1. Wound complications were less likely among women with incisions closed by sutures.
2. Skin closure with sutures required more time than staples.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Cesarean section (C-section) is an increasingly common obstetric procedure. Despite public health initiatives to decrease rates of primary and repeat Cesarean deliveries, Cesarean deliveries still represent nearly one third of all deliveries in the United States. While the safety of the procedure has improved over the years, it still represents a meaningful higher risk of morbidy and mortality compared to vaginal delivery. Prior studies have suggested that skin closure with sutures may be preferable to staples, with lower risk for wound complications and wound separation. Specifically, one large meta-analysis identified a lower risk for wound complications with suture skin closure but found that pain, cosmesis and patient satisfaction were similar and also that staple closure was associated with a shorter duration of surgery (see Relevant Reading). However, a 2011 survey of obstetricians showed that a majority of surgeons preferred to use staples and anecdotally, many obstetricians cite an increased risk for local skin reaction (e.g. granumola) when absorbable sutures are used to close the skin. The present work incorporated six new randomized controlled trials (RCTs) not included in earlier reviews. Authors evaluated pain perception, patient satisfaction, cosmesis, and operating time, in addition to wound complications. In line with previous studies, this study’s findings suggested that while slightly more time-consuming, closure with subcuticular absorbable sutures reduces the risk of wound complications.
Strengths of the study included meta-analysis of data exclusively from RCTs and specific evaluation of bias in each study. Limitations included variability in outcome data across the included studies. While there appears to be clinical data supporting the use of sutures over staples, detailed cost-effectiveness analyses are needed to best inform skin closure recommendations and guidelines. Further, prospective evaluation of wound complications and local skin reactions associated with staples compared to various types of suture (e.g. 4-0 vicryl or monocryl) are merited.
In-Depth [meta-analysis]: Systematic review of the literature identified RCTs that compared these methods of skin closure and synthesized available outcome data from 12 RCTs. The primary outcome of interest was wound complications and included infection, separation, hematoma, seroma or readmission for wound-related reasons. Secondary outcomes included pain perception, patient satisfaction, cosmesis (assessed by patients and providers) and operating time.
Women whose incisions were closed with delayed absorbable subcuticular suture were less likely to develop wound complications (RR 0.49, CI 0.28-0.87); this was true for both obese and non-obese patients. Women receiving sutures were also less likely to experience wound separation (RR 0.29, CI 0.20-0.43). Operating time was 7.20 minutes longer for skin closure with sutures compared to staples (p<0.01).
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