Composite Wound Complications Research Articles

Subcuticular skin closure at cesarean delivery with poliglecaprone-25 vs polyglactin-910: a randomized controlled trial

Cesarean delivery is a commonly performed surgical procedure worldwide. There is limited good-quality evidence regarding subcuticular skin closure with absorbable sutures in transverse incisions after cesarean delivery. This study aimed to compare poliglecaprone-25 (3-0) and polyglactin-910 (4-0) sutures for subcuticular skin closure in Pfannenstiel incisions among women undergoing cesarean delivery. In this double-blind, single-center, randomized controlled trial among women undergoing cesarean delivery (elective and emergency), 200 women were randomized (Group 1-subcuticular skin closure with poliglecaprone-25 [3-0] vs Group 2-subcuticular skin closure with polyglactin-910 [4-0]). All women received similar preoperative and postoperative care. A sample size of 200 women was selected with the aim of reducing the composite wound complication rate from 15.8% to 3.6% with a power of 0.80 and a 2-tailed α of 0.05. Thus, 90 women were required in each group, but 100 were selected to account for attrition. Composite wound complications (including surgical site infection, hematoma, seroma, need for resuturing or readmission for wound complications) were similar in the 2 groups (Group 1 vs 2: 16 vs 10; P=.293; relative risk, 1.28; 95% confidence interval, 0.91-1.79). Surgical site infection (8 vs 7; P=1.000; relative risk, 1.08; 95% confidence interval, 0.64-1.83), hematoma (1 vs 2; P=.561; relative risk, 0.66; 95% confidence interval, 0.13-3.31), seroma (8 vs 2; P=.052; relative risk, 1.65; 95% confidence interval, 1.17-2.33), need for resuturing (4 vs 3; P=.700; relative risk, 1.15; 95% confidence interval, 0.60-2.22), and need for readmission (4 vs 4; P=1.000) were similar in the 2 groups. Pain score on the visual analog scale at 3 days (3.2±1.0 vs 3.6±1.2) and 6 weeks after operation (1.6±0.8 vs 1.7±0.9;) was significantly lower in Group 1 (P=.023 and P=.033, respectively). There was no difference between observer and patient scar assessment scores measured at 6 weeks after operation (P=.069 and P=.431, respectively). Poliglecaprone-25 (3-0) and polyglactin-910 (4-0) subcuticular sutures were comparable regarding composite wound complications (surgical site infection, hematoma, seroma, wound separation or re-suturing, need for readmission) and cosmetic appearance (patient scar assessment score & observer scar assessment score) related to skin closure among women undergoing cesarean delivery through a Pfannenstiel incision in nonobese women (average body mass index, 25).

Feeding Jejunostomy Tube in Patients Undergoing Esophagectomy: Utilization and Outcomes in a Nationwide Cohort.

Feeding jejunostomy (JT) tubes are often utilized as an adjunct to optimize nutrition for successful esophagectomy; however, their utility has come into question. The aim of this study was to evaluate utilization and outcomes associated with JTs in a nationwide cohort of patients undergoing esophagectomy. The NSQIP database was queried for patients who underwent elective esophagectomy. JT utilization was assessed between 2010 and 2019. Post-operative outcomes were compared between those with and without a JT on patients with esophagectomy-specific outcomes (2016-2019), with results validated using a propensity score-matched (PSM) analysis based on key clinicopathologic factors, including tumor stage. Of the 10,117 patients who underwent elective esophagectomy over the past decade, 53.0% had a JT placed concurrently and 47.0% did not. Utilization of JTs decreased over time, accounting for 60.0% of cases in 2010 compared to 41.7% in 2019 (m = - 2.14 95%CI: [- 1.49]-[- 2.80], p < 0.01). Patients who underwent JT had more composite wound complications (17.0% vs. 14.1%, p = 0.02) and a higher rate of all-cause morbidity (40.4% vs. 35.5%, p = 0.01). Following PSM, 1007 pairs were identified. Analysis of perioperative outcomes demonstrated a higher rate of superficial skin infections (6.1% vs. 3.5%, p = 0.01) in the JT group. However, length of stay, reoperation, readmission, anastomotic leak, composite wound complications, all-cause morbidity, and mortality rates were similar between groups. Among patients undergoing elective esophagectomy, feeding jejunostomy tubes were utilized less frequently over the past decade. Similar perioperative outcomes among matched patients support the safety of esophagectomy without an adjunct feeding jejunostomy tube.

Standard-Dose Azithromycin in Class III Obese Patients Undergoing Unscheduled Cesarean Delivery.

Perioperative antibiotic prophylaxis reduces cesarean wound complications. This study investigates whether integration of standard-dose (500 mg) azithromycin prophylaxis reduced wound complications in patients with class III obesity (body mass index [BMI] ≥ 40 kg/m2) undergoing unscheduled cesarean delivery. Retrospective cohort study of patients with class III obesity undergoing unscheduled cesarean delivery in single hospital system from January 1, 2017, to January 1, 2020. A standard dose (500 mg) of azithromycin was integrated into system order sets in 2018. Medical history and postoperative wound outcomes were compared in pre- and postintegration cohorts. Wound complication was defined as composite of wound seroma, hematoma, superficial or deep infection. A total of 1,273 patients met inclusion criteria, 303 patients in the preorder set group, and 970 patients in the postorder set group. Demographics were similar between the pre- and postintegration cohorts, including BMI (median: 44.4 kg/m2, p = 0.84) and weight at delivery (mean: 121.2 ± 17.8 kg, p = 0.57). Patients in the postintegration cohort had lower rates of composite postpartum wound complication (7.9 vs. 13.9%, p = 0.002), superficial infection or deep infection/abscess (6.7 vs. 10.2%, p = 0.042), and postpartum readmission or unscheduled visits (18.7 vs. 24.4%, p < 0.029). Rates of chorioamnionitis and endometritis were similar between the pre- and postintegration groups (8.6 vs. 6.9%, p = 0.33, and 1.7 vs. 1.9%, p = 0.81, respectively). Patients in the postintegration cohort had lower risk of postoperative composite wound complication (unadjusted odds ratio [OR]: 0.54, confidence interval [CI]: 0.36-0.80, p = 0.002) and lower rates of wound infection (unadjusted OR: 0.63, 95% CI: 0.40-0.99, p = 0.044). When comparing patients who received azithromycin at delivery and patients who did not, standard-dose azithromycin reduced risk of postoperative wound complication (unadjusted OR: 0.67, 95% CI: 0.46-0.99, p = 0.043). A standard dose of azithromycin provides adequate perioperative prophylaxis in class III obese patients, decreasing rates of postcesarean wound complications and unscheduled postpartum outpatient visits. · Class III obese patients undergoing unscheduled cesarean have high rates of wound complications.. · Standard-dose azithromycin reduces risk of postcesarean wound infection in class III obese patients.. · Standard-dose azithromycin reduces readmission, unscheduled visits in class III obese patients..

Letter to the editor regarding the article by Elhage et al.: "Closed-incision negative pressure therapy at -125 mmHg significantly reduces surgical site complications following total hip and knee arthroplasties: A stratified meta-analysis of randomized controlled trials".

Letter to the editor regarding the article by Elhage et al.: "Closed-incision negative pressure therapy at -125 mmHg significantly reduces surgical site complications following total hip and knee arthroplasties: A stratified meta-analysis of randomized controlled trials".

Wound complications after simple vulvar excisions for premalignant and malignancy lesions: A National Surgical Quality Improvement Program database study (409)

Wound complications after simple vulvar excisions for premalignant and malignancy lesions: A National Surgical Quality Improvement Program database study (409)

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.

Wound complications following vulvar excision for nonmalignant lesions

BACKGROUNDThere is a paucity of literature regarding the outcomes following vulvar excision for nonmalignant lesions. This is a common procedure among gynecologists and gynecologic oncologists, and a body of evidence is warranted to guide clinical care and future research.OBJECTIVEThis study aimed to estimate the rate of wound complications following simple vulvar excision and to identify the risk factors for these outcomes. Our secondary objectives were to determine the rates of (1) positive margins and (2) occult carcinoma in the cases of vulvar dysplasia.STUDY DESIGNWe conducted a single-institution, retrospective cohort study of the patients who underwent simple vulvar excision procedures for suspected premalignant or benign lesions between June 2016 and February 2020. Our primary outcome was the rate of composite wound complications, including wound separation or breakdown, infection, or hematoma. Our secondary outcomes were the incidence of (1) margins positive for residual dysplasia and (2) occult minimally invasive carcinoma. The Fisher exact tests and chi-squared tests were used to compare the categorical variables and logistic regression models and independent student t tests were used for continuous variables, as appropriate. Multivariate stepwise selection and multiple logistic regression was performed to evaluate the risk factors for complications and generate the odds ratios.RESULTSOf the 338 patients included in the study, 143 (42.3%) experienced wound complication. Most of these complications were wound separation or breakdown (n=134, 39.6%), followed by infection (n=22, 6.5%), and hematoma (n=4, 1.2%). On multivariate analysis, the presence of high-grade vulvar dysplasia (adjusted odds ratio, 1.83; 95% confidence interval, 1.06–3.15), longer specimen diameter (adjusted odds ratio, 1.03; 95% confidence interval, 1.01–1.05), and lesion location on the perineum (adjusted odds ratio, 2.25; 95% confidence interval, 1.38–3.66) were independent risk factors. With high-grade vulvar dysplasia, the rate of positive margins was 50.2% (114/227) and that of occult microinvasive carcinoma was 17.2% (39/227). Notably, the primary and secondary outcomes were similar among gynecologic oncologists and gynecologists.CONCLUSIONWound complications following vulvar excision for nonmalignant lesions are common. Select groups may benefit from anticipatory counseling and future interventional studies to prevent complication. The incidence of positive surgical margins and occult minimally invasive carcinoma is also high, reflecting the challenging nature of treating vulvar disease.

Risks factors FOR wound complications after cesarean section

ObjectiveThe primary outcome was to determine risks factors for wound complications after cesarean section. Secondary outcome was the management of these complications. Study DesignWe performed a retrospective cohort study of consecutive cesarean deliveries performed at a secondary care facility between June 2017 and June 2019. Composite wound complications included infection, disruption and fluid collection occurring 30 days post-operatively. Medical records were reviewed and data including patient demographics, comorbidities, intra-partum characteristics were evaluated as potential risk factors for wound complications using multivariate logistic regression. Secondarily, post-operative management of wound complications was described. ResultsAmong 1520 patients undergoing cesarean section during the period of study, 67 developed wound complications (4.4 %). Mean Duration of local wound care was 41.35 days (2–95). Mean number of wound care related visits in our hospital was 4.85(1–11). Multivariate logistic regression analysis showed 2 significant independant risk factors: preeclampsia with OR 5.60, 95 % CI 2.83, 11.11 (p:<0.001), and premature rupture of the membranes with OR 9.76, 95 % CI 2.13, 44.77 (p: 0.003). ConclusionPreeclampsia and premature rupture of the membrane were independent risk factors for wound complications after cesarean section. Information regarding higher rates of wound complications and preventive measures should be provided to high-risk women prior to surgery.

Cesarean wound closure in body mass index 40 or greater comparing suture to staples: a randomized clinical trial

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. 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. 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. 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). 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.

The Association of Cesarean Skin Incision Length and Postoperative Wound Complications.

This study was aimed to evaluate the relationship between cesarean skin incision length and wound complications. Planned secondary analysis of a multicenter double-blind randomized trial of adjunctive azithromycin versus placebo (in addition to standard cefazolin) in women ≥24 weeks undergoing cesarean delivery during labor or ≥4 hours after membrane rupture. Skin incision length (cm) was measured just prior to skin closure. The primary outcome was a composite of wound complications (wound infection, separation, seroma, hematoma, or dehiscence) up to 6 weeks of postpartum. Individual components of the composite were examined as secondary outcomes. Outcomes were compared between groups defined by the lowest (≤25th), middle (25-75th) and highest (>75th) incision length quartiles. Logistic regression was used to adjust for potential confounding variables. Of the 2,013 women enrolled in the primary trial, 1,916 had recorded incision lengths and were included in this secondary analysis. The overall rate of composite wound complications was 7.8%. Median incision length was 15.0 cm (interquartile range: 14.0-16.5) with the lowest quartile defined as ≤14, middle as >14 to ≤16.5, and highest as >16.5 cm. Mean BMI, parity, use of staples, and duration of surgery differed significantly between the three incision length groups. In unadjusted analysis, the longest incision lengths were associated with an increased risk of the wound composite and wound infections (odds ratio [OR] = 2.27, 95% confidence interval [CI]: 1.43-3.60 and OR = 2.30, 95% CI: 1.27-4.15, respectively) compared with the shortest incision lengths. However, after multivariable adjustments, these associations were nullified. Additional analyses considering incision length as a continuous variable and using 10th/90th percentile cut-offs still did not suggest any associations with outcomes. Increasing skin incision length is not independently associated with an increased risk of postoperative wound complications. · After multivariable adjustments, skin incision length was not independently associated with an increased risk of postoperative wound complications.. · A reasonable incision length needed to safely perform the procedure should be used..

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.

Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. This is an update of a Cochrane Review first published in 2010 and subsequently updated in 2012, twice in 2014, in 2017 and 2018. To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We also assessed the side effects of vaginal cleansing solutions to determine adverse events associated with the intervention. We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (7 July 2019), and reference lists of retrieved studies. We included randomized controlled trials (RCTs) and quasi-RCTs assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. Cluster-RCTs were eligible for inclusion, but we did not identify any. We excluded trials that utilized vaginal preparation during labor or that did not use antibiotic surgical prophylaxis. We also excluded any trials using a cross-over design. We included trials published in abstract form only if sufficient information was present in the abstract on methods and outcomes to analyze. At least three of the review authors independently assessed eligibility of the studies. Two review authors were assigned to extract study characteristics, quality assessments, and data from eligible studies. We included 21 trials, reporting results for 7038 women evaluating the effects of vaginal cleansing (17 using povidone-iodine, 3 chlorhexidine, 1 benzalkonium chloride) on post-cesarean infectious morbidity. Trials used vaginal preparations administered by sponge sticks, douches, or soaked gauze wipes. The control groups were typically no vaginal preparation (17 trials) or the use of a saline vaginal preparation (4 trials). One trial did not report on any outcomes of interest. Trials were performed in 10 different countries (Saudi Arabia, Pakistan, Iran, Thailand, Turkey, USA, Egypt, UK, Kenya and India). The overall risk of bias was low for areas of attrition, reporting, and other bias. About half of the trials had low risk of selection bias, with most of the remainder rated as unclear. Due to lack of blinding, we rated performance bias as high risk in nearly one-third of the trials, low risk in one-third, and unclear in one-third. Vaginal preparation with antiseptic solution immediately before cesarean delivery probably reduces the incidence of post-cesarean endometritis from 7.1% in control groups to 3.1% in vaginal cleansing groups (average risk ratio (aRR) 0.41, 95% confidence interval (CI) 0.29 to 0.58; 20 trials, 6918 women; moderate-certainty evidence). This reduction in endometritis was seen for both iodine-based solutions and chlorhexidine-based solutions. Risks of postoperative fever and postoperative wound infection are also probably reduced by vaginal antiseptic preparation (fever: aRR 0.64, 0.50 to 0.82; 16 trials, 6163 women; and wound infection: RR 0.62, 95% CI 0.50 to 0.77; 18 trials, 6385 women; both moderate-certainty evidence). Two trials found that there may be a lower risk of a composite outcome of wound complication or endometritis in women receiving preoperative vaginal preparation (RR 0.46, 95% CI 0.26 to 0.82; 2 trials, 499 women; low-certainty evidence). No adverse effects were reported with either the povidone-iodine or chlorhexidine vaginal cleansing. Subgroup analysis suggested a greater effect with vaginal preparations for those women in labour versus those not in labour for four out of five outcomes examined (post-cesarean endometritis; postoperative fever; postoperative wound infection; composite wound complication or endometritis). This apparent difference needs to be investigated further in future trials. We did not observe any subgroup differences between women with ruptured membranes and women with intact membranes. Vaginal preparation with povidone-iodine or chlorhexidine solution compared to saline or not cleansing immediately before cesarean delivery probably reduces the risk of post-cesarean endometritis, postoperative fever, and postoperative wound infection. Subgroup analysis found that these benefits were typically present whether iodine-based or chlorhexidine-based solutions were used and when women were in labor before the cesarean. The suggested benefit in women in labor needs further investigation in future trials. There was moderate-certainty evidence using GRADE for all reported outcomes, with downgrading decisions based on limitations in study design or imprecision. As a simple intervention, providers may consider implementing preoperative vaginal cleansing with povidone-iodine or chlorhexidine before performing cesarean deliveries. Future research on this intervention being incorporated into bundles of care plans for women receiving cesarean delivery will be needed.

Wound complication among different skin closure techniques in the emergency cesarean section: a randomized control trial.

ObjectiveCesarean 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.MethodsPatients 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.ResultsThe 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).ConclusionThe use of staples for cesarean section skin closure is associated with an increased risk of wound complications and prolonged hospital stay postoperative visits.

Wound Complication Rates After Vulvar Excisions for Premalignant Lesions.

To assess the rate of wound complications and evaluate the effectiveness of antibiotic prophylaxis in vulvar wide local excision procedures. We performed a single-institution, retrospective cohort study of women undergoing vulvar surgery for premalignant lesions between January 2007 and January 2017. The primary outcome was a composite wound complication rate that included breakdown or infection within 8 weeks postoperatively. Data were analyzed using Fisher exact or χ test, Student t-test, and Poisson regression. Wound complications occurred in 154 (28.7%) of the 537 patients. Mean age was 52 years; most patients were white (83.1%), cigarette smokers (65.2%), had no prior vulvar treatment (54.4%), and had a preoperative diagnosis of high-grade squamous intraepithelial lesion (vulvar HSIL) (70.0%). The presence of other predisposing factors was similar between groups. In multivariate analysis, smoking (odds ratio [OR] 1.64, 95% CI 1.14-2.38) and primary rather than repeat vulvar surgery (OR 1.99, 95% CI 1.31-3.01) were associated with increased risk for wound complications. There was no significant difference in wound complications between women who received preoperative antibiotics and those who did not (30.4% vs 27.4%, P=.45), although the mean length of wound separation in the antibiotic group was shorter (1 vs 2 cm, P=.03). Wound complications are common among women undergoing surgery for vulvar HSIL, and interventional trials are warranted to evaluate the role of smoking cessation and prophylactic antibiotics to reduce postoperative morbidity.

Effect of intra-operative glove changing during cesarean section on post-operative complications: a randomized controlled trial.

To compare the rates of wound-related complications among women undergoing a cesarean section when the surgical team used intra-operative glove changing versus usual care. All women undergoing a cesarean section at a single, county hospital were randomized to usual care or intra-operative glove changing prior to abdominal closure. Participants were randomized at the time of decision for cesarean section; surgeons were not blinded to the randomization arm. The primary outcome was any wound-related complication, including wound hematoma, seroma, skin separation of at least 1cm, wound infection, or other incisional abnormality requiring treatment within 8weeks of surgery. To detect a reduction in the primary outcome from 17% in the control group to 9% in the intervention group with 80% power, a total of 554 women (277 per group) were required. Secondary outcomes included other infectious complications including endometritis and other superficial or deep soft tissue infections. From August 2015 to November 2016, 277 women were randomized to usual care and 276 women were randomized to intra-operative glove changing. The two groups were well balanced in terms of demographic data, comorbid conditions and surgical characteristics. Intra-operative glove changing led to a significant decrease in composite wound complications from 13.6% in the control group to 6.4% in the intervention group (p = 0.008). Intra-operative glove changing prior to abdominal closure during cesarean section significantly reduced the incidence of post-operative wound complications.

Comparison of staples vs subcuticular suture in class III obese women undergoing cesarean: a randomized controlled trial

Obesity is a risk factor for infectious morbidity and wound complications after cesarean delivery. There are currently insufficient data to determine optimal skin closure technique for cesarean delivery, specifically for those women with class III obesity, defined as a body mass index ≥40 kg/m2. We sought to compare stainless steel staples vs subcuticular suture for skin closure for cesarean delivery in class III obese women with body mass index ≥40 kg/m2. We conducted a randomized controlled trial at 2 teaching hospitals from 2015 through 2016 in which women with body mass index ≥40 kg/m2 undergoing cesarean delivery were randomly assigned to stainless steel staples or subcuticular suture skin closure. The primary outcome was composite wound complication defined as superficial or deep separation and infection occurring up to 6 weeks following delivery. Secondary outcomes included operative time, and patient pain and satisfaction scores. A total of 242 women were enrolled. In all, 119 in the staples group and 119 in the subcuticular suture group were analyzed. Maternal demographics and characteristics were similar in both groups. The composite wound complication frequency was 19.3% in the staples group and 17.6% in the subcuticular suture group (P= .74) with an overall wound complication incidence of 18.5% in the entire study cohort. There were also no differences in the frequencies of infection, or in superficial or deep wound separation between the 2 study groups. In a univariate analysis of predictors of wound complications, only current tobacco use was a significant predictor of wound complications (relative risk, 4.97; 95% confidence interval, 1.37-18.03; P= .02). Fewer women with staple closure would choose the same method with a future delivery (P= .01), however, self-reported pain and concern about wound healing were equal between the 2 groups. In class III obese women undergoing cesarean delivery, there was no difference in composite wound outcome up to 6 weeks postpartum between those who had staples and those who had subcuticular suture skin closure.

Effect of Intra-Operative Glove-Changing During Cesarean on Post-Op Complications: A Randomized Controlled Trial [12OP

INTRODUCTION: An increasing body of literature suggests that vaginal floral bacteria contribute to post-operative infectious morbidity when introduced to normally sterile environments during cesarean section. Surgeon's gloves, exposed to the lower genitourinary tract during delivery of an infant, may be an important vehicle of bacteria to the abdominal wall. Changing gloves during cesarean prior to abdominal wall closure may decreased bacterial transfer to the wound bed and therefore the incidence of wound complications following cesarean section. METHODS: This is a randomized controlled trial. Women undergoing non-emergent cesarean section were randomized to control conditions or intra-operative glove-changing, which entailed surgeons changing outer sterile gloves prior to abdominal closure. The primary outcome is composite wound complications, defined as the occurrence of seroma, hematoma, wound infection, skin separation of at least 1cm, or other incisional separation or abnormality requiring a bedside procedure Enrollment of 554 patients provides 80% power to detect a 50% reduction in the primary outcome from the approximately 15% incidence noted in the first 100 control subjects studied during a planned interim analysis. RESULTS: Of the first 409 patients analyzed, a significant reduction in composite wound complications is observed in the glove-changing group (11/185, 5.9%) compared to the control group (29/224, 12.9%), with p-value 0.018. At time of this submission, there are 145 subjects remaining to analyze, estimated to complete by December 2016. CONCLUSION: Preliminary analysis of this nearly completed randomized controlled trial indicates a trend toward reduction of composite wound complications following cesarean section when gloves are changed prior to abdominal closure.

Effect of skin coverage method following subcuticular suturing on wound infection rates at cesarean delivery

Objective: The objective of this study was to determine whether the use of cyanoacrylate skin glue following subcuticular skin closure was associated with a decrease in wound outcomes in comparison with subcuticular closure plus Steri-strips at cesarean delivery.Methods: This was a retrospective cohort study of patients undergoing cesarean delivery at a single center over a two-year period. The primary outcome of wound infection and secondary outcomes of wound separation and composite wound complication rate were assessed throughout the six-week postpartum period.Results: Of 660 women who met inclusion criteria, 35 (5.3%) experienced a wound infection and 90 (13.6%) experienced a wound separation. The composite wound complication rate was 16.4% (n = 108). Of the 515 cases with a skin coverage method noted, use of skin glue was associated with a marginal decrease in wound infections (p = 0.057), as well as a significantly reduced incidence of wound separation (p = 0.03) and composite wound complications (p = 0.006).Conclusion: Cyanoacrylate skin glue may be superior to Steri-strips for wound separation and composite wound complication rates when utilized with subcuticular suture at the time of cesarean delivery and may yield some benefit for prevention of wound infection.

Incidence of wound complications in cesarean deliveries following closure with absorbable subcuticular staples versus conventional skin closure techniques

ObjectiveTo determine if there is a significant difference in composite wound complications among traditional closure techniques versus absorbable subcuticular staple closure. Study designThis study is a retrospective cohort study of cesarean sections performed from January through September of 2014. Composite wound complications included surgical site infection, separation, and fluid collection. Medical records were reviewed and data including the patient demographics, comorbidities, closure type and wound complications were recorded. Patients with incomplete data were excluded. Data were analyzed with ANOVA or Fisher exact test, according to data type. ResultsOf the 186 patients identified, 176 patients were included in the data analysis (n=83 suture, n=49 traditional staple, n=44 the absorbable subcuticular staple). The groups were similar in all demographic categories; labor prior to delivery, estimated blood loss, and medical and pregnancy related comorbidities. The overall incidence of wound complications at our institution during this study was 5.7%. The incidence of complications among the suture and subcuticular staple closure was not significantly different (3.6% versus 0%, p=0.3), however there were significantly less complications in the suture and subcuticular staple closure groups when compared to traditional staple closure (14.3%) (p=0.03 and p=0.01, respectively). ConclusionHerein, we report a decreased incidence of composite wound complications with subcuticular staple closure versus traditional staple closure in patients undergoing cesarean section. Absorbable subcuticular staple closure represents a convenient, safe and cost-effective closure technique.

Role of subcutaneous closure in preventing wound complications after cesarean delivery with Pfannenstiel incision: a randomized clinical trial.

The aim of this study was to evaluate the role of suture closure of the subcutaneous tissue in preventing wound complications after cesarean section with a Pfannenstiel incision, and to investigate factors associated with wound complications. Patients undergoing cesarean delivery were randomly assigned to either suture closure or non-closure of the subcutaneous tissue. The participants were invited to two follow-up examinations at the 1st and 4th postoperative weeks for the detection of wound complications. The two main outcomes were composite wound complication and superficial wound separation. Factors associated with wound complications were analyzed using multiple logistic regression. During the study period, a total of 361 patients (176 in the closure group, 185 in non-closure group) were analyzed. Composite wound complication occurred in 23.3% (41/176) of the closure group, and in 20% (37/185) of the non-closure group with no significant difference (P = 0.44). Wound separation occurred in 2.3% (4/176) of the closure group and 1.6% (3/185) of the non-closure group without any significant differences (P = 0.64). None of the factors were found to be associated with the rate of composite complication. The significant factors found to be associated with wound separation were subcutaneous tissue thickness of 4 cm or more (P = 0.01) and maternal diabetes mellitus (P = 0.01), however they lost their significance in multivariate analyses. The rate of wound complications, including superficial wound separation, did not differ according to the subcutaneous closure in cesarean delivery with Pfannenstiel incision. It is not possible to predict wound complications using previously defined clinical and operative risk factors, including subcutaneous tissue thickness.