Subcutaneous tissue approximation in relation to wound disruption after cesarean delivery in obese women. Subcutaneous drain vs. suture in obese women undergoing cesarean delivery. A prospective, randomized trial. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery. Closure of the subcutaneous dead space and wound disruption after Cesarean delivery. Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery. Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized clinical trial.
To test the hypothesis that closure of the subcutaneous fat decreases the incidence of wound disruption after cesarean delivery.
                Two hundred forty-five women with at least 2 cm of subcutaneous fat were randomized to closure of the Camper fascia or no closure with cesarean delivery.
                Complications leading to disruption or opening of the incision were classified as wound seromas in 28 women (11.4%) and as wound infections in 17 (7.0%). The relative risk (RR) of seroma formation in the subcutaneous closure group was 0.3 with a 95% confidence interval (CI) of 0.1-0.7 (5.1 versus 17.2%), a statistically significant difference. There was no significant difference in the incidence of wound infections in the two study groups. Overall, there was a significant difference in the incidence of wound disruption from all causes between the two groups: 14.5% in the subcutaneous closure group compared with 26.6% when the subcutaneous tissues were not reapproximated (RR 0.5, 95% CI = 0.3-0.9).
                Closure of the subcutaneous tissue can significantly reduce the rate of postoperative wound disruption in women with at least 2 cm of subcutaneous adipose tissue. To determine if subcutaneous drain or closure of the subcutaneous layer decreases the incidence of wound complications in obese women undergoing cesarean delivery.
                Seventy-six obese women undergoing cesarean delivery and with at least 2 cm of subcutaneous fat were randomized to one of three groups: group 1 had suture closure of the subcutaneous tissue, group 2 had placement of a subcutaneous closed suction drain, and group 3 had neither suture closure nor drainage.
                Wound separation occurred in 12 (15.8%), seroma in 5 (6.6%) and infection in 3 (4%). There were no reports of wound hematoma. The overall incidence of any wound complication (infection, separation, seroma, hematoma) was higher in obese women who received neither subcutaneous suture nor drain as compared to obese women who received either subcutaneous suture closure or subcutaneous drain. The incidence of major wound complications (infection or separation) was also higher in obese women who received neither subcutaneous suture or drain compared to obese women who received either subcutaneous suture closure or subcutaneous drain.
                The use of closed suction drainage in the subcutaneous space may reduce the incidence of postoperative wound complications in obese women who have at least 2 cm of subcutaneous fat and undergo cesarean delivery. To compare the efficacy of subcutaneous suture reapproximation alone with suture plus subcutaneous drain for the prevention of wound complications in obese women undergoing cesarean delivery.
                We conducted a multicenter randomized trial of women undergoing cesarean delivery. Consenting women with 4 cm or more of subcutaneous thickness were randomized to either subcutaneous suture closure alone (n = 149) or suture plus drain (n = 131). The drain was attached to bulb suction and removed at 72 hours or earlier if output was less than 30 mL/24 h. The primary study outcome was a composite wound morbidity rate (defined by any of the following: subcutaneous tissue dehiscence, seroma, hematoma, abscess, or fascial dehiscence).
                From April 2001 to July 2004, a total of 280 women were enrolled. Ninety-five percent of women (268/280) had a follow-up wound assessment. Both groups were similar with respect to age, race, parity, weight, cesarean indication, diabetes, steroid/antibiotic use, chorioamnionitis, and subcutaneous thickness. The composite wound morbidity rate was 17.4% (25/144) in the suture group and 22.7% (28/124) in the suture plus drain group (relative risk 1.3, 95% confidence interval 0.8-2.1). Individual wound complication rates, including subcutaneous dehiscence (15.3% versus 21.8%), seroma (9.0% versus 10.6%), hematoma (2.2% versus 2.4%), abscess (0.7% versus 3.3%), fascial dehiscence (1.4% versus 1.7%), and hospital readmission for wound complications (3.5% versus 6.6%), were similar (P > .05) between women treated with suture alone and those treated with suture plus drain, respectively.
                The additional use of a subcutaneous drain along with a standard subcutaneous suture reapproximation technique is not effective for the prevention of wound complications in obese women undergoing cesarean delivery. To determine whether suture closure of subcutaneous dead space decreases wound disruption after Cesarean delivery.
                All patients undergoing Cesarean delivery at the New England Medical Center from September 1995 to June 1997 were eligible. One group (162 patients) was randomly assigned to have the subcutaneous fat layer closed with a running 3-0 plain suture. The other group (165 patients) had this layer left unclosed. Both groups had careful hemostasis of this layer with cautery and copious irrigation. All laboring and ruptured patients received prophylactic antibiotics. The patients were followed for 6 weeks after delivery for wound disruption.
                No significant differences were noted between the two groups with respect to demographic, obstetric, or surgical characteristics or loss to follow-up. Excluding those lost to follow-up (27 closed vs. 22 unclosed), there was no difference in wound infection (11 (8.1%) closed vs. 13 (9.1%) unclosed, RR 0.90, 95% CI 0.14, 2.08). There were decreases in risk of skin separation (three (2.2%) vs. six (4.2%), RR 0.53, 95% CI 0.42, 1.93) and seroma or hematoma formation (two (1.5%) vs. seven (4.9%), RR 0.30, 95% CI 0.06, 1.43) that were not statistically significant. Decreases that were not statistically significant were also noted for any wound disruption (14 (10.4%) vs. 21 (14.7%), RR 0.71, 95% CI 0.37, 1.33) and non-infected wound complication (three (2.2%) vs. eight (5.6%), RR 0.40, 95% CI 0.11, 1.47). Increasing gravidity and parity, and Cesarean delivery performed for failure to progress were independent risk factors for any wound complication. Controlling for these factors did not alter the effect of subcutaneous closure.
                Closure of the subcutaneous space does not increase and may protect against wound complications in patients undergoing Cesarean delivery. The purpose of this study was to determine the wound complication rates and patient satisfaction for subcuticular suture vs staples for skin closure at cesarean delivery.
                This was a randomized prospective trial. Subjects who underwent cesarean delivery were assigned randomly to stainless steel staples or subcuticular 4.0 Monocryl sutures. The primary outcomes were composite wound complication rate and patient satisfaction.
                A total of 435 patients were assigned randomly. Staple closure was associated with a 4-fold increased risk of wound separation (adjusted odds ratio [aOR], 4.66; 95% confidence interval [CI], 2.07-10.52; P < .001). Having a wound complication was associated with a 5-fold decrease in patient satisfaction (aOR, 0.18; 95% CI, 0.09-0.37; P < .001). After confounders were controlled for, there was no difference in satisfaction between the treatment groups (aOR, 0.71; 95% CI, 0.34-1.50; P = .63).
                Use of staples for cesarean delivery closure is associated with an increased risk of wound complications. Occurrence of a wound complication is the most important factor that influenced patient satisfaction.
                Published by Mosby, Inc. The purpose of this study was to compare a subcutaneous stitch closure and subcutaneous drain placement for the risk of wound disruption after cesarean delivery.
                This was a prospective randomized clinical trial that evaluated subcutaneous stitch closure, placement of a subcutaneous drain, or no closure for subsequent wound disruption risk in women with subcutaneous depth at >or=2 cm.
                The maternal demographics and intrapartum risk factors for postoperative wound disruptions were similar among the 964 study subjects, who were divided into 3 groups. Wound disruptions that required opening of the wound, irrigation, debridement, packing, and/or secondary delayed closure occurred in 9.7% of the women with no closure, 10.4% of the women in the stitch closure group, and 10.3% of the women in the closed drain group (P =.834).
                There appears to be no difference in the subsequent risk of wound complications when no closure of the subcutaneous tissue layers occurs versus suture closure or a closed drainage system.
Implications for practice

Closure of the subcutaneous fat may reduce wound complications but it is unclear to what extent these differences affect the well-being and satisfaction of the women concerned.


Implications for research

Further trials are justified to investigate whether the apparent increased risk of haematoma or seroma with non-closure of the subcutaneous fat is real. These should use a broader range of short- and long-term outcomes, and ensure that they are adequately powered to detect clinically important differences. Further research comparing blunt and sharp needles is justified, as are trials evaluating suturing materials and suturing techniques for the rectus sheath.