Does closure of Camper fascia reduce the incidence of post-cesarean superficial wound disruption?

OBJECTIVE: To determine whether closure of Camper fascia prevents the development of superficial wound disruption after cesarean delivery. METHODS: During a 1-year period, 438 women undergoing cesarean delivery were randomized into groups with and without approximation of Camper fascia with absorbable suture during closure of the abdominal incision. All women received routine postoperative care following our departmental guidelines. We reviewed charts after the puerperium to identify women with postoperative superficial wound disruption and to obtain demographic and delivery information for analysis. RESULTS: We found a significantly higher incidence of wound disruption in the group without the suture than in those in whom the tissue was approximated (P = .03). Four or more vaginal examinations and higher body mass index were also associated with a higher incidence of wound disruption (P = .05 and P = .04, respectively). Logistic regression correction for covariables that might influence the results of our main analysis revealed no effect of maternal age, parity, indications for cesarean delivery, duration of labor, duration of ruptured membranes, duration of surgery, use of internal monitoring, type of incision, use of antibiotic prophylaxis, surgeon's level of training, or maternal diabetes mellitus and/or hypertension. CONCLUSION: Approximation of Camper fascia with absorbable suture at closure of the abdominal incision during cesarean delivery appears to protect against postoperative superficial wound disruption and is therefore recommended.     

Pfannenstiel Incision Closure: A Review of Current Skin Closure Techniques

The goal of any skin closure technique is to produce appropriate skin approximation and adequate healing while minimizing pain, wound complications, cost, and scarring; the technique should be quick, cost-effective, and simple, while maximizing wound cosmesis and patient satisfaction. Although many studies have shown the superiority of staples for speed of closure, it is unclear if staples give a superior cosmetic result or reduce pain. Several randomized controlled trials have found that sutures are superior for cosmesis and that they decrease postoperative pain and are more cost-effective. There remains a paucity of data on wound infections and complications associated with closure technique. This review summarizes studies to date evaluating outcomes associated with wound closure using staples and sutures in repairing abdominal incisions and, in particular, assesses outcomes in the obstetric population with a Pfannenstiel incision.     

A phase II trial of a surgical protocol to decrease the incidence of wound complications in obese gynecologic oncology patients

Objectives

Obese women have a high incidence of wound separation after gynecologic surgery. We explored the effect of a prospective care pathway on the incidence of wound complications.

Methods

Women with a body mass index (BMI) ≥ 30 kg/m² undergoing a gynecologic procedure by a gynecologic oncologist via a vertical abdominal incision were eligible. The surgical protocol required: skin and subcutaneous tissues to be incised using a scalpel or cutting electrocautery, fascial closure using #1 polydioxanone suture, placement of a 7 mm Jackson-Pratt drain below Camper's fascia, closure of Camper's fascia with 3-0 plain catgut suture and skin closure with staples.Wound complication was defined as the presence of either a wound infection or any separation. Demographic and perioperative data were analyzed using contingency tables. Univariable and multivariable regression models were used to identify predictors of wound complications. Patients were compared using a multivariable model to a historical group of obese patients to assess the efficacy of the care pathway.

Results

105 women were enrolled with a median BMI of 38.1. Overall, 39 (37%) had a wound complication. Women with a BMI of 30–39.9 kg/m² had a significantly lower risk of wound complication as compared to those with a BMI > 40 kg/m² (23% vs 59%, p < 0.001). After controlling for factors associated with wound complications the prospective care pathway was associated with a significantly decreased wound complication rate in women with BMI < 40 kg/m² (OR 0.40, 95% C.I.: 0.18–0.89).

Conclusion

This surgical protocol leads to a decreased rate of wound complications among women with a BMI of 30–39.9 kg/m².     

Barbed sutures versus conventional sutures for uterine closure at cesarean section; a randomized controlled trial

Introduction: The aim of this randomized control trial was to compare the operative data and the early postoperative outcomes of cesarean sections in which the uterine incision was closed with a barbed suture (STRATAFIX? Spiral PDO Knotless Tissue Control Device, SXPD2B405, Ethicon Inc.) with those of cesarean sections in which the uterine incision was closed with a conventional smooth suture (VICRYL^?; Ethicon Inc.).

Materials and methods: One hundred pregnant patients were randomized in a 1:1 ratio to the Stratafix group or the Vicryl group. The uterine incision was closed by two layers of sutures in both groups. In the Vicryl group, the first layer was continuous and the second layer was interrupted. In the Stratafix group, both layers were continuous.

Results: The uterine closure time was significantly lower in the Stratafix group (224?±?46 versus 343?±?75?s, p?p value?=?.009). The mean blood loss during closure of uterine incision and mean hospital stay were lower in the Stratafix group but these differences failed to reach statistical significance.

Conclusion: The use of barbed suture for uterine incision closure at cesarean section is associated with shorter uterine closure time and similar early perioperative complications compared with conventional smooth suture. The difference between both groups in the technique of suturing the second layer of the uterine incision may be the cause of the reduction in the uterine closure time and the need for additional sutures to achieve hemostasis during suturing the uterine incision with a barbed suture. Further, well designed randomized controlled trials should be conducted to investigate the association between the type of suture (barbed or conventional smooth) and remote complications of cesarean section (infertility, pelvic pain, abnormal placentation and rupture uterus).     

A comparison of barbed and smooth sutures for ovine cesarean delivery

Objective

To determine the adequacy of barbed and smooth sutures for closing the uterus and fascia in pregnant ewes.

Methods

Nine ewes that underwent cesarean delivery were randomized to each receive 2 different suture materials for both the uterus and the fascia. The sutures used were: barbed poliglecaprone 25, smooth poliglecaprone 25, braided polyglactin 910, and smooth chromic sutures on the uterus; and barbed polydioxanone (PDO), barbed poliglecaprone 25, braided polyglactin 910, and smooth chromic sutures on the fascia.

Results

In 4 of the ewes, the fascia suture line failed prematurely, leading to dehiscence prior to planned euthanasia and necropsy. The remaining 5 ewes were euthanized on days 2, 7, or 28. All suture materials (smooth and barbed) were adequate for uterine closures. Barbed PDO, smooth poliglecaprone 25, and braided polyglactin 910 were adequate for fascia closures, whereas both barbed poliglecaprone 25 and smooth chromic resulted in premature suture line ruptures and fascia dehiscence.

Conclusion

In a small pilot study, absorbable knotless barbed suture was adequate and equivalent to absorbable knotted smooth suture for closing the uterus following ovine cesarean delivery. On the rectus fascia, however, sutures—whether barbed or smooth—with lower tensile strength resulted in fascial dehiscence.     

Wound strength in abdominal incisions: A comparison of two continuous mass closure techniques in rats

OBJECTIVES: The primary objective of this study was to determine whether continuous simple mass closure or continuous far-near, near-far (Smead-Jones) mass closure of longitudinal midline abdominal incisions results in a stronger wound. A second objective was to compare the time required to perform each type of closure.STUDY DESIGN: A midline laparotomy was performed on 102 male Sprague-Dawley rats. the skin was incised from xiphoid to pubis and reflected away from the midline. The rectus sheath was imprinted with a stamp to demarcate a standardized 5 cm midline incision. The stamp also provided loci for suture bites 5 mm from the incision edge and 10 mm apart. A longitudinal midline incision was made. Closure technique was determined by random assignment. The time required to close each incision was recorded. On postoperative day 7 wound strength was measured by inserting a condom into the abdomen and filling it with water until the abdomen burst. Pressure was measured in millimeters of mercury. Student t test, χ² test, and Fisher's exact test were used for statistical analysis.RESULTS: Animals closed with the continuous simple mass closure (n = 50) had a mean weight of 344.43 ± 33.2 gm (mean ± SD) and those closed with the continuous far-near, near-far mass closure technique (n = 52) weighed 344.86 ± 36 gm. Abdominal bursting pressure was 480.8 ± 62.6 mm Hg in the continuous simple group, whereas it was 554.4 ± 63.6 mm Hg in the continuous far-near, near-far group (p < 0.000001). The time required to close the wound with the continuous simple technique was 365.4 ± 66.2 seconds. The continuous far-near, near-far closure group required 570.6 ± 70.8 seconds (p < 000001).CONCLUSION: Our study reveals that the continuous far-near, near-far mass closure technique results in significantly greater wound strength than the continuous simple mass closure on the basis of the intraperitoneal pressure required to burst the abdomen. We believe that the far-near, near-far closure provides superior strength by creating two loops of suture over which forces that may disrupt the wound can be distributed. Furthermore, use of a continuous suture for this technique distributes tension along the entire length of the incision. Disruptive forces are thus divided evenly among all suture sites. A second purported advantage of continuous closur is the speed with which it can be performed. However, the greater wound strength of the continuous far-near, near-far technique comes at the expense of requiring 56% more time to complete than the continuous simple mass closure. Our data suggest that greater wound security is worth the increased time required for this repair.     

Abdominal wound closure using a running, looped monofilament polybutester suture: comparison to Smead-Jones closure in historic controls.

OBJECTIVE: To determine whether abdominal wound closure with a running, looped monofilament polybutester suture was as effective, inexpensive, and rapid as Smead-Jones closure using the same material. METHODS: Between April 19, 1990 and August 29, 1991, 154 patients undergoing major gynecologic surgery had wound closure using a running, looped monofilament polybutester suture. Controls were 154 patients undergoing similar surgical procedures in the 15 months immediately preceding the study period (January 5, 1989 to April 18, 1990) whose wounds were closed with 0 polybutester using the Smead-Jones technique. All patients received prophylactic cephalosporin antibiotic therapy and external pneumatic leg compression perioperatively. The subcutaneous tissues were not sutured after fascial closure, and the skin was closed with stainless-steel staples. There was no difference between the groups when compared by mean weight, mean ponderal index, number of previous abdominal operations, operative blood loss, or the use of chemotherapy or radiotherapy in the pre- or postoperative period. Both groups had similar rates of complicating medical conditions including insulin-dependent and non-insulin-dependent diabetes mellitus, hypertension, obstructive pulmonary disease, atherosclerotic coronary disease, or peripheral vascular disease. RESULTS: The use of a running closure with looped monofilament polybutester suture in the study patients resulted in a reduction in operating time when compared with controls. The rates of superficial separation and wound infection were similar in both groups. In the study group, there was one minor fascial separation and one wound dehiscence, which occurred when the running suture was inadvertently snipped during debridement of a superficial infection. CONCLUSION: Running closure with looped polybutester is an acceptable, inexpensive, and expeditious method of abdominal wound closure.     

Abdominal wound problems after hysterectomy with electrocautery vs. scalpel subcutaneous incision

The purpose of this study was to evaluate the relationship between postoperative abdominal incision problems and opening subcutaneous tissues with electrocautery or scalpel. Women scheduled for elective abdominal hysterectomy who gave informed consent were randomly assigned to subcutaneous abdominal wall tissue incision by electrocautery or scalpel. Postoperative abdominal wound problem diagnoses included seroma, hematoma, infection, or dehiscence without identifiable etiology. Fifteen of 380 women (3.9%) developed a wound problem; six had scalpel and nine had electrosurgical subcutaneous incisions (P = 0.4). Thicker subcutaneous tissues (P = 0.04) and concurrent pelvic infection (P < 0.001) were significant risk factors for postoperative wound problems. Only two women (0.5%) developed an infection. We conclude that the method of subcutaneous tissue incision was unrelated to the development of postoperative abdominal incision problems in 380 women undergoing elective abdominal hysterectomy.     

Subcuticular Suture Versus Staples for Skin Closure in Vertical Skin Incisions in Cesarean Sections

The purpose of the present study was to evaluate the frequency of wound complications comparing staples to suture closure of the skin. During a 6-month period, all patients who underwent cesarean delivery were assigned to have their skin approximated with either subcuticular sutures or surgical staples. The remainder of the closure techniques were the same in each group. Risk factors for wound complications were identified and statistically analyzed. Twelve hundred and eighty-nine patients were evaluated. Of the 731 women with skin closure via staples, 66 (9%) had a superficial wound separation compared with only 13 (2.3%) of 558 when subcuticular suture was used to approximate the skin edges (P < 0.0001). This was significant only for vertical skin incisions. Thus, closure of the skin with subcuticular suture at the time of cesarean reduced the incidence of wound disruption by more than fourfold.     

One layer closure of the abdominal wall

A one layer closure of the abdominal wall with a far-near, near-far suture has been used in 34 patients. This technique allows approximation of the fascia without pressure on the skin and leads to firm uncomplicated wound healing.     

Modified retropubic cystourethropexy

A variation of retropubic suspension of the urethrovesical junction was performed on 26 patients with urinary stress incontinence. Access to the retropubic space was through a low transverse muscle-splitting incision. Surgical technique consisted of securing a helical Prolene suture in the paraurethral fascia at each side of the bladder neck. Each suture was then passed through the abdominal wall fascia, exiting just above the symphysis pubis on either side of the midline, and tied to the opposite suture above the rectus fascia. The desired amount of elevation of the vesical neck was gauged by a Q-tip applicator inserted into the urethra just before the Prolene sutures were tied down. A cystotomy was performed to rule out any inadvertent penetration of the bladder by the nonabsorbable suture material, and the bladder was drained suprapubicly. The small number of cases and short follow-up times do not allow conclusions to be drawn at this time, but results to date have been encouraging.     

The biomechanical effects of tight suture closure upon fascia

The biomechanical effect of tight suture closure of fascial incisions in male rats was evaluated. The incision of rats in group 1 was closed with maximum tension on the first throw of the approximating knot. The incision of rats in group 2 was closed in a similar manner, however a 3.14 squared millimeter rod was placed in the suture loop before securing the first throw. The rod was removed after the knot was formed and fascial edges were observed to be loosely approximated. All rats were sacrificed after seven days. The abdominal fascial and muscle unit was dissected and a 1 by 6 centimeter strip containing two suture loops was excised. Scanning electron microscopic examination of tissue specimens, tensile strength measurements and energy-to-failure under tensile loading studies were performed. Specimens for hydroxyproline assay were obtained from the tissue immediately surrounding the incision and between two suture loops. The scanning electron microphotographs of group 1 showed tissue overlap from the excessive force on the initial knot throws. Wounds loosely approximated had proper alignment of the wound edges and had greater proliferative activity in the clefts of the wounds. The tensile strength and energy-to-failure studies showed loosely approximated wounds to be far stronger (p less than 0.001). No statistically significant difference (p greater than 0.05) was found between hydroxyproline assays of the two groups.     

Cesarean section, techniques and skin suture materials

AIM: The aim of the study was to compare the outcome, complications and costs of three skin suture techniques after Caesarean section. METHODS: The study sample was 310 women who underwent caesarean section between 2003 and 2007. The sample was divided into three groups: an intradermal suture with non-reabsorbable thread was applied in 98; metallic clips were placed in 90; 2-octyl-cyanoacrylate (2-OCA) glue was used for wound closure in 112. The sutures were checked at 4 days and 2 months after the operation to determine cosmetic outcome, patient compliance, strength of incision closure, allergic reactions, suture infection, and total cost of each technique. RESULTS: No substantial differences in strength of incision closure or cosmetic outcome between the techniques were found. Compliance was better in the group that received 2-OCA, while the total cost of suture alone was lower in the group that received the non-reabsorbable intradermal suture. CONCLUSION: The results suggests that following Caesarean section according to Stark, skin suture with 2-OCA glue has the advantage of greater patient compliance, while intradermal thread suture is less costly with a cosmetic outcome comparable to that of the other two techniques.     

Vaginal cuff dehiscence in laparoscopic hysterectomy: influence of various suturing methods of the vaginal vault

Vaginal cuff dehiscence (VCD) is a severe adverse event and occurs more frequently after total laparoscopic hysterectomy (TLH) compared with abdominal and vaginal hysterectomy. The aim of this study is to compare the incidence of VCD after various suturing methods to close the vaginal vault. We conducted a retrospective cohort study. Patients who underwent TLH between January 2004 and May 2011 were enrolled. We compared the incidence of VCD after closure with transvaginal interrupted sutures versus laparoscopic interrupted sutures versus a laparoscopic single-layer running suture. The latter was either bidirectional barbed or a running vicryl suture with clips placed at each end commonly used in transanal endoscopic microsurgery. Three hundred thirty-one TLHs were included. In 75 (22.7?%), the vaginal vault was closed by transvaginal approach; in 90 (27.2?%), by laparoscopic interrupted sutures; and in 166 (50.2?%), by a laparoscopic running suture. Eight VCDs occurred: one (1.3?%) after transvaginal interrupted closure, three (3.3?%) after laparoscopic interrupted suturing and four (2.4?%) after a laparoscopic running suture was used (p?=?.707). With regard to the incidence of VCD, based on our data, neither a superiority of single-layer laparoscopic closure of the vaginal cuff with an unknotted running suture nor of the transvaginal and the laparoscopic interrupted suturing techniques could be demonstrated. We hypothesise that besides the suturing technique, other causes, such as the type and amount of coagulation used for colpotomy, may play a role in the increased risk of VCD after TLH.     

Continuous abdominal fascial closure: a randomized controlled trial of poly(L-lactide/glycolide)

OBJECTIVE: The objective was to compare the handling characteristics and 相似文献   

Richter’s hernia occurring through a 5-mm laparoscopy sheath incision

We report a case of postoperative Richter’s hernia presenting through a 5-mm sheath incision. A 58-year-old woman having undergone laparoscopic hysterectomy 8 days before presented with severe left abdominal pain, nausea and light-headedness. The hypothesis of a sigmoid volvulus was suggested based on peroperative rectum and sigmoid release, the X-ray finding, and pain evolution. A secondary laparoscopic procedure allowed both diagnosis of a Richter’s hernia through a 5-mm sheath incision and surgical repair of the hernia. The use of this sheath during the laparoscopic vagina suture caused extension of the wound. Large 5-mm sheath defect sufficient for a Richter’s hernia can be created by multiple passes with small instruments and require surgical closure at the end of laparoscopy. Laparoscopy is useful in cases of postoperative complications, particularly when other complementary examinations are less informative.     

A Modified Technique of Temporary Suspension of the Ovary to the Anterior Abdominal Wall

Study Objective

To demonstrate a modified technique of temporary suspension of the ovary to the fascia of the anterior abdominal wall after operative laparoscopy for advanced stage-endometriosis to reduce postoperative adhesion formation.

It's time to challenge surgical dogma with evidence-based data

Surgical training is an apprenticeship with surgical techniques passed from one physician to another. Often these techniques are based more on surgical dogma than scientific evidence. Despite surgical dogma to the contrary, electrocautery is the preferred technique for wound creation, and peritoneal closure has no significant advantage over nonclosure. No method of handling the subcutaneous tissue is clearly superior; however, suture closure appears to have some advantages in preventing wound disruption. Subcuticular suture closure results in less pain and better patient satisfaction, and it is more cost-effective than surgical staples. These surgical techniques, as well as many others, need to be subjected to rigorous, randomized prospective trials. It is incumbent on each physician to ensure that his or her surgical techniques are evidence based and not simply the result of adherence to surgical dogma.     

Suture erosion and wound dehiscence with permanent versus absorbable suture in reconstructive posterior vaginal surgery

OBJECTIVE: This study was undertaken to determine the incidence of wound disruption after reconstructive posterior vaginal surgery with braided permanent versus absorbable suture. STUDY DESIGN: A retrospective cohort study of women undergoing posterior vaginal surgery. Outcomes included suture erosion, wound dehiscence, and additional surgical procedures. RESULTS: Ninety-nine procedures were performed with permanent sutures, followed by 111 with absorbable sutures. There were no differences in demographics or comorbidities between patient groups. Suture erosion/wound dehiscence occurred in 31.3% of the permanent suture group versus 9% of the absorbable suture group (P = .003, odds ratio [OR] = 7.5, 95% CI 2-28). The need for additional surgical intervention was 16.1% among permanent suture group versus no patients with absorbable suture. Performing a concomitant anal sphincteroplasty with permanent sutures significantly increased the incidence of suture erosion (P = .003, OR = 4.7, 95%CI 1.7-13.3). CONCLUSION: Permanent sutures increase the incidence in wound disruption and the need for additional surgical intervention in posterior colporrhaphy and anal sphincteroplasty.     

LiquiBand® Surgical S topical adhesive versus sutures for the closure of laparoscopic wounds. A randomized controlled trial

Cyanoacrylate adhesives offer the surgeon and patient an alternative to subcuticular suturing. LiquiBand® Surgical S (LBSS) is a new formulation with a blend of monomeric n-butyl and 2-octyl cyanoacrylates. In this study, the effectiveness, safety, and clinical utility of LBSS was compared to Vicryl^? sutures for the closure of laparoscopic incisions. This was a prospective randomized study of LBSS skin adhesive versus Vicryl^? sutures for the topical closure of laparoscopic surgical incisions. Subjects were asked to return at 2 weeks postsurgery to report complications and adverse events. Wounds were evaluated for apposition and cosmesis using a modified Hollander Wound Evaluation Scale (HWES). The Shapiro–Wilk test of normality was done. Independent-samples T test, Mann Whitney U test, and chi-square test were used to compare variables between the two wound closure methods. A total of 114 subjects participated in this trial completing all aspects of the study. Fifty-five subjects received sutures for topical wound closure, with 59 subjects receiving LBSS. Surgeons were found to be satisfied with 100 % of all applications using the LBSS device. One hundred percent of wounds closed with sutures and 98.9 % wounds closed with LBSS achieving an optimal HWES of 0. There was no statistical difference in cosmesis or complications for either method. Closure with LBSS was significantly faster by a mean of 2 min. LiquiBand® Surgical S is as good as sutures for the closure of laparoscopic wounds in terms of cosmesis and complications with the added benefit of being significantly faster.