31.7.21 Wound Complications: Subcuticular Suture versus Skin Staples for Skin Closure after Caesarean Section

Original Article

 

Subcuticular Suture VS Skin Staples for Skin Closure after CS

Wound Complications: Subcuticular Suture versus Skin Staples for Skin Closure after Caesarean Section

Sabahat Zafar

ABSTRACT

Objective: To compare the frequency of wound infection with subcuticular suture versus skin staples for skin closure after caesarean section.

Study Design: Randomized controlled trial study.

Place and Duration of Study: This study was conducted at the Department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore from January 2014 to July 2014.

Materials and Methods: A total of 500 cases (250 cases in each group). Patients were randomly divided in two equal groups. Patients in Group A were stitched by subcuticular suture maternal while patients in group B were stitched with metal staples.

Results: In group A, mean gestational age was 38.60±1.23 weeks and in group B, 38.71±1.33 weeks. Regarding parity, 120 patients (48.0%) from group A and 127 patients (50.8%) from group B were having parity 0-2. In group A, 130 patients (52.0%) and in group B, 123 patients (49.2%) were para 3-5. Wound infection was observed in 18 patients (7.2%) and 36 patients (14.4%) in groups A and B, respectively. There was a statistically significant difference between two groups (p=0.009).

Conclusion: A significantly less wound infection with subcuticular suture when the cesarean delivery skin incision was closed with suture rather than with staples.

Key Word: Caesarean section, Subcuticular suture, Skin staples for skin closure

Citation of article: Zafar S. Wound Complications: Subcuticular Suture versus Skin Staples for Skin Closure after Caesarean Section. Med Forum 2020;31(7):88-91

 

 

INTRODUCTION

Caesarean section is one of the most common obstetric procedures, and  on an average, 20-25% of pregnancies are delivered by CS. However; the rising incidence of CS has also led to an increase in complications, which are now reported to occur in 2.5-16% of cases.1 Most of the major steps during cesarean section have been evaluated and evidence-based recommendations made to enhance best practice.2 With regards to skin closure, skin can be reaproximated by a subcuticular suture immediately below the skin or by staples.

Skin wounds are the only step of CS in which patients are able to see and evaluate. It can be distressing for patients if they can see that their CS wound has not healed appropriately and this can impact upon their quality of life.3

 

 

Clinical Fellow ST3+ Southend University Hospital, UK

 

 

Correspondence: Dr. Sabahat Zafar, Clinical Fellow ST3+ Southend University Hospital, UK.

Contact No: 00447424467932

Email: dr.sabahat18@gmail.com

 

 

Received:    January, 2020

Accepted:    May, 2020

Printed:        July, 2020

 

 

 

 

 

 

 

 

 

Ominously, the precise technique used for wound closure following CS is the only step in this common operation that is not supported by conclusive evidence. Consequently, there is significant debate as to which technique and material should be used for CS skin closure.4

There are many different techniques used to close skin wounds, including subcuticular stitches with absorbable or non-absorbable sutures, interrupted stitches, staples and skin adhesives.5 Staples and subcuticular stitches are the most popular techniques. The most commonly used sutures are synthetic polyfilament sutures made from polyglycolic acid (Dexon) or polyglactin (Vicryl). Surgeons generally select the closure method and material according to personal preference. Existing studies on the rate of complications, the degree of patient satisfaction and the cost-effectiveness of CS have not yet identified the best evidence-based recommendation for wound closure technique and material; furthermore, existing data are contradictory.4

Some studies report increased rates of postoperative pain with sutures, while others describe increased rates of postoperative pain with staples.6,7 Other papers show no difference in cosmetic outcome and patient satisfaction when comparing between staples and sutures,8 although some have shown improved cosmetic outcomes with sutures.9 Worryingly, wound separation data are also contradictory. Staples have been associated with a shorter procedural time than subcuticular sutures, but with a higher incidence of wound separation.10 The present study was conducted aimed to compare the frequency of wound infection with subcuticular suture versus skin staples for skin closure after caesarean section.

MATERIALS AND METHODS

This randomized controlled trial was conducted at Department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore from 10th January 2014 to 9th July 2014 and comprised 500 cases. They were divided in two equal groups; each group comprised 250. Patients in Group A were stitched by subcuticular suture maternal while patients in group B were stitched with metal staples. All the females of age 18-40 years at term (gestational age >36 weeks on USG) and parity < 6 were included. Maternal obesity BMI >35 and high risk females, pre-eclamptic, eclamptic women and women with gestational diabetes were excluded from this study. Demographic information (name, age, gestational age, parity and contact) of the patients were obtained. All surgeries were done by a single surgical team. Patients were remained in ward for 3 days and discharged after complete wound examination. Patients were asked to come after 10 days of caesarean section or report earlier if they develop two or more of these symptoms i.e. redness, fever (>100°C), pus and serous discharge in wound. Patients who developed wound infection were managed as existing unit guidelines. The data was analyzed by using SPSS version 20. Chi square test was applied to compare frequency of wound infection both groups. P value <0.05 was considered as significant.

RESULTS

One hundred seventy three (69.2%) patients in group A and 179 (75.6%) patients in group B were between 20-30 years old and 77 (30.8%) patients in group A and 71 (24.4%) patients in group B were between 31-40 years of age. Mean age was 28.22±4.91 and 28.01±4.72 in group A and B, respectively (Table 1). In group A, mean gestational age was 38.60±1.23 weeks and in group B, 38.71±1.33 weeks (Table-2).

Regarding parity, 120 patients (48.0%) from group A and 127 patients (50.8%) from group B were having parity 0-2. In group A 130 patients (52.0%) and in group B, 123 patients (49.2%) were para 3-5 (Table-3). Wound infection was observed in 18 patients (7.2%) and 36 patients (14.4%) in groups A and B respectively. There was a statistically significant difference between two groups (p=0.009) (Table-4).

Table No.1: Distribution of cases by age

Age (Year)

Group A

Group B

No.

%

No.

%

20-30

173

69.2

179

75.6

31-40

77

30.8

71

24.4

Mean±SD

28.22±4.91

28.01±4.72

Table No.2: Distribution of cases by gestational age

Gestational age (week)

Group A

Group B

No.

%

No.

%

37-38

138

55.2

132

52.8

39-41

112

44.8

118

47.2

Mean±SD

38.60±1.23

38.71±1.33

Table No.3: Distribution of cases by parity

Parity

Group A

Group B

No.

%

No.

%

Para 0-2

120

48.0

127

50.8

Para 3-5

130

52.0

123

49.2

Table No.4: Comparison of wound infection

Wound infection

Group A

Group B

No.

%

No.

%

Yes

18

07.2

36

14.4

No

232

98.8

214

85.6

Chi Square            =       6.73

P value            =          0.009

DISCUSSION

Cesarean section is one of the most performing surgical procedures in all over the world with high rate of complications such as wound infection, cosmetic complications, post-operative pain, fever etc.11 Many of surgical techniques have been applied to reduce the complications rate especially wound infection, because it may lead to severe morbidity after surgical intervention.12,13 The present study was conducted aimed to compare the prevalence of wound infection with subcuticular suture versus staples for skin closure after cesarean section. In this regard 500 women were analyzed and divided equally in to two groups. Majority of women in both groups A and B were ages between 20 to 30 years 69.2% and 75.6%, Mean age was 28.22±4.91 and 28.01±4.72 and mean gestational age was 38.60±1.23 weeks and 38.71±1.33 weeks. No significant difference was observed regarding age and gestational age between both groups. These results showed similarity to many of other studies in which majority 70% to 80% of women had ages 20 to 30 years and average gestational age was 37.5 weeks.14-16

In presents study wound infection was observed in 18 patients (7.2%) and 36 patients (14.4%) in groups A and B respectively. There was a statistically significant difference between two groups (p=0.009). A study conducted by Hasdemir et al17 reported no significant difference in term of wound complication was observed between absorbable and nonabsorbable suture techniques with p-value >0.05. However, a study conducted by Nayak et al18 regarding comparison of subcuticular suture versus staples in term of wound complications after cesarean sections and they demonstrated that staples skin closure technique had significantly higher incidence of wound complications 30% as compared to 8% in subcuticular suture with p-value 0.0001.

Al-kadri et al19 reported that patients in the subcuticular group (G2) had a risk of developing overall wound complications that was double that for the group of patients treated by staples (OR = 2.41; 95% CI: 1.17-4.98; p = 0.02). Zaki et al20 reported no significant difference between both techniques regarding frequency of wound complications, 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.

Some other previous studies showed similarity to our study findings regarding wound complications in which sutures demonstrated a better technique with lower rate of wound complications as compared to staples for skink closure after cesarean sections.21,22

CONCLUSION

We concluded a significantly less wound infection with subcuticular suture when the cesarean delivery skin incision was closed with suture rather than with staples.

Author’s Contribution:

Concept & Design of Study:

Sabahat Zafar

Drafting:

Sabahat Zafar

Data Analysis:

Sabahat Zafar

Revisiting Critically:

Sabahat Zafar

Final Approval of version:

Sabahat Zafar

Conflict of Interest: The study has no conflict of interest to declare by any author.

REFERENCES

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2.      Hofmeyer GJ, Mathai M, Shah AN, Novikova N. Techniques for caesarean section. Cochrane Database Systemic Rev 2008:1.

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4.      Basha SL, Rochon ML, Quinones JN, Coassolo KM, Rust OA, Smulian JC.  Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery.  Am J Obstet Gynecol 2010; 285.e1:e8.

5.      Rousseau JA, Girard K, Turcot-Lemay L, Thomas N. A randomized study comparing skin closure in cesarean sections: staples vs subcuticular sutures. Am J Obstet Gynecol 2009;200:265 el-4.

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7.      Gartner I, Burckhardt T, Beinder E. Scar appearance of different skin and subcutaneous tissue closure technique in the cesarean section: a randomized study. Eur J Obstet Geneon Report Boil 2008;13.

8.      Tuuli MG, Rampersad RM, Carbone JF, Stamilio D, Macones GA, Odibo OA. Staples compared with subcuticular sutures for skin closure after cesarean section: a systemic review and meta-analysis. Am Coll Obstet Gynecol 2011;117 (3): 682-90.

9.      Gartner G, Burckhardt T, Beinder E. Department of Obstetrics and Gynecology, Clinic of obstetrics, University hospital of Zurich, Frauenklinikster.CH-8091Zurich, Switzerland Eur J Obstet. Gynecol Reproductive Biol 138(2008): 29-33.

10.  Wang H, Hong S, Teng H, Qiao L, Yin H. Subcuticular sutures versus staples   for skin closure after cesarean delivery: a meta-analysis. J Matern Fetal Neonat Med 2016;29(22):3705-11.

11.  Nitsche J, Howell C, Howell T. Skin closure with subcuticular absorbable staples after cesarean section is associated with decreased analgesic use. Arch Gynecol Obstet 2012;285(4):979-83.

12.  The Joint Commission. Implementation guide for NPSG.07.05.01 on surgical site infections: the SSI change project. Available at: https://www.joint commission.org/assets/1/18/Implementation_Guide_for_NPSG_SSI.pdf. Accessed May 14, 2017.

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14.  Mackeen AD, Khalifeh A, Fleisher J. Suture compared with staple skin closure after cesarean delivery: a randomized controlled trial. Obstet Gynecol 2014;123:1169-75.

15.  Basha SL, Rochon ML, Quinones JN, Coassolo KM, Rust OA, Smulian JC. Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery. Am J Obstet Gynecol 2010; 203: e1-e8.

16.  Maged AM, Mohesen MN, Elhalwagy A, Abdelaal H, Almohamady, Abdellatif AA, et al. Subcuticular interrupted versus continuous skin suturing in elective cesarean section in obese women: a randomized controlled trial, J Mat Fetal Neonat Med 2019; 32:24, 4114-9.

17.  Hasdemir PS, Guvenal T, Ozcakir HT, Koyuncu FM, Dinc Horasan G, Erkan M, Oruc Koltan S.. Comparison of subcuticular suture materials in cesarean skin closure. Surg Res Pract 2015;2015:141203.

18.  Nayak GB, Saha PK, Bagga R, Joshi B, Rohilla M, Gainder S, Sikka P. Wound complication among different skin closure techniques in the emergency cesarean section: a randomized control trial. Obstet Gynecol Sci 2020;63(1):27-34.

19.  Al-Kadri H, Elsherif E, Khan L, Fillimban HM. A comparison of subcuticular and staple skin closure techniques for Caesarian Section: A randomized controlled trial in King Abdul-Aziz Medical City Riyadh Saudi Arabia. Int Res J Med Med Sci 2018; 10: 30918.

20.  Zaki MN, TruongM, Pyra M, Kominiarik MA, Irwin T, et al. Wound complications in obese women after cesarean: a comparison of staples versus subcuticular suture. J Perinatol 2016;36(10):819-22.

21.  Inoue K, Michiura T, Fukui J, Mukaide H, Ozaki T, Miki H, Kaibori M, et al. A randomized controlled trial of running versus interrupted subcuticular sutures for skin closure in open gastric surgery. Int Surg 2018; 103(5-6): 305-14.

22.  Tuuli MG, Rampersad RM, Carbone JF, Stamilio D, Macones GA, Odibo AO. Staples compared with subcuticular suture for skin closure after cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol 2011;117(3):682–90.