#Grand Rounds

Suture or Staple for Tertiary or Higher-Order C-Section Closure?

BACKGROUND AND PURPOSE:

Data supports skin closure for cesarean sections with subcuticular suture rather than staples
Fox et al. (Obstet Gynecol., 2018) compared wound complications in women who received suture vs staple closure technique during tertiary or higher-order C-section

Retrospective cohort study
Participants: Women undergoing tertiary or higher-order C-sections
Cohorts not overlapping
- Prior to 2011 standard was staple closure, with suture closure beginning in spring of 2011
Patients received
- Appropriate prophylactic antibiotics
- Group practice is to close all layers (including peritoneum and rectus muscles)
- Closure of subcutaneous tissue if ≥2 cm
- Postop subcutaneous heparin if BMI >40
Decision of staples vs suture left to surgeon’s discretion
Staples: Removed postop day 4-7
Sutures: Running subcuticular suture of either 3-0 poliglecaprone (Monocryl) or 4-0 polyglactin (Vicryl) suture
- Wound closure strips removed 2 weeks later
Primary outcome: Wound complication, defined as
- Wound infection requiring antibiotics or
- Wound separation requiring wound packing or
- Reclosure any time up to 6 weeks after delivery

551 patients were involved in the study
- 192 (34.8%) received staple closure
- 359(65.2%) received suture closure
Suture closure was associated with a lower rate of wound complication (P=0.003)
- Suture: 4.7% (95% CI 3.0%-7.5%)
- Staple: 11.5% (95% CI 7.7%-16.7%)
Suture closure remained independently associated with a lower risk of a wound complication even after controlling for number of prior C-sections and participation of a resident in the closure
- Adjusted odds ratio 0.44 (95% CI 0.23-0.86)
Suture closure was associated with
- Longer operative time of approximately 10 minutes
- Shorter hospital stay (3 vs 4 days)

Suture closure is associated with an approximately 50% lower risk of wound complication (separation or infection) in women receiving a tertiary or higher-order C-section
These data are in keeping with similar results for first or second cesarean section (see ‘Related ObG Topics’ below)

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