Absorbable Sutures versus Staples for Cesarean Sections Victoria Fath Kent State University

Absorbable Sutures versus Staples for Cesarean Sections
Introduction
The Merriam-Webster Dictionary (n.d.) defines a Cesarean section as, "A surgical operation for giving birth in which a cut is made in the mother's body so that the baby can be removed through the opening." "Cesarean delivery is the most common major surgical procedure performed in the United States and elsewhere. Currently, approximately a third of pregnant women in the US and 15% worldwide deliver by cesarean, and this prevalence is on the rise" (Dana Figueroa et al., 2013, p. 33). Since Cesarean sections are incredibly common and are only increasing, the risks for complications, such as infections, increase with it. To try and decrease the risks as much as possible, this study aims to look at the differences between two types of closing material used in Cesarean sections; absorbent sutures and staples. Are absorbable sutures more effective and safer than staples for Cesarean sections? The purpose of this study is to compare absorbent sutures and staples for clients undergoing a Cesarean section and to see which material has a lesser risk for infection and wound complications, which is more cost effective for the hospital, and patient satisfaction. This paper will help shed light on this subject by compiling multiple research articles and journals to create a better understanding on which material is best to use.
Review of Literature There are a multitude of articles on the subject of absorbent sutures compared to staples. Every article, except for one, was a peer reviewed article with a study that was randomized and controlled. The exception article by Suzanne Corcoran et al. (2013) was, “A peer reviewed study that was a prospective observational cohort study involving active in-patient and postdischarge surveillance” (p. 1258). Each article describes which suture material is best in regards to reducing risks and complications from suturing. Some of the complications that can arise from the closure of a Cesarean section include wound infection, hematoma at the closure site, and the separation of the wound. A. Chunder, J. Devjee, S. M. Khedun, J. Moodley & T. Esterhuizen (2012) states that, "Some of these suture materials have been associated with lower wound infection rates, reduced pain, improved cosmetic outcomes and cost-effectiveness” (p. 374). Each article had its own conclusions as to which material was preferred for closure of a Cesarean section surgical opening. In addition, some articles stated that infections and complication rates were higher in staples while other articles states that patients with absorbent sutures experienced increased rates of those risks. Wound complications following a cesarean section do not only cause suffering for the patient, but for the hospital as well. Costly lawsuits can be filed against the hospital if an infection occurs in relation to the cesarean section. According to Suzanne L. Basha et al. (2010) The overall composite wound complication and wound separation rates for the entire cohort were 15.1% and 10.3% respectively. Wound separation occurred significantly more often in the staple group (17% vs 5%; P < .001), as did composite wound complication (22% vs 9%; P < .001) (p. 4). In addition, A. Chunder et al. (2012) stated that, “Wound complications occurred in 76 (7%) of the 1,100 patients: 1% (3/361) in group 1 (PGA sutures), 17% (65/373) in group 2 (SS), and 2% (8/366) in group 3 (nylon sutures)” (p. 375). In comparison, Catherine A. Feese, Steven Johnson, Emily Jones, & Donna S. Lambers (2013) stated that, “All 4 wound complications occurred in the absorbable group vs none in the metallic group” (p. 4). The environment of where these wound complications were occurring also needs to be taken into place. Some of the patients developed wound complications while still in the hospital while some developed wound complications at home. Hospital acquired wound infections should be as minimized as possible because there are trained professional to clean the wound, monitor the wound, and document what is going on with the wound. Home acquired wound infections are a different story, as the patient could be neglecting wound care or providing unsanitary conditions for proper wound healing. A. Chunder et al. (2012) described the appearance of wound complications as: Of wound complications, 64/76 (84%) occurred following discharge from hospital; 12 (16%) occurred during hospitalization (11 in group 2 and 1 in group 3). All 12 wound complications that occurred in hospital were classified as superficial and were detected within 24 hours of CS (p. 375). Cromi et al. (2010) also stated that there were 3 patients who developed infections, 1 in the absorbent suture group and 2 in the staple/nonabsorbent suture group. Each patient had their infections resolved at the 2 month follow up visit. Some articles also touched on patient satisfaction and pain resulting from the type of material used in the Cesarean section. Julie-Anne Rousseau, Karine Girard, Lucile Turcot-Lemay, & Nancy Thomas (2009) explained that in their study, “Pain at 6 weeks postoperatively was significantly less in the staple group (0.17vs 0.51; P =.04)” (p. 2). Some studies showed hardly any difference between the two suture materials in regards to pain. Anna J. M. Aabakke, Lone Krebs, Christian B. Pipper, & Niels J. Secher (2013) reported that, “There were no significant differences in pain scores at any time” and also touched on the subject of patient satisfaction, stating that, “Significantly more women preferred the stapled side, both overall (odds ratio [OR] 2.55; 95% confidence interval [CI] 1.18-5.52) and cosmetically (OR 2.76; 95% CI 1.24-5.74) (p. 880-881), and reported staples as their preferred technique (OR 2.00; 95% CI 1.10-3.64)” (p. 881). In contrast, Antonella Cromi et al. (2010) stated that, “In conclusion, the results reported herein show that in women undergoing cesarean delivery there are no long-term differences in cosmetic outcomes between stapled wounds and those closed with subcuticular sutures using different materials” (p. 7). This suggests that if there is no difference in cosmetic outcomes then patient satisfaction will be better. Cost effectiveness is also an important aspect to consider when choosing the best suture material. Dana Figueroa et al. (2013) writes that, “Furthermore, we estimate that the price of a stapler (not even including a staple removal kit) is at least 2.5 times the price of the absorbable suture” (p. 37). In contrast, Catherine A. Feese et al. (2013) stated that, “When cost was compared between groups, the average cost of each device, including placement and removal, was $285.60 for the absorbable stapler and $150.79 for the metallic staples, primarily due to the longer skin closure times for the absorbable stapler” (p. 4). This states that in Feese’s et al. (2013) study the absorbable sutures cost more than the metallic staples while in Figueroa’s et al. (2013) study the actual price of the stapler was 2.5 times the price of the absorbable suture. If you combine these two findings, 2.5 multiple by the price of the absorbable suture would be $714.00 for the metallic staples plus the stapler, making the staple method more costly than the absorbable sutures. All in all, there were many studies that had conflicting results when compared to other studies.

Conclusions An array of findings was presented in this paper. Sutures and staples were found to play an important part in a Cesarean section. Some studies found that sutures had a significantly less risk of infection, wound complication, and wound separation, while a select few studies found that staples had a lesser risk or even no difference at all between the two. One study found that patients who received staples were shown to have significantly decreased pain and another study showed that patients preferred the staple technique for cosmetic reasons. Staples and a staple device were also found to be less cost effective than sutures alone. The compiled evidence leads one to believe that absorbent sutures are the preferred suture material when comes to patient satisfaction in regards to cosmetic appearance, pain, cost effectiveness, and decreasing risks and complications associated with wound closure of a Cesarean section.
Clinical Implications There is not enough evidence to come to a concrete conclusion on which suture material is best for wound closure of a Cesarean section. All the studies showed conflicting results when compared to other studies, which made creating clinical implications difficult. However, more studies showed absorbent sutures to be the superior material to close wounds when compared to staples and nonabsorbent sutures. I would suggest for surgeons to begin using absorbent sutures as their go to material for wound closure in Cesarean section. I would also recommend for nurses to educate their patients on the differences between the two types of wound closure material to facilitate patients to choose which material they would like. More studies should be performed, nonetheless, in order to help clarify which material is truly the best material to use.
Suggestions for Future Research There were several studies which showed gaps in knowledge. Discussion of the type of techniques used in suturing the wound closure was missing in some studies. Certain studies also did not include whether patients were on medications that could affect the wound healing process. A lot of the studies had rather short follow ups, small groups of participants, and some studies had quite of bit of patient noncompliance with fully completing the study. I would suggest future research to focus primarily on polyglycolide for the material of absorbent sutures, nylon for the material of nonabsorbent sutures, and metallic surgical staples for the material of staples. Future research should also have a larger group of participants, which can also increase patient compliance, follow-ups for at least 1 year, as wound healing can take quite a bit of time, discussion of the techniques used for wound closure, as this can affect the outcome of wound healing, whether or not antibiotics were used pre or post-surgery, and detailed descriptions of any infections or wound complications during the course of following up with the participants.

References
Aabakke, A. J., Krebs, L., Pipper, C. B., & Secher, N. J. (2013). Subcuticular Suture Compared With Staples for Skin Closure After Cesarean Delivery. Obstetrics & Gynecology, 122(4), 878-884. Retrieved March 10, 2014, from http://dx.doi.org/10.1097/AOG.0b013e3182a5f0c3
Basha, S. L., Rochon, M. L., Quinones, J. N., Coassolo, K. M., Rust, O. A., & Smulian, J. C. (2010). Randomized Controlled Trial Of Wound Complication Rates Of Subcuticular Suture Vs Staples For Skin Closure At Cesarean Delivery. American Journal of Obstetrics and Gynecology, 203(3), 285.e1-285.e8. Retrieved March 10, 2014, from http://dx.doi.org/10.1016/j.ajog.2010.07.011 cesarean section. (n.d.). Merriam-Webster. Retrieved March 10, 2014, from http://www.merriam-webster.com/dictionary/cesarean%20section
Chunder, A., Devjee, J., Khedun, S., Moodley, J., & Esterhuizen, T. (2012). A randomised controlled trial of suture materials used for caesarean section skin closure: Do wound infection rates differ?. South African Medical Journal, 102(6). Retrieved March 10, 2014, from http://www.samj.org.za/index.php/samj/article/view/5357/4132
Corcoran, S., Jackson, V., Coulter-Smith, S., Loughrey, J., Mckenna, P., & Cafferkey, M. (2013). Surgical site infection after cesarean section: Implementing 3 changes to improve the quality of patient care. American Journal of Infection Control, 41(12), 1258-1263. Retrieved March 10, 2014, from http://dx.doi.org/10.1016/j.ajic.2013.04.020
Cromi, A., Ghezzi, F., Gottardi, A., Cherubino, M., Uccella, S., & Valdatta, L. (2010). Cosmetic outcomes of various skin closure methods following cesarean delivery: a randomized trial. American Journal of Obstetrics and Gynecology, 203(1), 36.e1-36.e8. Retrieved March 10, 2014, from http://dx.doi.org/10.1016/j.ajog.2010.02.001
Feese, C. A., Johnson, S., Jones, E., & Lambers, D. S. (2013). A randomized trial comparing metallic and absorbable staples for closure of a Pfannenstiel incision for cesarean delivery. American Journal of Obstetrics and Gynecology, 209(6), 556.e1-556.e5. Retrieved March 10, 2014, from http://dx.doi.org/10.1016/j.ajog.2013.08.001
Figueroa, D., Jauk, V. C., Szychowski, J. M., Garner, R., Biggio, J. R., Andrews, W. W., et al. (2013). Surgical Staples Compared With Subcuticular Suture for Skin Closure After Cesarean Delivery: A Randomized Controlled Trial. American College of Obstetrics and Gynecology, 121(1). Retrieved March 10, 2014, from http://journals.lww.com/greenjournal/Fulltext/2013/01000/Surgical_Staples_Compared_With_Subcuticular_Suture.7.aspx
Rousseau, J., Girard, K., Turcot-Lemay, L., & Thomas, N. (2009). A randomized study comparing skin closure in cesarean sections: staples vs subcuticular sutures. American Journal of Obstetrics and Gynecology, 200(3), 265.e1-265.e4. Retrieved March 14, 2014, from http://dx.doi.org/10.1016/j.ajog.2009.01.019