Skin Closure Technique Impacts Risk of Cesarean Wound Disruption or Infection

After a cesarean delivery, closing the incision with staples, compared with sutures, is associated with significantly more composite wound morbidity, according to the results of a new randomized controlled trial.¹
   
Most studies that have compared closure methods after cesarean delivery have inadequately examined wound morbidity outcomes, instead focusing on factors related to operative time, pain scores, cosmesis, and patient satisfaction. To better understand how closure techniques after a cesarean delivery affect wound disruption or infection, researchers randomized 398 women with viable pregnancies of at least 24 weeks’ gestation to wound closure with surgical staples or absorbable suture after a scheduled or unscheduled cesarean delivery. Standard care included staple removal at postoperative days 3 or 4 for low transverse incisions and postoperative days 7 to 10 for vertical incisions, with wound evaluations occurring at discharge (postoperative days 3 or 4) and at 4 to 6 weeks postoperatively.

Of the 398 patients participating in the trial, 198 were randomized to staples and 200 were randomized to sutures. Four patients in the suture group received staples. However, they remained in the suture group according to the intent-to-treat principle.

At hospital discharge, 7.1% of patients in the staple group, compared with 0.5% of patients in the suture group, had wound disruption or infection (P<.001). Of the original 398 trial participants, 350 patients (87.9%) attended their 4- to 6-week follow-up appointment, at which their surgical wounds were again evaluated. The cumulative risk of wound disruption or infection was 14.5% in the staples group and 5.9% in the suture group (P=.008). The median time of suture closure was 10 minutes longer than staples closure (58 minutes vs 48 minutes, respectively; P<.001). Secondary outcomes-pain, cosmesis, and patient satisfaction scores-were also measured, but no differences were noted between study groups.

According to the study authors, these findings are consistent with those of other similar studies, which determined that staples closure is associated with higher rates of self-reported wound morbidity.^2-4 However, the authors report that this trial had a higher number of obese participants (141 in the staples group and 124 in the suture group) than previous studies and that obese patients have the highest risk of wound morbidity.

Pertinent Points:
- The use of absorbable sutures is associated with significantly less wound morbidity than the use of staples for surgical closure after a cesarean delivery.
- These results support the use of sutures over staples, especially in women with a horizontal skin incision.

References:

1. Figueroa D, Jauk VC, Szychowski JM, et al. Surgical staples compared with subcuticular suture for skin closure after cesarean delivery. Obstet Gynecol. 2013;121:33-38.
2. Tuuli MG, Rampersad RM, Carbone JF, et al. Staples compared with subcuticular suture for skin closure after cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol. 2011;117:682-690.
3. Basha SL, Rochon ML, Quinones JN, et al. Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery. Am J Obstet Gynecol. 2010;203:285.e1-8.
4. Clay FS, Walsh CA, Walsh SR. Staples vs subcuticular sutures for skin closure at cesarean delivery: a metaanalysis of randomized controlled trials. Am J Obstet Gynecol. 2011;204:378-383.