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The decision to use sutures or staples to close incisions after a cesarean delivery has been debated in the obstetrics community, but results from a new study seem to give sutures the edge, at least for reducing surgical site infections.

Findings from a randomized, multicenter trial that assessed postoperative outcomes among women who had undergone C-section deliveries demonstrated that incision wounds closed with sutures had a 57% lower rate of complications compared with wounds closed with staples (10.6% versus 4.9%, adjusted odds ratio 0.43, 95% CI 0.23-0.78), reported Dhanya A. Mackeen, MD, MPH, of the Geisinger Health System in Danville, Pa., and colleagues in .

The authors, including president of the Society for Maternal-Fetal Medicine, also found that incisions closed with sutures were 80% less likely to have a wound separation of 1 cm or greater.

The results may support a shift among some obstetricians away from staples to sutures, according to experts who spoke with 乌鸦传媒.

"Surgeons in the past have preferred staples over sutures because staples are faster," explained from the Ohio State University Medical Center in Columbus.

"[Staples] were thought to be better for obese patients, and for patients who have undergone more than one C-section in the past," added Worly, who participated in the patient recruitment for the study by Mackeen's group.

In 39% of obstetricians said they used staples to close C-section incisions, and another 13% said they used sutures and staples equally. According to the CDC, from 2009 to 2011, .

The reliance on staples may have been because "only recently has support for sutures over staples become more clear," said , also from Ohio State. "This [randomized controlled trial], and , have both demonstrated reduced complications associated with suture closure of the skin -- this is relatively new information and important because of our focus on reducing surgical site infections."

Study Details

Mackeen's group enrolled 746 pregnant women at three hospitals into the CROSS study to test outcomes for sutures versus staples to close low-transverse C-section incisions.

From 2010 to 2012, the participants, all at least 23 weeks in gestation, were split into the two groups and then followed for postoperative complications, such as infection, hematoma, seroma, separation of 1 cm or longer, or readmission for any type of wound-related complication. All received prophylactic antibiotics before skin incision.

Women with high body mass index (BMI), first-time C-section, and repeat C-section were included in both groups. Women with uncontrolled diabetes or other serious health conditions were excluded from the trial.

The researchers attributed the lower rates of complication in the suture group to lower rates of wound separation. Only 1.6% of patients with sutures had their wound re-open compared with 7.4% of women in the staples group (aOR 0.20, 95% CI 0.07-0.51).

However, suture closure took an average of 9 minutes longer than staple closure.

Although the authors recognized that time might be an important factor in certain cases, they still recommended sutures for standard practice to close horizontal C-section delivery skin incisions "in an effort to decrease cesarean delivery morbidity related to wound complications."

"The multicenter nature of this study increases its external validity; the study population was diverse with respect to race, marital status, and insurance source," they wrote.

Why Stick With Staples?

Despite the growing evidence in favor of sutures, tradition may be one of the main drivers behind the continued use of staples, according to the experts who spoke with 乌鸦传媒.

"I was trained many years ago, and my mentors routinely preferred staples over sutures, especially for repeat surgeries," Thung said. "Many explanations were used to rationalize staple removal, but without good randomized trials, we really did not know what was better."

, of Spectrum Health in Grand Rapids, Mich. told 乌鸦传媒, that "it tends to be the older docs who have always [used staples] and they are more comfortable. Also, if there is a big time crunch, staples are about 5 minutes faster."

Bitner, who is director of Spectrum's Women's Health Network, said she informally polled the nurses at her hospital, which oversees roughly 10,000 deliveries per year, about the use of staples versus sutures, and they estimated that 30% of the obstetricians currently use staples.

Another reason that physicians may prefer staples is cost savings.

"Previous expert opinion suggested that staples were faster and therefore more cost-effective in a field where 'time is money,' and it was also thought that overweight patients and patients who had multiple C-sections would heal better, with lower rates of infection," according to Worly.

"They often are used for very sick or unstable patients who need to minimize their time on the operating table," added of Washington University in St. Louis, in an email.

Thung agreed, pointing out that shorter surgeries result in less surgical site infections, so the "speed" of using staples may be appropriate in patients at a high risk for complications, such as those who are obese, diabetic, or undergoing repeat surgery.

"I have no problems with using staples, but I do believe that if a provider is going to use staples in a high-risk patient, the staples should be left in for more than 3 to 4 days. Here at Ohio State, we do not routinely remove staples for our high risk women until a week after surgery," Thung said.

He cautioned that patients are discharged sooner than they used to be -- 3 days post-surgery versus 4 days or longer -- so "taking out staples in high risk patients that early may increase the risk of wound separation."

Study Limitations

"This study provides good evidence that many patients would benefit from having sutures instead of staples at the end of a C-section to close their skin," Worly said.

However, "this study looked at women with a very specific set of conditions that certainly do not apply to all future patients," he emphasized.

"At our institution, skin closure with dissolvable suture is now the standard of care for cesarean section," Goetzinger said. But staples still play a role in a small subset of patients.

For instance, "if a patient is having excessive bleeding and there is a high risk that they may need to return to the [operating room] for re-exploration, staples might be a more suitable option for skin closure," she explained.

Bitner said she uses sutures for aesthetic reasons ("a better plastic closure") and because patients don't have to worry about the staples being removed.

But she cautioned that "sometimes, if the skin is really stretched out from multiple C-sections, or if the patient has a history of large weight swings, then it is easier to line the skin up with staples, and in that case it does provide a better plastic closure."

And Goetzinger added that "more research is still needed to determine the optimal method of skin closure in morbidly obese patients as well as in patients who require a vertical midline incision."

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