education and on-job training of the health-care personnel were essential components of this intervention. In particular, after sharing literature evidences, including reviews [24][25][26][27] and guidelines, we observed improvements in the operating room discipline and a more rigorous compliance to SOPs and reporting tools. The supervision of younger doctors was encouraged according with literature [12,25,28]. ...
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Background. Surgical site infections are a leading cause of morbidity and mortality after caesarean section, especially in Low and Middle Income Countries. We hypothesized that a combined infection prevention and control with antimicrobial stewardship joint program would decrease the rate of post- caesarean section surgical site infections at the Obstetrics & Gynaecology Department of a Tanzanian tertiary hospital. Methods. The intervention included: 1. formal and on-job trainings on infection prevention and control; 2. evidence-based education on antimicrobial resistance and good antimicrobial prescribing practice. A second survey was performed to determine the impact of the intervention. The primary outcome of the study was post-caesarean section surgical site infections prevalence and secondary outcome the determinant factors of surgical site infections before/after the intervention and overall. The microbiological characteristics and patterns of antimicrobial resistance were ascertained. Results. Total 464 and 573 women were surveyed before and after the intervention, respectively. After the intervention, the antibiotic prophylaxis was administered to a significantly higher number of patients (98% vs 2%, p<0.001), caesarean sections were performed by more qualified operators (40% vs 28%, p=0.001), with higher rates of Pfannenstiel skin incisions (29% vs 18%, p<0.001) and of absorbable continuous intradermic sutures (30% vs 19%, p<0.001). The total number of post-caesarean section surgical site infections was 225 (48%) in the pre-intervention and 95 (17%) in the post intervention group (p<0.001). A low prevalence of gram-positive isolates and of methicillin-resistant Staphylococus aureus was detected in the post-intervention survey. Conclusions. Further researches are needed to better understand the potential of a hospital-based multidisciplinary approach to surgical site infections and antimicrobial resistance prevention in resource-constrained settings.
... 6 Mackeen AD and others 7 evaluated the impact of skin closure procedures and materials following C-section on operative and maternal results and reported that today no clear evidence is present as for the ideal skin closure procedure following C-section. 7 The rationale of the study is that conflicting results are recorded regarding wound infection in patients undergoing caesarean section and skin closure done either with sutures or skin staples and no local study is done to address this issue. ...
Article
A b s t ract Objective: To compare the frequency of wound infection in skin staples versus sutures for skin closure in patients undergoing caesarean section. Methodology: The randomized control trial study was conducted in the Department of Obstetrics & Gynaecology, Benazir Bhutto Hospital, Rawalpindi from 4th February 2015 to 3rd September 2015. A total of 654 cases were included in the study. Patients were divided into two groups. Group A was allotted for Skin Staples and Group B for sutures. Caesarean section was performed following the departmental protocols and skin closure was done according to randomization. A wound infection was recorded. Results: In this study, the mean age of patients was the same in both groups (29.64 ± 4.17 vs. 29.58 ± 4.54 years) respectively. Mean gestational age was also the same (38.48 ± 0.65 vs 38.57 ± 0.62). In skin staples group 53(16.2%) females underwent elective c-section and 274 (83.8%) emergency c-section. In sutures group 63(19.3%) cases underwent elective and 264(80.7%) cases had emergency c-section, p-value = 0.306. In skin staples group 40(12.2%) patients developed wound infection and in sutures group 19(5.8%) females got wound infection within 7th post-operative day. Wound infection was significantly lower in suture groups as compared to staples groups, p-value = 0.04. Conclusion: It is concluded that closure of the skin incision at caesarean delivery with the suture is associated with decrease incidence of wound infection as compared to staples.
... post-caesarean wounds, for which dehiscence rates as high as 6% have been reported). 25 The cohort study was conducted in a single geographical area (two large centres in Yorkshire, UK), and therefore the patient groups and the treatment availability observed may not be reflective of national or international patient populations or treatment availability. However, we have no reason to suspect that there are huge differences between these surgical patients and those elsewhere, particularly given the breadth of our inclusion criteria. ...
Article
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Background Most surgical incisions heal by primary intention (i.e. wound edges are apposed with sutures, clips or glue); however, some heal by secondary intention (i.e. the wound is left open and heals by formation of granulation tissue). There is, however, a lack of evidence regarding the epidemiology, management and impact on patients’ quality of life of these surgical wounds healing by secondary intention, resulting in uncertainty regarding effective treatments and difficulty in planning care and research. Objectives To derive a better understanding of the nature, extent, costs, impact and outcomes of surgical wounds healing by secondary intention, effective treatments, and the value and nature of further research. Design Cross-sectional survey; inception cohort; cost-effectiveness and value of implementation analyses; qualitative interviews; and pilot, feasibility randomised controlled trial. Setting Acute and community care settings in Leeds and Hull, Yorkshire, UK. Participants Adults (or for qualitative interviews, patients or practitioners) with previous experience of a surgical wound healing by secondary intention. Inclusion criteria varied between the individual workstreams. Interventions The pilot, feasibility randomised controlled trial compared negative-pressure wound therapy – a device applying a controlled vacuum to a wound via a dressing – with usual care (no negative-pressure wound therapy). Results Survey data estimated that treated surgical wounds healing by secondary intention have a point prevalence of 4.1 per 10,000 population (95% confidence interval 3.5 to 4.7 per 10,000 population). Surgical wounds healing by secondary intention most frequently occurred following colorectal surgery ( n = 80, 42.8% cross-sectional survey; n = 136, 39.7% inception cohort) and were often planned before surgery ( n = 89, 47.6% cross-sectional survey; n = 236, 60.1% inception cohort). Wound care was frequently delivered in community settings ( n = 109, 58.3%) and most patients ( n = 184, 98.4%) received active wound treatment. Cohort data identified hydrofibre dressings ( n = 259, 65.9%) as the most common treatment, although 29.3% ( n = 115) of participants used negative-pressure wound therapy at some time during the study. Surgical wounds healing by secondary intention occurred in 81.4% ( n = 320) of participants at a median of 86 days (95% confidence interval 75 to 103 days). Baseline wound area ( p ≤ 0.01), surgical wound contamination (determined during surgery; p = 0.04) and wound infection at any time ( p ≤ 0.01) (i.e. at baseline or postoperatively) were found to be predictors of prolonged healing. Econometric models, using observational, cohort study data, identified that, with little uncertainty, negative-pressure wound therapy treatment is more costly and less effective than standard dressing treatment for the healing of open surgical wounds. Model A (ordinary least squares with imputation) effectiveness: 73 days longer than those who did not receive negative-pressure wound therapy (95% credible interval 33.8 to 112.8 days longer). Model A cost-effectiveness (associated incremental quality-adjusted life-years): observables –0.012 (standard error 0.005) and unobservables –0.008 (standard error 0.011). Model B (two-stage model, logistic and linear regression) effectiveness: 46 days longer than those who did not receive negative-pressure wound therapy (95% credible interval 19.6 to 72.5 days longer). Model B cost-effectiveness (associated incremental quality-adjusted life-years): observables –0.007 (standard error 0.004) and unobservables –0.027 (standard error 0.017). Patient interviews ( n = 20) identified initial reactions to surgical wounds healing by secondary intention of shock and disbelief. Impaired quality of life characterised the long healing process, with particular impact on daily living for patients with families or in paid employment. Patients were willing to try any treatment promising wound healing. Health professionals ( n = 12) had variable knowledge of surgical wound healing by secondary intention treatments and, frequently, favoured negative-pressure wound therapy, despite the lack of robust evidence. The pilot feasibility randomised controlled trial screened 248 patients for eligibility and subsequently recruited and randomised 40 participants to receive negative-pressure wound therapy or usual care (no negative-pressure wound therapy). Data indicated that it was feasible to complete a full randomised controlled trial to provide definitive evidence for the clinical effectiveness and cost-effectiveness of negative-pressure wound therapy as a treatment for surgical wounds healing by secondary intention. Key elements and recommendations for a larger randomised controlled trial were identified. Limitations This research programme was conducted in a single geographical area (i.e. Yorkshire and the Humber, UK) and local guidelines and practices may have affected treatment availability, and so may not represent UK-wide treatment choices. A wide range of wound types were included; however, some wound types may be under-represented, meaning that this research may not represent the overall surgical wound healing by secondary intention population. The lack of randomised controlled trial data on the relative effects of negative-pressure wound therapy in surgical wounds healing by secondary intention resulted in much of the economic modelling being based on observational data. Observational data, even with extensive adjustment, do not negate the potential for unresolved confounding to affect the results, which can reduce confidence in conclusions drawn from observational data. Definitive evidence from a randomised controlled trial may be the only way to overcome this lack of confidence. Conclusions This research has provided new information regarding the nature, extent, costs, impacts and outcomes of surgical wounds healing by secondary intention, treatment effectiveness, and the value and nature of future research, while addressing previous uncertainties regarding the problem of surgical wounds healing by secondary intention. Aspects of our research indicate that negative-pressure wound therapy is more costly and less effective than standard dressing for the healing of open surgical wounds. However, because this conclusion is based solely on observational data, it may be affected by unresolved confounding. Should a future randomised controlled trial be considered necessary, its design should reflect careful consideration of the findings of this programme of research. Future work This research signals the importance of further research on surgical wound healing by secondary intention. Key research questions raised by this programme of research include (1) which treatments are clinically effective and cost-effective for surgical wound healing by secondary intention for all patients or for particular patient subgroups? (2) Can particular prognostic factors predict time to healing of surgical wound healing by secondary intention? And (3) do psychosocial interventions have the potential to improve quality of life in people with hard-to-heal surgical wound healing by secondary intention? Given that negative-pressure wound therapy has been widely adopted, with relatively little evidence to support its use, the design and outcomes of a randomised controlled trial would need to be carefully considered. We focused in this research on wound healing, and maintain, based on the findings of patient interviews, that this is a key outcome for future research. Impacts of negative-pressure wound therapy on outcomes such as infection and reoperation should also be considered, as should patients’ views of the treatment. The type of patient group recruited and the outcomes of interest will all influence the duration of follow-up of any planned study. The comparator in any future study will also need careful consideration. Trial registration Current Controlled Trials ISRCTN12761776. Funding This project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research ; Vol. 8, No. 7. See the National Institute for Health Research Journals Library website for further project information.
... Cesarean section (CS) is one of the most common operative procedures performed in modern obstetrics (Mackeen et al., 2012). ...
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ABSTRACT Objective: to evaluate the role of routine placing of a subcutaneous drain in obese diabetic women at cesarean section. Patients and Methods: Obese diabetic term pregnant women, admitted for cesarean section included in this study. The included women randomly allocated to one of two groups: group I, including women who had a subcutaneous drain left before closure of the skin; and group II, including women who had no subcutaneous drain left. The primary outcome measures; rate of superficial surgical site infection (SSI). Secondary outcome measures; wound seroma, superficial wound breakdown, postoperative fever and postoperative pain. Results: There was no significant difference between two studied groups regarding; superficial SSI, superficial wound breakdown and post-operative fever. There was significant difference between group I (Drain group) and group II (No Drain) regarding; wound seroma (8 cases 8 (9.6%) versus 23 cases (26.7%); respectively)), relative risk was 0.3 (95%CI; 0.17-0.75) and postoperative pain required analgesics (median 5 (range; 3-6) versus 16 (range; 12-18); respectively), relative risk was 3.3 (95%CI; 1.2-8.6). Conclusion: Routine subcutaneous drainage in cesarean section for obese diabetic women seems to be significantly associated with reduced rates of wound seroma and post-operative pain. Key words Cesarean section, subcutaneous drain, obesity and diabetes mellitus.
... Only a small number of research studies evaluated the impact of various subcutaneous tissue and skin closure methods at cesarean section (CS) [1,2]. In a metaanalysis, a major decline in incision site rupture was revealed when suturing the subcutaneous tissue in women with a subcutaneous depth >2 cm [3,4]. However, the outcome of these, the research performed, are made on a small number of patients, insufficient follow-up period of time for accurate longterm assessment [5,6]. ...
... Optimization of CD surgical techniques has been studied to decrease morbidities for all-comers; however, many aspects of the procedure do not have a firm evidence basis, including skin closure technique. 9 A 2013 systematic review reported conflicting data on whether sutures or staples were superior; ultimately a definitive recommendation was not made. 1 A Cochrane review concluded that surgical staples and absorbable sutures had similar outcomes, 10 whereas later metaanalyses of randomized controlled trials suggested sutures were associated with a decreased risk of wound complications. 11,12 The meta-analysis looked specifically at obesity and concluded the difference remained significant when obesity was present although risk was not stratified by body mass index (BMI). ...
Article
Background Cesarean delivery is the most common major surgical procedure performed in the United States. Women with class III obesity have an increased risk of cesarean delivery and have wound complication rates higher than healthy body mass index counterparts. Available evidence regarding optimal wound closure is lacking specific to the population of women with class III obesity despite a known increased rate of wound complications. Objective This study aimed to compare rates of postoperative wound complications among women with class III obesity (body mass index of ≥40 kg/m²) undergoing cesarean delivery with skin closure by either subcuticular suture or surgical staples. Study Design Patients were randomly assigned to skin closure by nonabsorbable stainless steel surgical staples or subcuticular suture of the surgeon’s choice at the time of cesarean delivery at 2 university hospitals. Randomization was stratified for scheduled vs unscheduled cesarean delivery and for the 2 study sites. The primary outcome was the rate of any documented wound complication during the first 6 weeks after delivery. Any predictors of the composite outcome that in univariate analysis had a P<.20 were entered into a forward logistic regression. Sample size was calculated based on published literature and estimating the rate of wound complications within 6 weeks of follow-up at 20% with staples and 10% with sutures. For a power of 0.80 with a 2-tailed of 0.05, a total of 199 participants per group were required. Results From September 2015 to May 2019, 232 women were randomized to staples (n=117) or sutures (n=115). Nearing the planned interim analysis, enrollment in the study was concluded administratively owing to low enrollment. With loss to follow-up and exclusions, a total of 90 women were analyzed in each group. In the suture group, one-third was closed with braided suture and two-thirds were closed with monofilament suture. Median staple removal was 5 days postoperatively. Fewer composite wound complications were noted in the surgical staples group than the subcuticular suture group (20.0% vs 27.6%), although this difference was not statistically significant (P≥.5). The rate of surgical site infection was significantly lower in the staples group (10.5% vs 22.7%; P=.041). In the multiple logistic regression, the 3 significant independent predictors of the outcome were body mass index (odds ratio, 1.08; P=.004), scheduled vs unscheduled cesarean delivery (odds ratio, 0.40; P=.018), and study site (odds ratio, 0.36; P=.028). Conclusion Surgical staples or subcuticular suture for skin closure at the time of cesarean delivery in women with a body mass index of ≥40 kg/m² resulted in similar composite wound complication rates; however, lower cesarean wound infection rates were noted among wounds closed with staples.
... Formal education and on-job training of the health-care personnel were essential components of this intervention. In particular, after sharing literature evidences, including reviews [24][25][26][27] and guidelines, we observed improvements in the operating room discipline and a more rigorous compliance to SOPs and reporting tools. The supervision of younger doctors was encouraged according with literature [12,25,28]. ...
Article
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Background: Surgical site infections are a leading cause of morbidity and mortality after caesarean section, especially in Low and Middle Income Countries. We hypothesized that a combined infection prevention and control with antimicrobial stewardship joint program would decrease the rate of post- caesarean section surgical site infections at the Obstetrics & Gynaecology Department of a Tanzanian tertiary hospital. Methods: The intervention included: 1. formal and on-job trainings on infection prevention and control; 2. evidence-based education on antimicrobial resistance and good antimicrobial prescribing practice. A second survey was performed to determine the impact of the intervention. The primary outcome of the study was post-caesarean section surgical site infections prevalence and secondary outcome the determinant factors of surgical site infections before/after the intervention and overall. The microbiological characteristics and patterns of antimicrobial resistance were ascertained. Results: Total 464 and 573 women were surveyed before and after the intervention, respectively. After the intervention, the antibiotic prophylaxis was administered to a significantly higher number of patients (98% vs 2%, p < 0.001), caesarean sections were performed by more qualified operators (40% vs 28%, p = 0.001), with higher rates of Pfannenstiel skin incisions (29% vs 18%, p < 0.001) and of absorbable continuous intradermic sutures (30% vs 19%, p < 0.001). The total number of post-caesarean section surgical site infections was 225 (48%) in the pre-intervention and 95 (17%) in the post intervention group (p < 0.001). A low prevalence of gram-positive isolates and of methicillin-resistant Staphylococus aureus was detected in the post-intervention survey. Conclusions: Further researches are needed to better understand the potential of a hospital-based multidisciplinary approach to surgical site infections and antimicrobial resistance prevention in resource-constrained settings.
... Cesarean section (CS) rates are rising globally with greater efforts directed to decrease morbidity associated with it. 1,2 Many randomized trials assessed different techniques that would decrease the possibility of surgical-site infections (SSI) resulting from CS including parietal peritoneum closure, 3 different techniques of skin closure, 4 abdominal cavity irrigation, 5 exteriorization of the uterus 6 and many others. [7][8][9] However, data about the effect of uterine cleaning are scarce. ...
Article
Aim: The aim of the study was to compare the rates of postpartum endometritis due to uterine cleaning and no cleaning in patients delivered by elective cesarean section. Methods: This was a randomized clinical trial conducted at the Obstetrics and Gynecology Department, Suez Canal University Hospital, Ismailia, from June 2019 to November 2019. We recruited patients undergoing cesarean delivery aged 18-45 years with singleton pregnancy, intact membranes, either first or repeated delivery, without labor pains. Patients were allocated into two groups, uterine cleaning (336 patients) and no cleaning (312 patients). The main outcome measure was the occurrence of postpartum endometritis. Results: Both groups were matched in their demographic characters. Twelve patients (3.6%) developed endometritis in the cleaning group versus one patient (0.3%) in the other one. Estimated blood loss was 754.35 ± 247.13 and 730.36 ± 232.77 for the cleaning and no cleaning groups, respectively, with a P value of 0.201. Septic wound infection (21 patients, 6.3%) was predominant in the cleaning group. Conclusion: Uterine cleaning after delivery of the placenta during CS can be omitted as a surgical step during the operation. It was associated with increased rates of postpartum endometritis and blood loss.
Article
Objective: To compare wound complication rates after skin closure with staples and subcuticular suture in obese gynecology patients undergoing laparotomy through a midline vertical incision. Methods: In this randomized controlled trial, women with body mass indexes (BMIs) of 30 or greater undergoing surgery by a gynecologic oncologist through a midline vertical incision were randomized to skin closure with staples or subcuticular 4-0 monofilament suture. The primary outcome was the rate of wound complication, defined as the presence of a wound breakdown, or infection, within 8 weeks postoperatively. Secondary outcomes included operative time, Stony Brook scar cosmetic score, and patient satisfaction. A sample size of 162 was planned to detect a 50% reduction in wound complications. At planned interim review (n=82), there was no significant difference in primary outcome. Results: Between 2013 and 2016, 163 women were analyzed, including 84 who received staples and 79 suture. Women who received staples were older (mean age 59 compared with 57 years), had lower mean BMI (37.3 compared with 38.9), and fewer benign indications for surgery (22 compared with 27). There were no differences in wound complication rates between staple compared with suture skin closure (28 [33%] compared with 25 [32%], relative risk 1.05, 95% confidence interval [CI] 0.68-1.64). Women with staples reported worse median cosmetic scores (four of five compared with five of five, P<.001), darker scar color (37 [49%] compared with 13 [18%], relative risk 2.69, 95% CI 1.57-4.63), and more skin marks (30 [40%] compared with three [4%], relative risk 9.47, 95% CI 3.02-29.65) compared with women with suture closure. There was no group difference regarding satisfaction with their scar. Stepwise multivariate analysis revealed BMI (odds ratio [OR] 1.13, 95% CI 1.07-1.20), maximum postoperative glucose (OR 1.01, 95% CI 1.00-1.01), and cigarette smoking (OR 4.96, 95% CI 1.32-18.71) were correlates of wound complication. Conclusion: Closure of midline vertical skin incisions with subcuticular suture does not reduce surgical site wound complications compared with staples in obese gynecology patients. Clinical trial registration: ClinicalTrials.gov, NCT01977612.
Article
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Background The rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting. Methods Pathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS). ResultsFive clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate. Conclusions Further research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.
Chapter
This chapter provides information on wound dehiscence, citing two case studies. Wound dehiscence is the separating or bursting open of a wound along the surgical suture line. It is usually superficial but deeper fascial dehiscence may occur with resulting evisceration, where internal organs, namely bowel, protrude slightly or actually spill outside of the open surgical incision. Wound dehiscence usually presents between days 7 and 14 following surgery, usually at the time of staple or suture removal. Wound infection is the most important risk factor for wound dehiscence. The chapter talks about the risk factors, care of superficial dehiscence, full-thickness wound dehiscence, negative pressure wound therapy and postoperative care. Minimally invasive surgical approaches should be adopted where possible, even if this necessitates referral to specialist centers. Pneumonia and wound infection should be prevented where possible and treated promptly should these conditions develop.
Article
Objective: To compare the clinical efficacy between subcuticular sutures and staples for skin closure after cesarean delivery. Methods: PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science were searched. Only RCTs comparing subcuticular sutures to staples following cesarean delivery were included. The primary outcome was the incidence of wound complications, consisting of wound infection, wound separation, hematoma and seroma. Risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) was calculated. Results: Ten RCTs were included in this analysis. Subcuticular sutures were associated with significantly decreased incidence of wound complications compared to staples (RR 1.88, 95% CI 1.45-2.45). The operation time was significantly shortened when closure with staples was performed (MD -8.66 min, 95% CI -10.90 to -6.42). The two groups were comparable regarding cosmetic outcome at 6-8 weeks postoperatively, whereas subcuticular sutures were associated with a better cosmesis at 6-12 months postoperatively. There were no significant differences between groups in terms of hospital stay, postoperative pain and patient satisfaction. Conclusions: Compared with staples following cesarean delivery, subcuticular sutures are associated with decreased risk of wound complications and better long-term cosmetic outcome, but slightly prolong duration of surgery.
Article
Background: There are various possible methods of skin closure in total hip arthroplasty (THA) through a lateral skin incision. The cost and time required for each can vary between techniques. The objective of this study was to determine whether there is a difference in patient and surgeon rating of scar outcome using a combination of subcuticular suture and skin adhesive (subcuticular MONOCRYL and DERMABOND [SMD]) vs staples for skin closure after THA. Methods: Patients undergoing THA were recruited from a university hospital. Patients were randomized to staples or SMD. Patient and Observer Scar Assessment Scale data were collected postoperatively. In addition, visual analog scale pain scores, wound drainage, length of stay, time to closure, and total cost were collected. Results: One hundred twenty-nine patients were available for final analysis. There was no significant difference in Patient and Observer Scar Assessment Scale scores at 6 weeks or 3 months (P = .71). There was no difference in visual analog scale pain scores (P = .64, P = .49). The staple group had a higher rate of discharge on postoperative days 1 and 3 (P < .001, P < .001) but had a 1.6-minute shorter time of closure (P < .001). There was no significant difference in length of stay or total cost (P = .5). Conclusion: Although there are some small initial advantages to each method of skin closure, there is little difference in scar outcome when comparing SMD and staples.
Chapter
Die Sectio stellt sowohl für die Schwangere wie auch für den Fetus eine sehr sichere Entbindungsalternative dar. Seit den 1970er-Jahren steigt die Sectiorate kontinuierlich. Wie weit das Entbindungsrisiko bei einer elektiven Sectio mit dem bei einer natürlichen Geburt vergleichbar ist, bleibt ungeklärt. Die Entscheidung einer Schwangeren für die Entbindung durch eine medizinisch nicht indizierte Sectio setzt eine umfassende Aufklärung voraus, zu der auch die Auswirkungen auf Folgeschwangerschaften gehören. Die bei einer sekundären Sectio höhere Komplikationsrate ist durch eine medizinische Indikation gerechtfertigt. Eine präoperative Ultraschalldiagnostik ermöglicht eine sorgfältige Planung des Eingriffs. Die Operationstechnik muss verschiedenen Aspekten wie Gestationsalter, Lage und Größe des Fetus, sowie Einlings- oder Mehrlingsschwangerschaft Rechnung tragen. Eine gewebsschonende Operationstechnik ermöglicht einen Eingriff von kurzer Dauer mit möglichst geringem Blutverlust.
Article
The incidence and presentation of complications of caesarean section. The surgical management of intrapartum and postpartum haemorrhage. Risk factors for, and prevention and treatment of postpartum sepsis. Presentation, investigation and repair of bladder injuries when recognised intraoperatively and following delayed presentation. Risk factors for, and recognition and management of suspected ureteric injury intraoperatively and postoperatively. Bowel complications including intraoperative bowel injury and management, postoperative ileus and Ogilvie syndrome. Particular risks and complications associated with caesarean section at full dilatation. Caesarean section in the developing world. To be aware of the most common and serious complications of caesarean section. To be able to describe recognition and initial surgical management of suspected bladder, ureteric and bowel injuries. To be familiar with delayed presentations of visceral injuries and have a systematic approach to investigation of suspected injury. To understand the impact of caesarean section complications in resource-poor countries. Appropriate, accurate preoperative counselling regarding risks and consent. Awareness of personal competency in managing specific complications.
Article
This is the protocol for a review and there is no abstract. The objectives are as follows: To examine the efficacy and acceptability of subcuticular sutures for skin closure in non-obstetric surgery.
Article
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Backgrounds/Aims Open surgery for choledochal cyst has a disadvantage of skin incision scar from operative wound, which can be a definite disadvantage especially in young female patients. This study focused on the cosmetic aspect of skin incision for resection of choledochal cyst in young female patients. Methods During a 2-year study period, 11 adult female patients aged less than 40 years underwent primary resection of choledochal cyst by a single surgeon. The cosmetic effect of two types of skin incision was evaluated. Results The patients underwent mini-laparotomy through either a right subcostal incision (n=8) or an upper midline incision (n=3). The mean length of skin incision was 10 cm for right subcostal incisions and 9 cm for upper midline incisions. It took approximately 1 hour to repair the operative wound meticulously in both groups. At the 6 month to 1 year follow-up, a slight bulge on the skin scar was observed in 3 (37.5%) patients of the right subcostal incision group and 1 (33.3%) patient of the upper midline incision group. Conclusions The results of this preliminary study support the claim that cosmetic effect of the upper midline incision for CCD surgery appears to be non-inferior to that of the right subcostal incision if the incision is placed accurately and repaired very meticulously.
Article
Background: This study was carried out to evaluate the preoperative and intraoperative risk factors associated with surgical site infection amongst gynecology patients and its impact on postoperative recovery.Methods: A prospective, observational study was conducted among 285 patientsWho underwent surgery over a period of two years. Diagnosis of SSI was made as per CDC criteria. Various risk factors and impact of SSI on postoperative recovery were analysed. Statistical analysis was carried out with SPSS version 16.0. Range and mean was calculated for continuous variables and overall incidence rate of SSI is also calculated. Pearson Chi-square test was used to test risk factor association with SSI. Odds ratios and 95% confidence intervals (CI) was calculated. Significance was assumed at a p value of less than 0.05.Results: The incidence of SSI was found to be 52 out of 285 women (46%). Majority of SSI, i.e. 49 out of 52 (94%) were superficial in nature. Deep SSI was seen in 3 patients (6%). No organ/space infection was noted in any patient. Women who were over 50 years had higher risk of developing SSI than women between 36 to 50 years (OR 0.519 Vs 0.214). The risk of SSI was 4 times in case of clean contaminated wounds as compared to clean wounds (OR 3.877). The risk further increased to 7 times in case of dirty wounds (OR 6.753). Other risk factors which are significantly associated with SSI were BMI (p value <0.001), midline incisions (p <0.001) and Mattress suture (p <0.001). Presence of previous scar had intraoperative adhesions, weaker scar and poor healing which predispose to development of SSI. Comorbidities which influence SSI’s in the present study are diabetes mellitus (OR 5.49, 95% CI 2.506-12.066, P <0.001), anaemia (OR 4.63, Cl 2.458-8.756) and hypertension (OR 2.46, Cl 0.994-6.117). Wound swab was sterile in 33(63%) cases and 18(35%) cases showed growth of the organism. Most common organism noted was E. coli 9 (50%) followed by Klebsiella and Staph aureus.Conclusions: SSIs are increasing in the current scenario due to increase in the number of surgeries, however they can be prevented by early identification and optimization of medical comorbidities and BMI. Meticulous preoperative workup and intraoperative surgical steps are important in reducing the risk of developing SSI. A decrease in infection rate can lead to substantial reduction in the burden of disease.
Article
Objective: To evaluate whether omission of intrauterine cleaning increases intraoperative and postoperative complications among women who deliver via cesarean section. Methods: We randomized 206 women undergoing primary elective cesarean deliveries to intrauterine cleaning or omission of cleaning. Postpartum endomyometritis rates across groups was the primary outcome. We also examined secondary outcomes. To detect a 20% difference in infection rate between the cleaned and the noncleaned groups (two-tailed [alpha] = 0.05, [beta] = 0.2), 103 women were required per group. Analysis was by intention-to-treat. Results: Two hundred six were randomized as follows: 103 to intrauterine cleaning and 103 to omission of cleaning after placental delivery. There were no statistically significant differences in the rate of endomyometritis between the two groups (2.0 versus 2.9%, RR = 0.60; 95% CI 0.40–1.32). There were no statistically significant differences in postpartum hemorrhage rates (5.8 versus 7.7%, RR 0.75; 95% CI 0.6–1.2), hospital readmission rates (2.9 versus 3.8%, RR 0.75; 95% CI 0.5–1.6), time to return of gastrointestinal function, need for repeat surgery, or quantitated blood loss between the two groups. Conclusion: Our randomized controlled trial provides evidence suggesting that omission of intrauterine cleaning during cesarean deliveries in women at low risk of infection does not increase intraoperative or postoperative complications.
Article
Purpose: To compare clinical and economic outcomes of cesarean deliveries with skin closure via skin staples plus waterproof wound dressings (SSWWD) versus 2-octyl cyanoacrylate plus polymer mesh tape (2OPMT). We hypothesized that cesarean deliveries with skin closure via 2OPMT may be associated with a lower rate of wound complications and infections as compared with skin closure via SSWWD; we also hypothesized that, accordingly, 2OPMT may be associated with lower hospital length of stay (LOS), hospital costs, and all-cause readmissions as compared with SSWWD. Methods: Retrospective, observational study using a research database derived from administrative records routinely contributed by hundreds of hospitals in the USA. We queried the database for patients aged 18–49 years who had an in-hospital low transverse cesarean delivery between 1 January, 2012 and 31 March, 2017. Using records of medical supplies used during deliveries, we identified deliveries for which skin closure was performed via either SSWWD (SSWWD group) or 2OPMT (2OPMT group). Our primary study outcome was a composite endpoint of infection/wound complication diagnosis during the hospital stays in which the deliveries were performed. Our secondary outcomes included: length of stay (LOS) and total hospital costs for the hospital stays in which the deliveries were performed, and all-cause readmissions (30/60/90 days post discharge) to the same hospital in which the delivery was performed. We compared outcomes between propensity-score matched groups using regressions accounting for hospital-level clustering and non-Gaussian empirical outcome distributions. Results: Each group comprised 2133 patients (4266 total patients; mean age = 30.3y [SD = 4.6]). Compared with the SSWWD group, the 2OPMT group had statistically significant lower rates of complications (infection, 0.7 versus 1.6%, p = 0.011; wound complication, 0.6 versus 1.3%, p = 0.036; composite, 0.9 versus 2.0%, p = 0.002), shorter LOS (mean = 3.5d[SD = 1.6] versus 3.7 d [SD = 1.8], p = 0.007), and lower total hospital costs (mean = $8879 [SD = $3157] versus $9313 [SD = $3311], p = 0.025). Between-group differences for 30/60/90-day all-cause readmissions were statistically insignificant. Conclusions: This large observational study is the first of its kind and provides evidence that cesarean delivery skin closure with 2OPMT is associated with lower rates of in-hospital infection and wound complications, lower LOS, lower total hospital costs as compared with SSWWD.
Article
Aim: To know which have been the variations of the Pfannenstiel-Kerr technique and how they have influenced maternal morbidity and mortality. Methods: An electronic search was carried out in PubMed, Medline and Cochrane, of works in English and Spanish languages, regardless of the country of origin, preferably randomized and controlled between 2010 and 2020, on variations in the original surgical technique, with emphasis on the differences between the PfannenstielKerr and Miglav-Ladash techniques. Results: The more importants variations regarding morbidity and mortality were: 1. Preferring the transverse skin incision, especially the Joel Cohen type; 2. Lateral blunt dissection of the subcutaneous and cranio-caudal aponeurosis, after its incision; 3. Digital and lateral separation of the rectus abdominis muscles; 4. Digitally and laterally prolong the hysterotomy; 5. Uterine incision closure, without externalizing the uterus, in one or two suture planes, indifferently; 6. Do not suture the visceral and parietal peritoneum or approach the rectus abdominis; 7. Closure of the subcutaneous to separate points, if the thickness is greater than 2 cm. Conclusions: Modifications to the original technique achieved a statistically significant decrease in operative time, the number of sutures, the requirement for analgesics, blood loss, febrile morbidity, as well as operative wound infection and hospital stay. Keywords: Cesarean section, Surgical technique, Pfannenstiel-Kerr, Misgav-Ladach.
Article
Pregnant women with obesity are at increased risk of a multitude of complications of pregnancy and adverse perinatal outcomes. The risk of some of these complications, such as neural tube defects or preeclampsia, may be mitigated by some medications. Other complications, such as diabetes, venous thromboembolism, and infections, require treatment with medications. Given the changes in pharmacokinetics and pharmacodynamics during pregnancy, which is further enhanced by obesity, the optimal medication and its dose is often researched. This chapter further explores the different complications and common medications that women with obesity are likely to require.
Article
In this Commentary, we explain the case for a standardized cesarean delivery surgical technique. There are three strong arguments for a standardized approach to cesarean delivery, the most common major abdominal surgery performed in the world. First, standardization within institutions improves safety, efficiency, and effectiveness in health care delivery. Second, surgical training among obstetrics and gynecology residents would become more consistent across hospitals and regions, and proficiency in performing cesarean delivery measurable. Finally, standardization would strengthen future trials of cesarean delivery technique by minimizing the potential for aspects of the surgery which are not being studied to bias results. Before 2013, more than 155 randomized controlled trials, meta-analyses or systematic reviews were published comparing various aspects of cesarean delivery surgical technique. Since 2013, an additional 216 similar studies have strengthened those recommendations and offered evidence to recommend additional cesarean delivery techniques. However, this amount of cesarean delivery technique data creates a forest for the trees problem, making it difficult for a clinician to synthesize this volume of data. In response to this difficulty, we propose a comprehensive, evidence-based and standardized approach to cesarean delivery technique.
Article
There are hardly more randomized controlled trials than for the different aspects of cesarean sections. This is of special importance since the cesarean section rate is in excess of 30% in most developed countries and therefore is probably the most frequently performed operation in women. Therefore, a technique which is associated with the lowest possible morbidity is crucial. This review article summarizes the current evidence for the optimal technique, supplemented by local experience. © 2020, Springer Medizin Verlag GmbH, ein Teil von Springer Nature.
Article
Background: Following surgery, surgical wounds can be closed using a variety of devices including sutures (subcuticular or transdermal), staples and tissue adhesives. Subcuticular sutures are intradermal stitches (placed immediately below the epidermal layer). The increased availability of synthetic absorbable filaments (stitches which are absorbed by the body and do not have to be removed) has led to an increased use of subcuticular sutures. However, in non-obstetric surgery, there is still controversy about whether subcuticular sutures increase the incidence of wound complications. Objectives: To examine the efficacy and acceptability of subcuticular sutures for skin closure in non-obstetric surgery. Search methods: In March 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: All randomised controlled trials which compared subcuticular sutures with any other methods for skin closure in non-obstetric surgery were included in the review. Data collection and analysis: Two review authors independently identified the trials, extracted data and carried out risk of bias and GRADE assessment of the certainty of the evidence. Main results: We included 66 studies (7487 participants); 11 included trials had more than two arms. Most trials had poorly-reported methodology, meaning that it is unclear whether they were at high risk of bias. Most trials compared subcuticular sutures with transdermal sutures, skin staples or tissue adhesives. Most outcomes prespecified in the review protocol were reported. The certainty of evidence varied from high to very low in the comparisons of subcuticular sutures with transdermal sutures or staples and tissue adhesives; the certainty of the evidence for the comparison with surgical tapes and zippers was low to very low. Most evidence was downgraded for imprecision or risk of bias. Although the majority of studies enrolled people who underwent CDC class 1 (clean) surgeries, two-thirds of participants were enrolled in studies which included CDC class 2 to 4 surgeries, such as appendectomies and gastrointestinal surgeries. Most participants were adults in a hospital setting. Subcuticular sutures versus transdermal sutures There may be little difference in the incidence of SSI (risk ratio (RR) 1.10; 95% confidence interval (CI) 0.80 to 1.52; 3107 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce wound complications (RR 0.83; 95% CI 0.40 to 1.71; 1489 participants; very low-certainty evidence). Subcuticular sutures probably improve patient satisfaction (score from 1 to 10) (at 30 days; MD 1.60, 95% CI 1.32 to 1.88; 290 participants; moderate-certainty evidence). Wound closure time is probably longer when subcuticular sutures are used (MD 5.81 minutes; 95% CI 5.13 to 6.49 minutes; 585 participants; moderate-certainty evidence). Subcuticular sutures versus skin staples There is moderate-certainty evidence that, when compared with skin staples, subcuticular sutures probably have little effect on SSI (RR 0.81, 95% CI 0.64 to 1.01; 4163 participants); but probably decrease the incidence of wound complications (RR 0.79, 95% CI 0.64 to 0.98; 2973 participants). Subcuticular sutures are associated with slightly higher patient satisfaction (score from 1 to 5) (MD 0.20, 95% CI 0.10 to 0.30; 1232 participants; high-certainty evidence). Wound closure time may also be longer compared with staples (MD 0.30 to 5.50 minutes; 1384 participants; low-certainty evidence). Subcuticular sutures versus tissue adhesives, surgical tapes and zippers There is moderate-certainty evidence showing no clear difference in the incidence of SSI between participants treated with subcuticular sutures and those treated with tissue adhesives (RR 0.77, 95% CI 0.41 to 1.45; 869 participants). There is also no clear difference in the incidence of wound complications (RR 0.62, 95% CI 0.35 to 1.11; 1058 participants; low-certainty evidence). Subcuticular sutures may also achieve lower patient satisfaction ratings (score from 1 to 10) (MD -2.05, 95% CI -3.05 to -1.05; 131 participants) (low-certainty evidence). In terms of SSI incidence, the evidence is uncertain when subcuticular sutures are compared with surgical tapes (RR 1.31, 95% CI 0.40 to 4.27; 354 participants; very low-certainty evidence) or surgical zippers (RR 0.80, 95% CI 0.08 to 8.48; 424 participants; very low-certainty evidence). There may be little difference in the incidence of wound complications between participants treated with subcuticular sutures and those treated with surgical tapes (RR 0.90, 95% CI 0.61 to 1.34; 492 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce the risk of wound complications compared with surgical zippers (RR 0.55, 95% CI 0.15 to 2.04; 424 participants; very low-certainty evidence). It is also uncertain whether it takes longer to close a wound with subcuticular sutures compared with tissue adhesives (MD -0.34 to 10.39 minutes; 895 participants), surgical tapes (MD 0.74 to 6.36 minutes; 169 participants) or zippers (MD 4.38 to 8.25 minutes; 424 participants) (very low-certainty evidence). No study reported results for patient satisfaction compared with surgical tapes or zippers. Authors' conclusions: There is no clear difference in the incidence of SSI for subcuticular sutures in comparison with any other skin closure methods. Subcuticular sutures probably reduce wound complications compared with staples, and probably improve patient satisfaction compared with transdermal sutures or staples. However, tissue adhesives may improve patient satisfaction compared with subcuticular sutures, and transdermal sutures and skin staples may be quicker to apply than subcuticular sutures. The quality of the evidence ranged from high to very low; evidence for almost all comparisons was subject to some limitations. There seems to be no need for additional new trials to explore the comparison with staples because there are high-quality studies with large sample sizes and some ongoing studies. However, there is a need for studies exploring the comparisons with transdermal sutures, tissue adhesives, tapes and zippers, with high-quality studies and large sample sizes, including long-term assessments.
Article
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Objective: Cesarean section is the most commonly performed obstetrical surgical procedure; however, there are no standard guidelines on appropriate skin closure techniques and materials. Only few comparative studies have been conducted on different skin closure techniques, and they have shown conflicting results. Therefore, we compared different skin closure techniques during emergency cesarean section to identify the best technique with minimal wound complication rates. Methods: Patients were randomized into 3 groups (group A, n=100; group B, n=102; and group C, n=98). In group A, the skin was closed using staples; in group B, via the subcuticular technique using monocryl 3-0; and in group C, using mattress suture nylon (2-0). The primary outcome was a composite of wound complications, including infection, seroma, gaping, and need for resuturing and antibiotic administration. The secondary outcome included closure time, pain perception, patient satisfaction, and cost. Analyses were performed in accordance with the intention-to-treat principle. Results: The composite wound complication rate in the entire cohort was 16.6% (n=50); the complication rate was significantly higher in group A than in the other groups. Infection was the most common wound complication observed in the entire study group (86%) and was significantly higher in group A than in groups B and C (P≤0.001). Conclusion: The use of staples for cesarean section skin closure is associated with an increased risk of wound complications and prolonged hospital stay postoperative visits.
Article
Objective: To determine if there are differences in scar healing and cosmetic outcome between early and late metal staples removal after cesarean delivery. Study design: Randomized controlled trial, in which patients undergoing a scheduled nonemergent cesarean delivery were randomly assigned to early staples removal versus late staples removal. Outcome assessors were blinded to group allocation. Scars were evaluated 8 weeks after cesarean delivery. Primary outcome measures were Patient and Observer Scar Assessment Scale (POSAS) scores. Secondary outcome measures included surgical site infection, wound disruption, hematoma, or seroma. Results: During the study period, 104 patients were randomized. There were no between-group differences in maternal demographics. Both groups had similar indications for cesarean delivery and similar rate of previous one or more cesarean delivery. Patient and Observer Scar Assessment Scale were similar for patients (p = .932) and for physician observer (p = .529). No significant differences were demonstrated between the groups in the rate of surgical site infection or wound disruption. Conclusions: Removal of stainless steel staples on postoperative 4 versus postoperative 8 after cesarean delivery showed similar outcome without significant effect on incision healing. Therefore, timing of removal staples after cesarean delivery could be performed based on patients and surgeon preference.
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Die Sectio stellt sowohl für die Schwangere wie auch für den Fetus eine sehr sichere Entbindungsalternative dar. Seit den 1970er-Jahren steigt die Sectiorate kontinuierlich. Wie weit das Entbindungsrisiko bei einer elektiven Sectio mit dem bei einer natürlichen Geburt vergleichbar ist, bleibt ungeklärt. Die Entscheidung einer Schwangeren für die Entbindung durch eine medizinisch nicht indizierte Sectio setzt eine umfassende Aufklärung voraus, zu der auch die Auswirkungen auf Folgeschwangerschaften gehören. Die bei einer sekundären Sectio höhere Komplikationsrate ist durch eine medizinische Indikation gerechtfertigt. Eine präoperative Ultraschalldiagnostik ermöglicht eine sorgfältige Planung des Eingriffs. Die Operationstechnik muss verschiedenen Aspekten wie Gestationsalter, Lage und Größe des Fetus, sowie Einlings- oder Mehrlingsschwangerschaft Rechnung tragen. Eine gewebsschonende Operationstechnik ermöglicht einen Eingriff von kurzer Dauer mit möglichst geringem Blutverlust.
Article
Objective: To investigate optimal timing of dressing and staples removal after cesarean delivery (CD). Methods: This prospective clustered clinical trial enrolled women undergoing CD between January 1, 2013, and October 31, 2014, at Hadassah-Hebrew University Hospital, Jerusalem. Women were assigned to one of five clusters differing in timing of dressing and staples removal. We assessed scar healing at 6 weeks. Results: 920 women completed telephone questionnaires. Wound healing did not differ significantly among the clusters: the healing complication rate was 21% in the control group (n=46) and ranged from 18% to 26% (n=27-50) in clusters two to five (P=0.49). More healing complications were observed in women with a body mass index (BMI) of more than 35 kg/m2 versus 35 kg/m2 or less (P=0.016), urgent versus elective CD (P=0.013), preterm premature rupture of the membranes (PPROM) versus intact membranes (P=0.016), and chorioamnionitis at delivery versus no chorioamnionitis (P=0.001). 586 (64%) women underwent physician assessment at staples removal and at 6 weeks post CD. Conclusions: Timing of dressing and staples removal has no effect on CD scar healing in low- and high-risk parturients. A BMI of more than 35 kg/m2 , urgent CD, PPROM, and chorioamnionitis were associated with mal-healing, regardless of cluster. Clinicaltrials.gov: NCT01724255.
Chapter
Obesity alone increases the likelihood of operative wound infections after cesarean delivery by fourfold. Antibiotic prophylaxis is a well‐accepted evidence‐based practice for all patients undergoing cesarean delivery and is of particular importance in obese women, playing a critical factor in the prevention of surgical site infections. According to the 2007 Report on Confidential Enquiries into Maternal Death in the United Kingdom, 67 percent of deaths directly attributable to anesthesia occurred in obese parturients. Obese pregnant women appear to have a more variable response to intrathecal anesthetic dosing than non‐obese women. Obesity alone is considered a minor factor for venous thromboembolism, even in the case of a cesarean delivery. Pneumatic compression devices should be used as recommended for all patients undergoing cesarean delivery. Chemoprophylaxis may be done with low‐molecular weight heparin (LMWH) or unfractionated heparin 5000 units every eight hours starting eight hours after delivery.
Article
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Purpose: To compare two suture threads, poliglecaprone 25 and nylon, used as intradermal suture for skin closure in women undergoing their first cesarean section. Methods: This is a randomized clinical trial. A total of 60 women undergoing their first cesarean section were enrolled and prospectively assessed. They were randomly allocated to group I (n=30), which received an intradermal suture with nylon 4.0 or to group II (n=30), which had an intradermal suture with poliglecaprone 25, 4.0. The main author took standardized photographs of the scar 6 months after the operation. Four independent raters, two senior obstetricians and two senior plastic surgeons (a male and a female physician from each specialty) assessed the photographs.The panelists rated the scar according to Trimbos scale, composed by the subscales hypertrophy, color and width of the scar. Results: At baseline, patients in both groups were similar regarding age and body mass index. Five patients withdraw the study, four from group and one from group II. Scars of patients from group II were significantly less hypertrophic (p=0.001), thinner (p=0.019) and had more acceptable color (p=0.019). Conclusion: The intradermal suture with poliglecaprone 25 for skin closure after cesarean incision provides better aesthetic result.
Article
Introduction: Surgeons are often judged based on the cosmetic appearance of any scar after surgery rather than the functional outcome of treatment, especially when considering facial wounds. Objective: We performed a systematic review of the literature to determine whether absorbable or non-absorbable suture materials result in different cosmetic outcomes for patients requiring primary closure of facial wounds. Methods: An extensive systematic review was carried out to identify studies meeting our inclusion criteria. Risk of bias in each study was assessed using the Cochrane risk of bias assessment tool. Data were extracted from those articles that met our inclusion criteria, and statistical analysis was carried out using the Cochrane RevMan. Results: We found no significant difference in any aspect of our analysis including Visual Analogue Cosmesis scale, Visual Analogue Satisfaction scale, infection, dehiscence, erythema or stitch marks. Most authors concluded that they prefer to use absorbable sutures. However, the overall quality of evidence is poor, and significant variation exists regarding the methods of assessment between papers. Conclusion: Use of absorbable suture material appears to be an acceptable alternative to non-absorbable suture material for the closure of facial wounds as they produce similar cosmetic results.
Article
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Background: Surgical site infection (SSI) rates vary from 1% to 5% in the month following surgery. Due to the large number of surgical procedures conducted annually, the costs of these SSIs can be considerable in financial and social terms. Many interventions are used with the aim of reducing the risk of SSI in people undergoing surgery. These interventions can be broadly delivered at three stages: preoperatively, intraoperatively and postoperatively. The intraoperative interventions are largely focused on decontamination of skin using soap and antiseptics; the use of barriers to prevent movement of micro-organisms into incisions; and optimising the patient's own bodily functions to promote best recovery. Both decontamination and barrier methods can be aimed at people undergoing surgery and operating staff. Other interventions focused on SSI prevention may be aimed at the surgical environment and include methods of theatre cleansing and approaches to managing theatre traffic. Objectives: To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre. Methods: Published Cochrane systematic reviews reporting the effectiveness of interventions delivered during the intraoperative period in terms of SSI prevention were eligible for inclusion in this overview. We also identified Cochrane protocols and title registrations for future inclusion into the overview. We searched the Cochrane Library on 01 July 2017. Two review authors independently screened search results and undertook data extraction and 'Risk of bias' and certainty assessment. We used the ROBIS (risk of bias in systematic reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the certainty of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. Main results: We included 32 Cochrane Reviews in this overview: we judged 30 reviews as being at low risk of bias and two at unclear risk of bias. Thirteen reviews had not been updated in the past three years. Two reviews had no relevant data to extract. We extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included gloving, use of disposable face masks, patient oxygenation protocols, use of skin antiseptics for hand washing and patient skin preparation, vaginal preparation, microbial sealants, methods of surgical incision, antibiotic prophylaxis and methods of skin closure. Overall, the GRADE certainty of evidence for outcomes was low or very low. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high- or moderate-certainty evidence, 39 provided low-certainty evidence and 31 very low-certainty evidence. Of the nine comparisons that provided evidence for the outcome of mortality, five provided low-certainty evidence and four very low-certainty evidence.There is high- or moderate-certainty evidence for the following outcomes for these intraoperative interventions. (1) Prophylactic intravenous antibiotics administered before caesarean incision reduce SSI risk compared with administration after cord clamping (10 trials, 5041 participants; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.81; high-certainty evidence - assessed by review authors). (2) Preoperative antibiotics reduce SSI risk compared with placebo after breast cancer surgery (6 trials, 1708 participants; RR 0.74, 95% CI 0.56 to 0.98; high-certainty evidence - assessed by overview authors). (3) Antibiotic prophylaxis probably reduce SSI risk in caesarean sections compared with no antibiotics (82 relevant trials, 14,407 participants; RR 0.40, 95% CI 0.35 to 0.46; moderate-certainty evidence; downgraded once for risk of bias - assessed by review authors). (4) Antibiotic prophylaxis probably reduces SSI risk for hernia repair compared with placebo or no treatment (17 trials, 7843 participants; RR 0.67, 95% CI 0.54 to 0.84; moderate-certainty evidence; downgraded once for risk of bias - assessed by overview authors); (5) There is currently no clear difference in the risk of SSI between iodine-impregnated adhesive drapes compared with no adhesive drapes (2 trials, 1113 participants; RR 1.03, 95% CI 0.66 to 1.60; moderate-certainty evidence; downgraded once for imprecision - assessed by review authors); (6) There is currently no clear difference in SSI risk between short-term compared with long-term duration antibiotics in colorectal surgery (7 trials; 1484 participants; RR 1.05 95% CI 0.78 to 1.40; moderate-certainty evidence; downgraded once for imprecision - assessed by overview authors). There was only one comparison showing negative effects associated with the intervention: adhesive drapes increase the risk of SSI compared with no drapes (5 trials; 3082 participants; RR 1.23, 95% CI 1.02 to 1.48; high-certainty evidence - rated by review authors). Authors' conclusions: This overview provides the most up-to-date evidence on use of intraoperative treatments for the prevention of SSIs from all currently published Cochrane Reviews. There is evidence that some interventions are useful in reducing SSI risk for people undergoing surgery, such as antibiotic prophylaxis for caesarean section and hernia repair, and also the timing of prophylactic intravenous antibiotics administered before caesarean incision. Also, there is evidence that adhesive drapes increase SSI risk. Evidence for the many other treatment choices is largely of low or very low certainty and no quality-of-life or cost-effectiveness data were reported. Future trials should elucidate the relative effects of some treatments. These studies should focus on increasing participant numbers, using robust methodology and being of sufficient duration to adequately assess SSI. Assessment of other outcomes such as mortality might also be investigated as part of non-experimental prospective follow-up of people with SSI of different severity, so the risk of death for different subgroups can be better understood.
Article
Background: Surgical site infection (SSI) following caesarean section is a problem for women and health services. Caesarean section is a high volume procedure and the estimated incidence of SSI may be as high as 9%. Objectives: The objective of this study was to identify a suite of perioperative strategies and surgical techniques that reduce the risk of SSI following caesarean section. Search strategy: Six electronic databases were searched to systematically review literature reviews, systematic reviews and meta-analyses published from 2006 to 2016. Search terms included: endometritis, SSI, caesarean section, meta-analysis, review, systematic. Selection criteria: Studies were sought in which competing perioperative strategies and surgical techniques relevant for caesarean section were identified and quantifiable infection outcomes were reported. General surgical infection control techniques were excluded. Data collection and analysis: Data on study characteristics and clinical effectiveness were extracted. Quality, including bias within individual studies, was examined using a modified A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist. Recommendations for SSI risk reducing strategies were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results: Of 466 records retrieved, 44 studies were selected for the evidence synthesis. Recommended strategies were: administer pre-incision antibiotic prophylaxis, prepare the vagina with iodine-povidone solution and spontaneous placenta removal. Conclusions: We recommend clinicians implement pre-incision antibiotic prophylaxis, vaginal preparation and spontaneous placenta removal as an infection control bundle for caesarean section. This article is protected by copyright. All rights reserved.
Article
The aim of this study was to evaluate the reported techniques used in caesarean sections in order to form a general perspective of the procedural options for this frequently performed operation. The PubMed database and Cochrane Reviews were searched separately with the key words 'caesarean', 'abdominal entry', 'abdominal incision', 'uterine repair', 'peritoneal repair', 'closure of abdominal incision', 'suture materials', 'extraction of the placenta' and 'review'. Reviews, meta-analyses and prospective randomised trials were included in this review. In conclusion, although caesarean delivery is a very common operation, standardised and globally accepted techniques for caesarean section have not been described. The best surgical techniques for this operation are still unknown. Although the long-term follow-up results from two large, prospective, randomised studies are pending, further research is needed to establish an evidence-based, standardised approach for caesarean sections.
Article
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OBJECTIVE: In this study; high viscosity topical skin adhesive 2-octylcyanoacrylate was compared to polypropylene subcuticular suture method in the wound closure of Pfannenstiel incision. MATERIALS-METHODS: Forty women aged 21–75 operated with Pfannenstiel incision were included in this single center, prospective randomized, controlled clinical study. Subjects were randomized to two groups. In the first group (Group I, n=20) high viscosity topical skin adhesive 2-octylcyanoacrylate was used. In the 2nd group (Group II, n=20), the skin was closed using 3/0 subcuticular running polypropylene sutures. In all the cases; incision length, subcutaneous skin thickness, time taken to suture the skin defect, formation of hematoma, seroma, superficial or deep wound disruption, infection and keloid parameters in postoperative 2nd day, 7th day and 40th day were assessed. Cosmetic appearance and patient satisfaction were checked on the postoperative 40th day. RESULTS: In both groups, ages, body mass index, incision length and subcutaneous skin thickness were similar. In group I, skin closure time was significantly shorter as compared to group II (1.2 to 3.9 minutes respectively, p
Article
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Objective: Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Design: Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30
Article
To investigate the routine use of a skin stapling device for the closure of midline abdominal wounds, 48 patients were randomized to receive skin staples or subcuticular polydioxanone sutures. The mean (range) time for closure with staples was 8.0 (3.4–14.8) s cm−1 while subcuticular closure took 12.7 (9.6–28.0) s cm−1. The mean time saved per patient with skin staples was 77s. Wound pain and requirements for analgesia were significantly lower in the sutured group. The mean cost per patient was £ 1.41 for subcuticular closure and £7.72 for stapling; the latter also incurred an additional cost of £6.27 for staple removal. No clear benefit derives from the use of staples in the closure of abdominal wounds.
Article
The purpose of the present study was to evaluate the frequency of wound complications comparing staples to suture closure of the skin. During a 6-month period, all patients who underwent cesarean delivery were assigned to have their skin approximated with either subcuticular sutures or surgical staples. The remainder of the closure techniques were the same in each group. Risk factors for wound complications were identified and statistically analyzed. Twelve hundred and eighty-nine patients were evaluated. Of the 731 women with skin closure via staples, 66 (9%) had a superficial wound separation compared with only 13 (2.3%) of 558 when subcuticular suture was used to approximate the skin edges (P < 0.0001). This was significant only for vertical skin incisions. Thus, closure of the skin with subcuticular suture at the time of cesarean reduced the incidence of wound disruption by more than fourfold.
Article
There are various methods of delivery of placenta at caesarean section. These include placental drainage with spontaneous delivery, cord traction and manual removal. The last two methods: cord traction (usually combined with massage or expression of the uterus) and manual removal are frequently used. The review identified 15 studies involving 4694 women. Delivery of the placenta by cord traction at caesarean section has more advantages compared to manual removal. These are less endometritis; less blood loss; less decrease in haematocrit levels postoperatively; and shorter duration of hospital stay.
Article
Caesarean section is a common operation. Techniques vary depending on both the clinical situation and the preferences of the operator. To compare the effects of 1) different types of uterine incision, 2) methods of performing the uterine incision, 3) suture materials and technique of uterine closure (including single versus double layer closure of the uterine incision) on maternal health, infant health, and health care resource use. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2007). All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during caesarean section. Two authors evaluated trials for inclusion and methodological quality without consideration of their results according to the stated eligibility criteria and extracted data independently. We identified 30 studies, of which 15 (3972 women) were included. Ten trials compared single layer uterine closure with double layer uterine closure (2531 women), two trials compared blunt with sharp dissection at the time of the uterine incision (1241 women), and two trials compared auto-suture devices with traditional hysterotomy (300 women). Blunt dissection was associated with a reduction in mean blood loss at the time of the procedure when compared with sharp dissection of the uterine incision (one study, 945 women, mean difference (MD) -43.00, 95% confidence interval (CI) -66.12 to -19.88). There was no statistically significant difference related to need for blood transfusion (one study, 945 women, risk ratio (RR) 0.22, 95% CI 0.05 to 1.01). The use of an auto-suture instrument when compared with traditional methods of hysterotomy was associated with no difference in the amount of blood loss during the procedure (one study, 200 women, MD -87.00, 95% CI -175.09 to 1.09), but a statistically significant increase in the duration of the procedure (one study, 197 women, MD 3.30, 95% CI 0.02 to 6.62). Single layer closure compared with double layer closure was associated with a statistically significant reduction in mean blood loss (three studies, 527 women, MD -70.11, 95% CI -101.61 to -38.60); duration of the operative procedure (four studies, 645 women, MD -7.43, 95% CI -8.41 to -6.46); and presence of postoperative pain (one study, 158 women, RR 0.69, 95% CI 0.52 to 0.91). While caesarean section is a common procedure performed on women worldwide, there is little information available to inform the most appropriate surgical technique to adopt.
Article
A transverse suprapubic (Pfannenstiel) incision is widely used during open gynecologic surgery and cesarean delivery, and is associated with a better cosmetic result 1. It was reported that 73.9% of obstetricians in the United Kingdom closed with a subcuticular suture after cesarean delivery 2. Alderice et al. 3, in a Cochrane Review of skin closure at cesarean delivery, included only one trial (66 women) that compared subcuticular absorbable suture with staples, and which showed more favorable results with the former. We hypothesized that an absorbable suture that does not require removal will be associated with greater patient satisfaction.
Article
A prospective, randomised study was conducted to compare the wound closure performance and cosmetic outcome of caesarean section wounds closed with traditional Prolene suture or a new wound closure device (Leukosan(®) SkinLink). Sixty-one patients referred to primary section were allocated to wound closure with either Leukosan(®) SkinLink or Prolene suture. Cosmetic outcome as the primary measure was evaluated by the patient, the surgeon as well as by independent examiners blinded to the method of wound closure. Evaluations were recorded at 3, 6 and 12 months following wound closure. Both methods of wound closure scored equally high on the visual analogue scale for cosmetic evaluation at the 3-, 6- and 12-month follow-ups as assessed by the patient, surgeon and the blinded observers. The study has shown that innovative methods for wound closure compared with traditional methods such as suture providing excellent cosmetic results represent a valid alternative to physician and patient for surgical incisions.
Article
The purpose of this study was to determine the wound complication rates and patient satisfaction for subcuticular suture vs staples for skin closure at cesarean delivery. This was a randomized prospective trial. Subjects who underwent cesarean delivery were assigned randomly to stainless steel staples or subcuticular 4.0 Monocryl sutures. The primary outcomes were composite wound complication rate and patient satisfaction. A total of 435 patients were assigned randomly. Staple closure was associated with a 4-fold increased risk of wound separation (adjusted odds ratio [aOR], 4.66; 95% confidence interval [CI], 2.07-10.52; P < .001). Having a wound complication was associated with a 5-fold decrease in patient satisfaction (aOR, 0.18; 95% CI, 0.09-0.37; P < .001). After confounders were controlled for, there was no difference in satisfaction between the treatment groups (aOR, 0.71; 95% CI, 0.34-1.50; P = .63). Use of staples for cesarean delivery closure is associated with an increased risk of wound complications. Occurrence of a wound complication is the most important factor that influenced patient satisfaction.
Article
The objective of the study was to compare scar quality associated with different types of wound closure methods after cesarean section (CS). Patients were randomized to have skin closure following CS with either staples or 3 different types of subcuticular sutures. Scar quality was evaluated 2 and 6 months postoperatively. The Vancouver Scar Scale, the Patient and Observer Scar Assessment Scale (POSAS), and a visual analog scale were used as scar assessment tools. Of the 180 patients who were recruited, 123 successfully completed the study. No difference in both subjective and objective scar rating was detected across groups at either 2 months or 6 months. In the overall study population, objective scores correlated with patient rating, and correlation was strongest between the observer and patient components of the POSAS (r = 0.48). In women undergoing CS, stapled wounds and those closed with subcuticular sutures result in equivalent cosmetic appearance of the scar.
Article
We sought to compare postoperative pain according to the skin closure method (subcuticular sutures vs staples) after an elective term cesarean section. A randomized controlled trial of 101 women was performed. Women were randomly assigned to subcuticular sutures or staples. Operative technique and postoperative analgesia were standardized. Stratification was used for primary vs repeat cesareans. Analog pain and satisfaction scales ranging from 0-10 were completed at postoperative days 1 and 3, and at 6 weeks postoperatively. A digital photograph of the incision was taken at 6 weeks postoperatively and evaluated by 3 independent blinded observers. Pain at 6 weeks postoperatively was significantly less in the staple group (0.17 vs 0.51; P = .04). Operative time was shorter in that group (24.6 vs 32.9 minutes; P < .0001). No difference was noted for incision appearance and women's satisfaction. Staples are the method of choice for skin closure for elective term cesareans in our population.
Article
To investigate the routine use of a skin stapling device for the closure of midline abdominal wounds, 48 patients were randomized to receive skin staples or subcuticular polydioxanone sutures. The mean (range) time for closure with staples was 8.0 (3.4-14.8) s cm-1 while subcuticular closure took 12.7 (9.6-28.0) s cm-1. The mean time saved per patient with skin staples was 77 s. Wound pain and requirements for analgesia were significantly lower in the sutured group. The mean cost per patient was 1.41 pounds for subcuticular closure and 7.72 pounds for stapling; the latter also incurred an additional cost of 6.27 pounds for staple removal. No clear benefit derives from the use of staples in the closure of abdominal wounds.
Article
Skin staples were compared with two conventional suture methods for speed, convenience, effectiveness and cost. One hundred and ninety-five patients having linear abdominal incisions were randomly allocated to one of three methods of interrupted skin closure--polypropylene sutures, polyglactin sutures or stainless steel staples and the wounds were assessed over 30 days. The mean rate of wound closure using sutures was 4.2 cm per minute while staples were faster at 22.5 cm per minute and saved an average of three minutes per wound. The time saved was considerably greater with long incisions. Staples cost 50p more per 15 cm wound than either suture. In other respects the three methods were comparable except that polyglactin caused the least wound pain. We believe the advantages of speed and convenience of skin staples outweigh the extra cost, provided the disposable instruments are reused until empty.
Article
The Proximate stapler was compared with usual skin closure in a randomized trial, with 137 patients having elective abdominal and breast surgery. The median duration of skin closure with the Proximate stapler was 80 seconds, which was significantly shorter than the median of 242 seconds with conventional closure. No difference was found with regard to wound infection, but pain was more frequent after stapling.
Article
To compare skin closure with staples and subcuticular suture. Obstetric patients undergoing cesarean section with a Pfannenstiel incision were prospectively randomized to skin closure with staples or subcuticular suture. Pain and cosmesis were assessed postoperatively. Patients reported significantly less pain following subcuticular closure at both the time of discharge (P < or = .01) and the postoperative visit (P < or = .002). Incisions closed with subcuticular suture were found to be more cosmetically attractive by both patients (P = .04) and physicians (P = .01) at the postoperative visit. Pfannenstiel skin incisions closed with subcuticular closure following cesarean section result in less postoperative discomfort and are more cosmetically appealing at the six-week postoperative visit as compared to incisions closed with staples.
Article
The objective was to determine the usefulness of cyanocrilate when closing cesarean wounds, in comparison with silk and nylon usual sutures. 74 patients with cesarean without background of previous abdominal surgery or infection were observed. Patients were divided into two groups: the use of cyanocrilate to close skin on medium and Pfannenstiel incisions was practiced on 44 patients, and on the remaining 30 patients integrating the control group, silk or nylon suture was used. The population characteristics did not show differences. Evaluated parameters were as follows; both groups showed similar little to moderate pain. Pruritus predominated in the cyanocrilate group (CIAN) on about 18.1% vs 13.2% on the control group. Marks on the skin largely predominated on the control group with silk (75%), while there were no marks on the CIAN group. The reaction to a foreign body was greater in the CIAN group, 15.9% versus 6.6% in the control group. Superficial dehiscence on the CIAN group was 6%, while it was 10% on the control group. The CIAN group showed 2.2% of hematomas, and the group of control 6.6%. Poorly coapted edges resulted in 4.5% on the CIAN group versus 20% on the control group. Skin closure average time on the CIAN was 62.8 sec and 283 on the control group. The use of cyanocrilate on the cesaran wounds closure showed: efficiency, safety and surgical time reduction, the scar aesthetics was improved and costs were reduced.
Article
To determine what surgical techniques are used by obstetricians in the UK for elective and emergency caesarean section operations. A postal questionnaire to all members and fellows of the Royal College of Obstetricians and Gynaecologists (RCOG) resident in the UK, requesting information about the use of surgical techniques and antibiotic and anticoagulant prophylaxis for elective and emergency caesarean sections. The response rate was 78.7%. A range of techniques was used for all procedures in caesarean section operations. Only a few techniques were used by more than 80% of obstetricians, including double layer closure of the uterus, use of prophylactic antibiotics and Pfannenstiel abdominal entry (for elective caesarean sections). There were few large differences in practice between elective and emergency caesarean sections. In emergency operations, more obstetricians use the Joel-Cohen method of abdominal entry (32.7 versus 16%) and more usually use prophylactic antibiotics and heparin (93.2 versus 85.4% and 45.8 versus 32.9%, respectively). There was wide variation in the surgical techniques used by obstetricians for caesarean section operations. There is an urgent need for future research to evaluate many aspects of caesarean section operations on substantive short- and long-term outcomes.
Article
There is not enough evidence to say whether particular techniques for closing the abdominal wall during caesarean section are better than others. Different techniques and suture materials are used in caesarean section for closure of the rectus sheath (fibrous material enclosing the muscles of the abdominal wall). No research has examined whether any technique for closing the rectus sheath is preferable. The subcutaneous fat (between the sheath and the skin) may be left to heal without suturing, or can be closed using a variety of techniques. Closing the subcutaneous fat may reduce the risk of some wound complications (haematoma and seroma) but further research is needed to investigate how these outcomes affect the well-being and recovery of the women concerned.
Article
Background: Different techniques have been described to reduce morbidity during caesarean section. After the baby has been born by caesarean section and the placenta has been extracted, temporary removal of the uterus from the abdominal cavity (exteriorisation of the uterus) to facilitate repair of the uterine incision has been postulated as a valuable technique. This is particularly so when exposure of the incision is difficult and when there are problems with haemostasis. Several clinical trials have been done, with varying results, including substantial reduction in the rate of postoperative infection and morbidity with extra-abdominal closure of the uterine incision, and less associated peri-operative haemorrhage. Subsequent studies suggest that the method of placental removal rather than method of closure of the uterine incision influences peri-operative morbidity. Objectives: To evaluate the effects of extra-abdominal repair of the uterine incision compared to intra-abdominal repair. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register (September 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2003), MEDLINE (1966 to July 2003) and PubMed (1966 to 2003). Selection criteria: Randomised controlled trials involving a comparison of uterine exteriorisation with intra-abdominal repair of the uterine incision in women undergoing caesarean section. Data collection and analysis: Two reviewers independently assessed the trials identified for inclusion. We compared categorical data using relative risks and 95% confidence intervals and continuous data using the weighted mean difference with 95% confidence intervals. We tested for statistical heterogeneity between trials using the I squared test. Where no significant heterogeneity (greater than 50%) existed, we pooled data using a fixed effect model. If significant heterogeneity existed, a random effects model was used. Main results: Six studies were included, with 1294 women randomised overall, and 1221 women included in the analysis. There were no statistically significant differences between the groups in most of the outcomes identified, except for febrile morbidity and length of hospital stay. With extra-abdominal closure of the uterine incision, febrile morbidity was lower (relative risk 0.41, 95% confidence interval (CI) 0.17 to 0.97), and the hospital stay was longer (weighted mean difference 0.24 days, 95% CI 0.08 to 0.39). Reviewers' conclusions: There is no evidence from this review to make definitive conclusions about which method of uterine closure offers greater advantages, if any. However, these results are based on too few and too small studies to detect differences in rare, but severe, complications.
Article
To compare the efficacy of subcutaneous suture reapproximation alone with suture plus subcutaneous drain for the prevention of wound complications in obese women undergoing cesarean delivery. We conducted a multicenter randomized trial of women undergoing cesarean delivery. Consenting women with 4 cm or more of subcutaneous thickness were randomized to either subcutaneous suture closure alone (n = 149) or suture plus drain (n = 131). The drain was attached to bulb suction and removed at 72 hours or earlier if output was less than 30 mL/24 h. The primary study outcome was a composite wound morbidity rate (defined by any of the following: subcutaneous tissue dehiscence, seroma, hematoma, abscess, or fascial dehiscence). From April 2001 to July 2004, a total of 280 women were enrolled. Ninety-five percent of women (268/280) had a follow-up wound assessment. Both groups were similar with respect to age, race, parity, weight, cesarean indication, diabetes, steroid/antibiotic use, chorioamnionitis, and subcutaneous thickness. The composite wound morbidity rate was 17.4% (25/144) in the suture group and 22.7% (28/124) in the suture plus drain group (relative risk 1.3, 95% confidence interval 0.8-2.1). Individual wound complication rates, including subcutaneous dehiscence (15.3% versus 21.8%), seroma (9.0% versus 10.6%), hematoma (2.2% versus 2.4%), abscess (0.7% versus 3.3%), fascial dehiscence (1.4% versus 1.7%), and hospital readmission for wound complications (3.5% versus 6.6%), were similar (P > .05) between women treated with suture alone and those treated with suture plus drain, respectively. The additional use of a subcutaneous drain along with a standard subcutaneous suture reapproximation technique is not effective for the prevention of wound complications in obese women undergoing cesarean delivery.
Article
The purpose of this study was to provide evidenced-based guidance for surgical decisions during cesarean delivery. We performed MEDLINE, PubMed, EMBASE, and COCHRANE searches with the terms cesarean section, cesarean delivery, cesarean, pregnancy, randomized trials, and each technical aspect of cesarean delivery. All randomized trials that covered a surgical aspect of cesarean delivery were included in the review. Each surgical step of cesarean delivery was reviewed separately. US Preventive Services Task Force recommendations favor blunt uterine incision expansion, prophylactic antibiotics (either ampicillin or first-generation cephalosporin for just 1 dose), spontaneous placental removal, non-closure of both visceral and parietal peritoneum, and suture closure or drain of the subcutaneous tissue when thickness is > or =2 cm. Cesarean delivery techniques that are supported by good quality recommendations should be performed routinely. All technical aspects that have recommendations with lower quality should be researched with adequately powered and designed trials.
Article
Publication bias and related bias in meta-analysis is often examined by visually checking for asymmetry in funnel plots of treatment effect against its standard error. Formal statistical tests of funnel plot asymmetry have been proposed, but when applied to binary outcome data these can give false-positive rates that are higher than the nominal level in some situations (large treatment effects, or few events per trial, or all trials of similar sizes). We develop a modified linear regression test for funnel plot asymmetry based on the efficient score and its variance, Fisher's information. The performance of this test is compared to the other proposed tests in simulation analyses based on the characteristics of published controlled trials. When there is little or no between-trial heterogeneity, this modified test has a false-positive rate close to the nominal level while maintaining similar power to the original linear regression test ('Egger' test). When the degree of between-trial heterogeneity is large, none of the tests that have been proposed has uniformly good properties.
Article
Suture knots present several disadvantages in wound closure, because they are tedious to tie and place ischemic demands on tissue. Bulky knots may be a nidus for infection, and they may extrude through skin weeks after surgery. Needle manipulations during knot-tying predispose the surgeon to glove perforation. A barbed suture was developed that is self-anchoring, requiring no knots or slack management for wound closure. The elimination of knot tying may have advantages over conventional wound closure methods. This prospective, randomized, controlled trial was designed to show that the use of barbed suture in dermal closure of the Pfannenstiel incision during nonemergent cesarean delivery surgery produces scar cosmesis at 5 weeks that is no worse than that observed with conventional closure using 3-0 polydioxanone suture. Cosmesis was assessed by review of postoperative photographs by a blinded, independent plastic surgeon using the modified Hollander cosmesis score. Secondary endpoints included infection, dehiscence, pain, closure time, and other adverse events. The study enrolled 195 patients, of whom 188 were eligible for analysis. Cosmesis scores did not significantly differ between the barbed suture group and the control group. Rates of infection, dehiscence, and other adverse events did not significantly differ between the two groups. Closure time and pain scores were comparable between the groups. The barbed suture represents an innovative option for wound closure. With a cosmesis and safety profile that is similar to that of conventional suture technique, it avoids the drawbacks inherent to suture knots.
Article
Caesarean section is a common operation with no agreed standard on operative techniques and materials to use. The skin layer can be repaired by sub cuticular stitch immediately below the skin layer, an interrupted stitch or with skin staples. A great variety of materials and techniques are used for skin closure after caesarean section and there is a need to identify which provide the best outcomes for women. To compare the effects of skin closure techniques and materials on maternal outcomes and time taken to perform a caesarean section. We searched the Cochrane Pregnancy and Childbirth Group trials register (August 2002). All randomised comparisons of skin closure techniques in caesarean section. Three papers were identified from the search. Data were extracted independently by two reviewers. On further inspection two were not considered to be randomised controlled trials. Only one small randomised controlled trial, involving 66 women, was included in the review. Frishman et al compared staples with absorbable sub-cuticular suture for closure following caesarean section. While operating time was significantly shorter when using staples, the use of absorbable sub cuticular suture resulted in less postoperative pain and yielded a better cosmetic result at the post-operative visit. There is no conclusive evidence about how the skin should be closed after caesarean section. Questions regarding the best closure technique and material and the outcomes associated with each remain unanswered. The appearance and strength of the scar following caesarean section is important to women and the choice of technique and materials should be made by women in consultation with their obstetrician based on the limited information currently available.
Article
In a caesarean section operation, there are various types of incisions in the abdominal wall that can be used. These include vertical and transverse incisions, and there are variations in the specific ways the incisions can be undertaken. The review of studies identified 4 trials involving 666 women. The Joel-Cohen incision showed better outcomes than the Pfannenstiel incision in terms of less fever for women, less postoperative pain, less blood loss, shorter duration of surgery and shorter hospital stay. However, the trials did not assess possible long-term problems associated with different surgical techniques.
Article
To determine the role of skin and subcutaneous space closure in caesarean section on the cosmetic appearance of the scar and the patients' satisfaction. 153 patients undergoing caesarean section without prior abdominal delivery were included and randomly assigned in a non-blinded study to four different combinations of skin and subcutaneous tissue closure. The scar was assessed after a period of at least 4 months by a self-developed protocol and the patient was asked to complete a survey regarding her satisfaction with the scar. One hundred patients were eligible for long-term evaluation of the scar. Skin closure by either staples or intracutaneous suture in combination with closure or non-closure of the subcutaneous space has a comparable outcome in view of cosmetic outcome and patient satisfaction. All four methods of skin closure seem to be a reasonable choice in caesarean section because they have comparable cosmetic outcome, do not differ with respect to the patients' satisfaction and bear comparable costs.
Article
The aim of the study was to compare the outcome, complications and costs of three skin suture techniques after Caesarean section. The study sample was 310 women who underwent caesarean section between 2003 and 2007. The sample was divided into three groups: an intradermal suture with non-reabsorbable thread was applied in 98; metallic clips were placed in 90; 2-octyl-cyanoacrylate (2-OCA) glue was used for wound closure in 112. The sutures were checked at 4 days and 2 months after the operation to determine cosmetic outcome, patient compliance, strength of incision closure, allergic reactions, suture infection, and total cost of each technique. No substantial differences in strength of incision closure or cosmetic outcome between the techniques were found. Compliance was better in the group that received 2-OCA, while the total cost of suture alone was lower in the group that received the non-reabsorbable intradermal suture. The results suggests that following Caesarean section according to Stark, skin suture with 2-OCA glue has the advantage of greater patient compliance, while intradermal thread suture is less costly with a cosmetic outcome comparable to that of the other two techniques.
Article
Rates of caesarean section (CS) have been rising globally. It is important to use the most effective and safe technique. To compare the effects of complete methods of caesarean section; and to summarise the findings of reviews of individual aspects of caesarean section technique. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3) and reference lists of identified papers. Randomised controlled trials of intention to perform caesarean section using different techniques. Two review authors independently assessed studies and extracted data. 'Joel-Cohen based' compared with Pfannenstiel CS was associated with: less blood loss, (five trials, 481 women; weighted mean difference (WMD) -64.45 ml; 95% confidence interval (CI) -91.34 to -37.56 ml); shorter operating time (five trials, 581 women; WMD -18.65; 95% CI -24.84 to -12.45 minutes); postoperatively, reduced time to oral intake (five trials, 481 women; WMD -3.92; 95% CI -7.13 to -0.71 hours); less fever (eight trials, 1412 women; relative risk (RR) 0.47; 95% CI 0.28 to 0.81); shorter duration of postoperative pain (two comparisons from one trial, 172 women; WMD -14.18 hours; 95% CI -18.31 to -10.04 hours); fewer analgesic injections (two trials, 151 women; WMD -0.92; 95% CI -1.20 to -0.63); and shorter time from skin incision to birth of the baby (five trials, 575 women; WMD -3.84 minutes; 95% CI -5.41 to -2.27 minutes). Serious complications and blood transfusions were too few for analysis.Misgav-Ladach compared with the traditional method (lower midline abdominal incision) was associated with reduced: blood loss (339 women; WMD -93.00; 95% CI -132.72 to -53.28 ml); operating time (339 women; WMD-7.30; 95% CI -8.32 to -6.28 minutes); time to mobilisation (339 women; WMD -16.06; 95% CI -18.22 to -13.90 hours); and length of postoperative stay for the mother (339 women; WMD -0.82; 95% CI -1.08 to -0.56 days). Misgav-Ladach compared with modified Misgav-Ladach methods was associated with a longer time from skin incision to birth of the baby (116 women; WMD 2.10; 95% CI 1.10 to 3.10 minutes). 'Joel-Cohen based' methods have advantages compared to Pfannenstiel and to traditional (lower midline) CS techniques, which could translate to savings for the health system. However, these trials do not provide information on mortality and serious or long-term morbidity such as morbidly adherent placenta and scar rupture.
Hypertrophic cesarean section scarring: polyglycolic acid and nylon sutures in a randomized trial
  • Roungsipragarn R
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Dermal closure time in cesarean delivery Pfannenstiel incision using a barbed suture [abstract]
  • Paglia MJ
  • Parham T
  • Sinclair T
  • Murtha AP
Cesarean delivery: subcuticular suture versus staples for skin closure
  • Gilstrap Bohmanvr
  • Iiilc
  • Levenokj
  • Littlebb
  • Raminsm
  • Goldaberkg
BohmanVR, Gilstrap IIILC, LevenoKJ, LittleBB, RaminSM, GoldaberKG, et al. Cesarean delivery: subcuticular suture versus staples for skin closure. American Journal of Obstetrics and Gynecology 1993;168(1 Pt 2):437.
Cesarean delivery: subcuticular suture versus staples for skin closure
  • V R Bohman
  • Iii Gilstrap
  • Lc
  • K J Leveno
  • B B Little
  • S M Ramin
  • K G Goldaber
Bohman VR, Gilstrap III LC, Leveno KJ, Little BB, Ramin SM, Goldaber KG, et al. Cesarean delivery: subcuticular suture versus staples for skin closure. American Journal of Obstetrics and Gynecology 1993;168(1 Pt 2):437.