[Physician Comment] Suture closure superior to staples after cesarean delivery

Image: PD 

1. Suture closure following cesarean section offers significantly less morbidity than staple closure.

2. Although suture closure takes longer, it is economically and medically superior to staple closure.

This is one of the largest studies to show a significant benefit for sutured closure over staple closure following cesarean section. Overall, the study found that staple closure was associated with significantly higher rates of wound disruption and infection both at hospital discharge and follow-up as compared with suture closure. Although operative time was significantly longer with suture closure, there was no difference in pain, patient satisfaction, or cosmetic outcome.

The trial was stopped early because of indications that the incidence of wound morbidity was higher than previously expected and that suture closure was in fact beneficial. In addition, the study still found significant differences between the two groups, despite enrolling over 200 fewer subjects than initially planned. Given the personal and societal costs of cesarean section wound morbidities, the benefits of suture closure may outweigh the extra time the procedure takes.

Click to read the study in Obstetrics & Gynecology

Click to view this study on Clinicaltrials.gov

Study author Dr. Alan T. N. Tita, MD, PhD, talks to 2 Minute Medicine: Assistant professor of Obstetrics and Gynecology, University of Alabama at Birmingham

“Health workers need to be aware of these findings because they add to the accumulating evidence suggesting that although the use of subcuticular suture as compared with staples for cesarean wound closure slightly prolongs the operative time, it significantly reduces the frequency of wound complications (including breakdown) that may take weeks to heal. Since leaving the staples longer than the 3-4 days allowed in the trial is of uncertain benefit (and unlikely to reduce wound complications to levels lower than observed with sutures) but will involve a supplementary clinic visit, many obstetric providers and patients will likely prefer suture.”

Primer: In the United States, one in three women deliver infants by cesarean section, which is currently the most common major surgical procedure preformed. Despite this, operative techniques and materials have not been standardized (1,3). Key reasons why a cesarean delivery may be performed include infant positioning or size, delayed labor, complications during labor, multiple gestations, maternal request, or previous C-section (1,2,3).

After an epidural and spinal block, an incision is made in the lower abdomen through the skin and the uterus. Once the infant and placenta have been removed, the uterus is closed with either absorbable subcutaneous surgical sutures or non-absorbable metal staples. There are pros and cons to each method—staples are easier to place but significantly more expensive where as sutures take time and fine skills—although there is currently little conclusive evidence pointing one way or another (2,3).

Although it may be medically necessary, it is important to remember that a cesarean delivery is still a surgical procedure and thus holds the same inherent risks to the mother as any other surgery. The most common complications include wound infection, wound disruption, hemorrhage, damage to internal organs and complications with future pregnancies (2,4).

This study set out to evaluate the risks of wound disruption or infection after cesarean wound closure with surgical staples versus absorbable suture.

Background reading:

1. Up-to-date: C-section (Beyond the basics).
2. Up-to-date: Cesarean delivery, technique.
3. The Cochrane Library: Techniques and materials for skin closure in caesarean section.
4. Wound complications after cesarean sections.

This [randomized controlled] trial: Women were randomized at the time of incision closure to either surgical metallic staples (n=198) or 4-0 Monocryl absorbable subcuticular sutures (n=200). Wounds were evaluated at hospital discharge (3-4 days postop) and postpartum examinations (4-6 weeks post-op).

Of the women closed with staples, 7.1% were found to have either infection or wound disruption at hospital discharge, compared to 0.5% in the sutures group (p<0.001). At the 4-6 week follow-up the incidence was 14.5% in the staple group and 5.9% in the suture group (p=0.008). These results remained after adjustment for BMI and prior C-section. Median total operative time was significantly in the suture group as compared with the staples group (58 min vs. 48 min).

In sum: This is one of the largest studies to show a significant benefit for sutured closure over staple closure following cesarean section. Overall, the study found that staple closure was associated with significantly higher rates of wound disruption and infection both at hospital discharge and follow-up as compared with suture closure. Although operative time was significantly longer with suture closure, there was no difference in pain, patient satisfaction, or cosmetic outcome.

The trial was stopped early because of indications that the incidence of wound morbidity was higher than previously expected and that suture closure was in fact beneficial. In addition, the study still found significant differences between the two groups, despite enrolling over 200 fewer subjects than initially planned. Given the personal and societal costs of cesarean section wound morbidities, the benefits of suture closure may outweigh the extra time the procedure takes.

Click to read the study in Obstetrics & Gynecology

Click to view this study on Clinicaltrials.gov

By [MS] and [LH]

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