Interpertation
As previously mentioned, subcutaneous tissue approximation during CD has been demonstrated to reduce post-operative wound complications.23 In a randomized controlled trial of 116 women following CD by Husslein et al. (2014), subcutaneous tissue closure was associated with lower rates of post-operative hematomas as compared to the non-closure group (4% vs. 25%, p<0.005).24 A 2017 meta-analysis of ten studies (n=3,696) by Pergialiotis et al. (2017), which evaluated the rates of wound complications between closure and non-closure of the subcutaneous layer during CD, reported a significant reduction in all wound complications in favor of the closure technique group (odds ratio 0.66, 95% CI 0.47–0.93).12 Other studies found subcutaneous tissue approximation to be more efficient with increased subcutaneous thickness.11,25 Following these results, current guidelines recommend suturing the subcutaneous tissue if the thickness measured is 2 cm and above.14,15Nevertheless, there is a limited data regarding the preferred surgical technique.
In a randomized trial, Alalfy et al. (2019) compared 198 women assigned for continuous subcutaneous suturing and 199 women assigned for interrupted sutures.12 The results indicated significantly higher complications rates in the continuous suturing group as compared with interrupted suturing group. Rates of wound infection in their study reached 8.6% in the continuous suturing group as compared with only 1.5% in the interrupted suturing group (odds ratio 6.1, CI 1.8–21.3, p=0.001). However, one should notice that in contrast with our study, women with previous CD or medical histories, such as gestational diabetes mellitus, hypertension disorders, or a BMI above 30kg/m2 were excluded. In addition, the methodology of that study has been criticized, as critical information such as sample size calculation, methods of randomization, and reports on the decision of variables used for regression analysis were lacking.26 In contrast, we demonstrated a significant advantage for continuous subcutaneous suturing, and although retrospective, included a large heterogeneous group of 6,281 patients who may better represent common daily practice. Our cohort, that nearly reached the pooled number of patients evaluated in the meta-analysis performed by Pergialiotis et al.,12 enabled us to describe and compare outcomes between subgroups of elective and emergent CD.