INFECTIOUS DISEASES

In addition, patients should be hospitalized for treatment if they are judged to be at risk for noncompliance, lack a reliable support system at home, or have previously failed outpatient management.

A technique that reduces C-section wound complications in the obese

Closure method, but not surgical drains, lowers morbidity

Ramsey PS, White AM, Guinn D, et al. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery. Obstet Gynecol. 2005;105:967–973.

• In obese women having cesarean delivery, closure of the subcutaneous layer reduces risk of wound complications such as seroma, hematoma, incisional abscess, and fascial dehiscence. Addition of a closed system drain did not improve outcome beyond that achieved with subcutaneous closure alone.

Summary

This prospective randomized trial at 5 medical centers assessed the role of 2 surgical techniques in decreasing the risk of wound complications after cesarean delivery in 280 obese women. Patients with subcutaneous thickness greater than or equal to 4 cm were randomized to either subcutaneous suture closure alone (149 women) or suture plus drain (131 women).

The primary study outcome was composite wound morbidity rate, defined by any of the following: subcutaneous tissue dehiscence, seroma, hematoma, incisional abscess, or fascial dehiscence.

Addition of drain did not improve wound morbidity

A running, nonlocking suture of 3-0 Vicryl was used for closure of the subcutaneous layer. The drain used was the Jackson-Pratt surgical drain (10 mm), and it was placed below the layer of subcutaneous suture and then connected to bulb suction. The drain was removed on the third postoperative day, or sooner, if drain output was less than 30 mL in 24 hours. The drain exited the wound via a separate stab site lateral to the incision. All of the skin incisions were closed with staples, which were removed 7 to 14 days after surgery. All patients received standard skin preparations and prophylactic antibiotics.

The composite wound morbidity rate was 17.4% in the suture group and 22.7% in the suture plus drain group (P=NS). Individual wound complication rates were similar in the 2 groups. The authors concluded that the surgical drain did not improve outcome beyond that achieved by closure of the subcutaneous layer.

Commentary

Endometritis and wound disruption are the most common complications of cesarean delivery. Wound complications clearly are the more serious, for they inevitably lead to persistent patient discomfort, prolonged hospitalization, and increased expense. Moreover, they may necessitate additional surgical intervention to drain a seroma, hematoma or abscess or to repair a fascial dehiscence.

Postcesarean wound complications are particularly likely in the obese, and, unfortunately, the prevalence of obesity is steadily increasing among obstetric patients.

In a landmark study of wound infections in many different types of surgery, Cruse and Foord⁴ demonstrated that sutures in the subcutaneous space actually increased the wound complication rate. DelValle and colleagues⁵ were among the first to challenge this observation and show that, at least in women having cesarean delivery, reapproximation of Camper’s fascia reduced risk of wound disruption.

Is thickness of subcutaneous layer a key determinant of wound morbidity?

Naumann et al⁶ and Vermillion and colleagues⁷ subsequently demonstrated that thickness of the subcutaneous layer was the key determinant of wound complications. Chelmow and colleagues⁸ recently published an excellent meta-analysis confirming that, in women with a subcutaneous layer greater than 2 cm, closure of the subcutaneous layer with suture significantly reduced the rate of wound disruption.

In the present study, the authors evaluated moderately to severely obese women who had a subcutaneous layer of 4 cm or greater. In light of the previous reports reviewed above, they were justified in omitting a treatment group in which no closure was done. The trial was well designed and included patients from varied populations. Not surprisingly, composite wound morbidity rates were high in both groups.

The addition of the surgical drain did not improve the morbidity rate, however. In fact, even though the drainage system was closed, women in the combined treatment group actually had slightly higher, although not statistically significant, rates of composite morbidity and individual morbidities.

Recommendations

When to omit drain

In view of the added time required to place the drain, greater patient discomfort, and the increased expense associated with the drain, this intervention should not be used in high-risk women having cesarean delivery.

DRUG THERAPYWe’ve lost 2 key weapons in our antibiotics arsenal