Cesarean Skin Closure Research Articles

Suture Compared With Staples for Skin Closure After Cesarean Delivery: A Systematic Review and Meta-analysis.

Absorbable suture is the preferred method of cesarean skin closure compared with metal staples, because it decreases wound complications. Two recently published trials in patients with obesity contradict this evidence. The goal of this meta-analysis was to assess whether suture remains the recommended method of cesarean skin closure, regardless of obesity status. MEDLINE through OVID, PubMed, Cochrane Database, and ClinicalTrials.gov were searched from inception until September 24, 2021. Published randomized controlled trials (RCTs) comparing subcuticular absorbable suture with nonabsorbable metal staples for cesarean skin closure were included. Non-RCTs, RCTs that did not compare staples with suture, and ongoing trials were excluded. Fourteen studies met inclusion criteria. Data were individually abstracted and entered into RevMan. Fixed and random effects models were used. The Cochrane risk-of-bias tool was used to assess each study. The primary outcome, a sensitivity analysis of wound complications (excluding studies at high risk of bias), showed a significant decrease in wound complications when the cesarean skin incision was closed with suture compared with staples (10 studies; 71/1,497 vs 194/1,465; risk ratio [RR] 0.47, 95% CI 0.25-0.87). When all studies were analyzed, there remained a significant decrease in wound complications when the skin was closed with suture (14 studies; 121/1,780 vs 242/1,750; RR 0.59, 95% CI 0.36-0.97). Of the individual wound complications, wound separation was significantly decreased with suture closure compared with staples (11 studies; 55/1,319 vs 129/1,273; RR 0.43, 95% CI 0.32-0.58). In patients with obesity, there remained a significant decrease in wound complications with suture closure of the skin incision compared with staples (five studies; 34/507 vs 67/522; RR 0.51, 95% CI 0.34-0.75). Closure of the cesarean skin incision with suture decreased composite wound complications by 50% as compared with closure with staples; a significant decrease persisted regardless of obesity status. PROSPERO, CRD42021270378.

Staples versus subcuticular suture for cesarean skin closure in obese women: A systematic review and meta-analysis

AimCesarean section (CS) in obese women poses many surgical, anesthetic, and logistical challenges. This systematic review and meta-analysis aimed to compare the outcomes between staples versus subcuticular suture for cesarean skin closure in obese women undergoing CS. MethodsPubMed, EMBASE and CENTRAL databases were searched for relevant articles using the keywords cesarean section, cesarean delivery, staple, suture, closure and obese. Randomized controlled trials (RCTs), prospective and retrospective studies comparing between staples and subcuticular suture for wound closure in obese women (BMI ≧ 30 kg/m2) were eligible for inclusion. Outcomes were composite wound complication, wound separation, infection and wound appearance satisfaction. ResultsFour studies (two RCTs, one retrospective, one post hoc analysis of an RCT) met the inclusion criteria, with a total of 2,038 obese women undergoing CS, of whom 984 had wound closure by staples and 1,054 had wound closure by subcuticular suture. Pooled analysis did not show significant differences on the risk for composite wound complication, infection, wound appearance satisfaction score or wound separation between staples and sutures. ConclusionsIn obese women receiving CS, it appears there are no significant differences in wound complication, infection, satisfaction scores or wound separation between staples and subcuticular suture. These findings may help optimize risk stratification for obese CS patients. A larger study size meta-analysis is needed to confirm the findings.

1190: Suture vs. staples for cesarean skin closure in class III obesity: A randomized controlled trial

To compare rates of postoperative wound complications among women with Class III obesity (BMI ≥ 40) undergoing cesarean delivery (CD) with skin closure either by subcuticular sutures vs surgical staples. Patients were randomly assigned to skin closure by staples or subcuticular suture at the time of CD. Randomization was stratified for scheduled or unscheduled/labored CD and for the two study sites. The primary outcome was the rate of any documented wound complication during the first six weeks postpartum. Covariates considered were gestational age at delivery, number of prior CDs, diabetes diagnosis, labor, preoperative antibiotic use, preoperative vaginal prep, and tobacco use. To further evaluate the surgical outcome in this population, we also considered location of incision and incision to delivery interval. Sample size was calculated based on published literature and estimating a rate of wound complications at 6 weeks of follow-up at 20% with staples and 10% with sutures. For a power of 0.80 with a two-tailed of 0.05, an N of 199 per group was required. Nearing the planned interim analysis, enrollment in the study was concluded administratively due to extended duration. From September 2015 through May 2019, 232 women were randomized at two University hospitals, 120 to staples and 111 to sutures. Fewer wound complications were noted in the surgical staples group when compared to the subcuticular suture group (24.4 vs. 34.1%), although this difference was not found to be statistically significant (RR 0.72, 95% CI 0.43-1.18, p=0.185). In multiple logistic regression, the two significant independent predictors of the outcome were BMI (OR 2.35, 95% CI 1.16-4.76) and unscheduled CD (OR 1.11, 95% CI 1.06-1.18). Among obese women with BMI ≥ 40 undergoing CD, wound complication rates in the first 6 weeks postpartum are not significantly different when comparing skin closure using either surgical staples or subcuticular suture. The results of our study demonstrate that either technique is acceptable, allowing physician and patient preferences to be considered.

WOUND COMPLICATIONS;

Cesarean section is the most commonly performed abdominal operations on women worldwide. Its rate has increased markedly in recent years in most developed countries. Due to insufficient available data regarding the best suture materials for cesarean skin closure, we conducted a study “to compare the efficacy of 2 suture materials non absorbable prolene 2-0 and absorbable suture vicryl (2-0), brand Ethicon as subcuticular skin stitches in women undergoing elective cesarean section. Study Design: Prospective, observational study. Setting: Department of Obstetrics and Gynecology, Bahawal Victoria Hospital Bahawalpur. Period: 6 months. Materials and Methods: A total of 200 women fulfilling inclusion and exclusion criteria as above were enrolled for the present study. They were divided into 2 groups of 100 each by systematic sampling technique. Results: There is statistically significant difference related to post-operative wound complication parameters between non absorbable vs absorbable suture material on day 8, 15, 30 and 45. More number of patients having absorbable suture had pain, tenderness swelling and indurations. Maximum number of participants, that is, 86 (86%) and 93 (93%) from Group 1 showed excellent wound healing at day 30 and day 45 of caesarean section as compared to 63 (63%) and 66 (68%) from Group 2. Conclusion: The non-absorbable suture (prolene) was better in terms of wound healing and cosmesis as compared to absorbable suture used in our study (vicryl).

Patient preferences for method of cesarean skin closure: secondary outcomes from a randomized trial

Objective: To assess patient preference for sutures or staples for cesarean wound closure.Methods: This is a planned secondary analysis of a randomized controlled trial of 746 women in which suture and staples were compared for cesarean skin closure. Enrolled patients were asked to complete preoperative and postoperative surveys to assess preferred closure. Reasons for expressed preferences were elicited for each patient. Preferences were stratified by a number of cesarean deliveries (CD). We sought to determine if patients had a specific preference for wound closure due to personal experience or a personal belief that one method may be more beneficial with respect to pain and appearance.Results: We surveyed 550 patients preoperatively and 627 postoperatively. Women with a prior CD were more likely to have a skin closure preference compared with women having a primary CD (p < .05). Women who had a prior closure with suture rather than staples were significantly more likely to have a preference for the same wound closure method (p < .01). Avoiding the need for staple removal was the main reason women preferred suture closure, both preoperatively and postoperatively. The higher the number of the previous CD, the greater the preference for future closure with suture over staples (p < .05).Conclusions: Women undergoing cesarean delivery prefer suture as the method for skin closure compared with staples.

Patient satisfaction and cosmetic outcome in a randomized study of cesarean skin closure

Objective: To evaluate patient satisfaction and patient and physician assessment of scar appearance after cesarean skin closure with suture versus staples.Methods: Women undergoing cesarean delivery (CD) at ≥23 weeks’ gestation via low-transverse skin incisions at three hospitals in the CROSS Consortium were randomized to receive skin closure using subcuticular absorbable suture or nonabsorbable metal staples. The primary outcome of this substudy, patient satisfaction, was assessed by surveys at the postpartum visit using a 10-point Likert scale. Scar outcomes according to patients and trained observers were assessed at the primary research site using the Patient and Observer Scar Assessment Scale (POSAS). The POSAS is comprised of a patient-completed assessment including subjective data such as pain and itchiness, and an observer-completed assessment about cosmetic criteria.Results: Between June 2010 and August 2012, 746 women were randomized; 370 received suture and 376 received staples. Satisfaction data were available for 606 (81%). Complete patient scar assessment data were available for 577 (77%) and complete observer scar assessment data were available for 275 (57% of the 480 planned for evaluation at the primary research site). Demographic data for women in the two groups were similar. Satisfaction with the closure method was higher (superior) among women who received suture closure: median 10 (interquartile range 9, 10) versus 9 (interquartile ranges (IQR) 6, 10); p < .01. The suture group also had higher satisfaction with the scar’s appearance at the postpartum visit: median nine (IQR 7, 10) versus 8 (IQR 6, 10); p = .02. Receiving one’s preferred closure method was associated with higher patient satisfaction, and wound complications were associated with lower satisfaction. POSAS scores were superior (lower) in the suture group. Patient Scar Assessment Scale scores were median 15 (IQR 10, 25) for sutures versus 20 (IQR 11, 28) for staples; p < .01. Observer Scar Assessment Scale scores were median 12 (IQR 9, 15) for sutures versus 13 (IQR 9, 16) for staples; p = .01.Conclusions: Satisfaction with the closure method, satisfaction with the scar’s appearance, and patient and physician assessments of scar cosmesis were all superior in those closed with suture. These results further support the use of sutures for cesarean skin closure.Trial registration: ClinicalTrials.gov identifier: NCT01211600.

Pain Associated With Cesarean Delivery Skin Closure: A Randomized Controlled Trial.

To assess pain perception and pain medication use between women who underwent suture and those who underwent stapling for skin closure after cesarean delivery. This was a secondary analysis of a prospective, multicenter, randomized clinical trial conducted from 2010 to 2012 at three hospitals in the United States. We evaluated pain outcomes associated with skin closure of a low transverse skin incision for cesarean delivery. Patient-reported pain and pain medication use during hospitalization and 6 weeks postpartum were evaluated as prespecified secondary outcomes of the trial. A total of 746 women were randomized to cesarean skin closure with sutures (n=370) or staples (n=376). There were no significant differences between the two groups with regard to pain perception during hospitalization (median average in-hospital pain score 3.9 in each group, P=.914), or at 4-8 weeks postsurgery (one in each group, P=.949). There were no significant differences in pain medication use during hospitalization (suture: 56 mg of intravenous morphine; staples: 54 mg, P=.545) or 4-8 weeks postpartum. We observed no differences in patient-reported pain or pain medication use among women who underwent skin closure with suture and those who underwent stapling after cesarean delivery. Taken in conjunction with the primary analysis that showed decreased wound morbidity with suture closure, the results of this study support the use of suture closure of the cesarean delivery skin incision. ClinicalTrials.gov, www.clinicaltrials.gov, NCT01211600. I.

Absorbable Subcuticular Staples Compared With Suture for Cesarean Closure

INTRODUCTION: Cesarean skin closure data are limited, although recent studies indicate subcuticular suture is superior to external metal staples. The INSORB subcuticular staple is designed to combine the speed of a stapler with the superior wound approximation of suture, but data on INSORB are limited. This study compared INSORB staples with subcuticular suture for cesarean skin closure. METHODS: In this prospective, randomized, nonblinded, parallel-group trial, patients were stratified by prior cesarean delivery, body mass index (BMI, calculated as weight (kg)/ [height (m)]2), and surgeon skill level. Eligible women were at least age 18 and 24 weeks of gestation.Exclusion criteria were BMI greater than 50, chorioamnionitis, intrauterine fetal death, and multifetal gestation. The primary outcome was operative time. Secondary outcomes included patient and surgeon satisfaction, needlestick injury, pain, wound complications, and cost. RESULTS: Of 220 randomized patients, 206 were included in the final intention-to-treat analysis (103 per group). Baseline characteristics were similar. The subcuticular staple group had significantly shorter skin closure time (2.6 versus 8.5 minutes, P<=.001) and trended toward shorter operative time (54.0 versus 58.0 minutes, P=.053). The cost reduction with subcuticular staples was $172 – $829 per case. There were no differences in analgesic use, wound complications, or patient satisfaction. One needlestick injury occurred with suture. Surgeons were more likely to recommend (97% versus 85%, P=.004) and use (98% versus 82%, P<=.001) subcuticular staples in the future. CONCLUSION: For cesarean delivery, the INSORB staple is faster and more cost-effective than subcuticular suture and has equivalent analgesic use, wound complications, and patient satisfaction. (C) 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.

Wound morbidity with staples compared with suture for cesarean skin closure by diabetic status

Objective: To determine if the risk of post-cesarean wound morbidity in patients undergoing staple versus suture closure is modified by diabetic status.Methods: Secondary analysis of a randomized trial of skin closure with subcuticular 4-0 monocryl suture or surgical staples after cesarean delivery. The primary outcome was a composite of wound disruption or infection within 4–6 weeks. We compared the association between this outcome and skin closure method by diabetic status (also stratified by gestational or pregestational) using the Breslow–Day test for interaction.Results: Of 350 patients, 179 were randomized to staples and 171 to suture. Of the 67 (19.1%) diabetic patients, 35 were gestational and 32 pregestational. The incidence of composite wound morbidity in non-diabetics was 16.7% for staples and 3.6% for suture (p ≤ 0.001, RR: 4.6, 95% CI: 1.8–11.8); it was 5.7% for staples and 15.6% for sutures in diabetics (p = 0.25, RR: 0.4, 95% CI: 0.1–1.7). The corresponding Breslow–Day p value indicated a significant difference between diabetics and non-diabetics (p = 0.002). Stratified further by gestational and pregestational diabetes, the RRs were 0.3 (95% CI: 0.03–2.4) and 0.5 (95% CI: 0.05–5.0) compared to non-diabetics, respectively. Each diabetic sub-group was significantly different from non-diabetics (Breslow–Day p values for homogeneity p = 0.005 and p = 0.045, respectively).Conclusions: The use of staples compared with subcuticular suture for cesarean skin closure is associated with increased wound morbidity. While this is true for non-diabetics, further studies of diabetics are needed to evaluate for a null or opposite effect of closure type.

Comparison of Subcuticular Suture Materials in Cesarean Skin Closure.

Aim. Comparison of the rate of wound complications, pain, and patient satisfaction based on used subcuticular suture material. Methods. A total of 250 consecutive women undergoing primary and repeat cesarean section with low transverse incision were prospectively included. The primary outcome was wound complication rate including infection, dehiscence, hematoma, and hypertrophic scar formation within a 6-week period after operation. Secondary outcomes were skin closure time, the need for use of additional analgesic agent, pain score on numeric rating scale, cosmetic score, and patient scar satisfaction scale. Results. Absorbable polyglactin was used in 108 patients and nonabsorbable polypropylene was used in 142 patients. Wound complication rates were similar in primary and repeat cesarean groups based on the type of suture material. Skin closure time is longer in nonabsorbable suture material group in both primary and repeat cesarean groups. There was no difference between groups in terms of postoperative pain, need for additional analgesic use, late phase pain, and itching at the scar. Although the cosmetic results tended to be better in the nonabsorbable group in primary surgery patients, there was no significant difference in the visual satisfaction of the patients. Conclusions. Absorbable and nonabsorbable suture materials are comparable in cesarean section operation skin closure.

Suture versus staples for skin closure after cesarean: a metaanalysis

We sought to perform a metaanalysis to synthesize randomized clinical trials of cesarean skin closure by subcuticular absorbable suture vs metal staples for the outcomes of wound complications, pain perception, patient satisfaction, cosmesis, and operating time. A systematic search was performed using MEDLINE, Cochrane Databases, and ClinicalTrials.gov registries. We included randomized trials comparing absorbable suture vs metal staples for cesarean skin closure. Data were abstracted regarding wound complications, patient pain perception, patient satisfaction, cosmesis as assessed by the physician and patient, and operating time. Twelve randomized trials with data for the primary outcome on 3112 women were identified. Women whose incisions were closed with suture were significantly less likely to have wound complications than those closed with staples (risk ratio, 0.49; 95% confidence interval [CI], 0.28-0.87). This difference remained significant even when wound complications were stratified by obesity. The decrease in wound complications was largely due to the lower incidence of wound separations in those closed with suture (risk ratio, 0.29; 95% CI, 0.20-0.43), as there were no significant differences in infection, hematoma, seroma, or readmission. There were also no significant differences in pain perception, patient satisfaction, and cosmetic assessments between the groups. Operating time was approximately 7 minutes longer in those closed with suture (95% CI, 3.10-11.31). For patients undergoing cesarean, closure of the transverse skin incision with suture significantly decreases wound morbidity, specifically wound separation, without significant differences in pain, patient satisfaction, or cosmesis. Suture placement does take 7 minutes longer than staples.

Patient Satisfaction and Cosmetic Outcome in a Randomized Study of Cesarean Skin Closure

INTRODUCTION: To determine which of the two most common methods of cesarean skin closure resulted in greater patient satisfaction and better cosmetic outcome. METHODS: We conducted a prospective, multicenter, randomized clinical trial in which women undergoing cesarean delivery via low transverse skin incisions were allocated to skin closure with suture or staples. Patients were asked to rate their satisfaction with closure method and with skin cosmesis using a Likert scale. We used a validated scar assessment tool (the Patient and Observer Scar Assessment Scale with subjective and objective components) to evaluate cosmetic outcome. To minimize interobserver variability, we limited cosmetic outcome assessments to the primary research site. Standardized assessments were performed by one of seven trained clinicians who were blinded to the skin-closure technique. RESULTS: A total of 746 women were randomized from 2010–2012: satisfaction data were available for 606 (81%). Overall satisfaction with closure method and satisfaction with skin cosmesis were significantly higher in women who received suture closure (Table 1). There was a positive correlation between cosmetic satisfaction and overall satisfaction. Both the subjective and objective components of the Patient and Observer Scar Assessment Scale favored suture.CONCLUSION: Suture closure was associated with greater patient satisfaction and improved patient and physician cosmetic assessments as compared with staple closure of the skin incision at cesarean delivery.

290: Patient preference for method of cesarean skin closure

To determine which method of skin closure is preferred by patients undergoing cesarean (CS), whether receiving their preferred skin closure affects overall satisfaction and if surgical closure was correlated with choice of closure for future CS.

450: Patient perception of pain and analgesic use in a randomized study of cesarean skin closure

450: Patient perception of pain and analgesic use in a randomized study of cesarean skin closure

Cesarean skin closure preferences: a survey of obstetricians

Objective: In light of the limited evidence directing cesarean skin closure techniques, we evaluated the factors guiding obstetricians’ preferences for closure method.Methods: From 07/11 to 12/11, an online survey was sent to obstetricians in ACOG Regions I and II. Obstetricians were asked to indicate their cesarean skin closure preferences when considering various factors and to rank the importance of these factors in their decision. Practice type, experience and usual method of closure were also assessed.Results: Responses were received from 470 of 1400 surveyed (34% response rate), of which 422 were analyzed. Similar proportions reported primarily using sutures (39%) or staples (48%); 13% use both methods equally. More obstetricians at community hospitals primarily use sutures (48% versus 39%, p < 0.001), while more at university hospitals primarily use staples (57% versus 30%, p < 0.001). Listed in decreasing order of importance, sutures were preferred when considering patient satisfaction, keloid susceptibility, cosmesis, first Pfannenstiel incisions or cost. Staples were preferred when considering wound infections, obese patients, chorioamnionitis, HIV/AIDS or busy labor floors (p < 0.001).Conclusion: The limited evidence to guide cesarean skin closure forces obstetricians to rely on personal experience. Our survey indicates that despite this limitation, obstetricians have specific preferences for cesarean skin closure method.

Retrospective Review of Wound Complications Following Skin Closure by Either Percutaneous Metal Staples or Absorbable Subcuticular Staples in Patients Undergoing Cesarean Delivery

Objective: To determine the wound complication rate of patients undergoing cesarean delivery skin closure by either percutaneous metal staples or absorbable subcuticular staples in a large teaching hospital. Methods: This was a retrospective chart review of six hundred sixty patients who underwent cesarean delivery skin closure with either metal staples or absorbable staples. The primary outcome examined was the development of any wound complications. Results: Two hundred forty eight patients were eligible for analysis in the metal staple group compared to sixty-five patients in the absorbable staple group. A 7.7% wound complication rate was observed in the absorbable staple group compared to a 21.3% wound complication rate in the metal staple group. A statistical difference (p=0.01) was noted between the two groups. Body mass index between both groups were also statically different yielding 37 kg/m2 in the metal staple arm group versus 32 kg/m2 (p ≤ 0.001) in the absorbable staple group. Conclusion: Percutaneous metal staples were associated with more wound complications compared to absorbable subcuticular staples. Body mass index was greater in the percutaneous metal staple group as compared to the absorbable subcuticular staple group.

801: Diabetic status modifies the association of wound morbidity with staples as compared with subcuticular suture for cesarean skin closure

801: Diabetic status modifies the association of wound morbidity with staples as compared with subcuticular suture for cesarean skin closure