Recently published randomized trials examining skin closure technique on postcesarean wound complications have produced conflicting results. We performed a metaanalysis of trials comparing staples and subcuticular sutures for skin closure at cesarean section (CS). Pooled outcome measures were calculated using random effects models. Primary outcomes were rates of wound dehiscence (separation) and a composite wound complication rate. Secondary outcomes were patient satisfaction, operating time, and postoperative pain. A total of 877 women from 5 trials were included. Both wound separation (pooled odds ratio, 4.01; P < .0001) and composite wound complication (pooled odds ratio, 2.11; P = .003) rates were higher with staples. The use of staples reduced operating time (weighted mean difference, –5.05 minutes; P = .021). Data on postoperative pain and patient satisfaction were insufficient for metaanalysis. Our findings suggest a possible benefit with subcuticular sutures compared to skin staples for skin closure at CS. However, the optimal skin closure technique at CS demands further study.
The cesarean section (CS) was first described in Roman times but only at the start of the 20th century did it begin to offer acceptable morbidity and mortality for both mother and baby. It is now one of the most common surgical procedures performed globally and CS rates continue to increase. In England, for instance, 25% of all babies in 2009 were born via the abdominal route, compared to 19% 10 years previously. Similar rates are evident in the United States (31% in 2006). Over the past 50 years, evidence-based refinements have been made to surgical practice at CS, but there still remain many areas of contention regarding the optimal operative technique.
Wound complications are a major source of morbidity after CS and contribute to prolonged hospital stay and rates of readmission. Age, body mass index (BMI), length of incision, and timing of prophylactic antibiotic administration have all been associated with postcesarean surgical site infection (SSI). Duration of membrane rupture, a risk factor unique to the pregnant patient, also impacts on infection-related morbidity. However, the role of skin closure technique on wound complication rates in obstetrics is poorly studied.
Despite the recent emergence of tissue adhesives for wound closure, the principal debate surrounding skin closure at CS has been between skin staples and subcuticular (intracutaneous) sutures. This issue has been extensively studied in other surgical specialties but until very recently, there were limited data on which to base recommendations for CS. A 2008 Cochrane review identified only 1 small randomized trial on this issue with insufficient numbers on which to base any recommendations. Since then, several randomized trials addressing this issue have been published with conflicting conclusions. Although some studies have found no difference in wound outcomes by closure technique, others have shown staples to be the superior choice. In contrast, other randomized studies have concluded that sutures are the preferred closure material creating genuine clinical equipoise in this area. We present a metaanalysis of randomized controlled trials (RCT) examining skin closure technique at CS to provide practitioners with an evidence base for choosing the correct closure method for this common surgical procedure.
Materials and methods
This metaanalysis was conducted according to recommendations of the PRISMA statement. The PubMed, MEDLINE, and Cochrane Databases were searched in September 2010 for English-language articles without time restrictions. Combinations of the search terms “c(a)esarean,” “skin,” “closure,” “staples,” “sutures,” “randomis(z)ed,” and “technique” were used to identify eligible studies. This search was performed independently by 2 authors (F.S.H.C. and C.A.W.). Abstracts of the publications identified by the primary search were reviewed. In addition, online trial registries ( www.controlled-trials.com and www.clinicaltrials.gov ) were searched for eligible studies. Finally, abstracts from the annual meetings of the Society for Maternal-Fetal Medicine (SMFM), 2001 through 2009, were searched for suitable studies ( www.ajog.org/content/SMFM_supplements ).
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