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.