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PAPER PRESENTATION

Department of Obstetrics & Gynecology

Presented by: Dr. [Resident's Name], Junior Resident (MS/DNB Gynec)

Date: [Date] | Guided by: Dr. [Guide's Name], Professor & HOD

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PAPER DETAILS

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1. INTRODUCTION

• PCOS (Polycystic Ovary Syndrome) is the most common cause of anovulatory infertility, affecting 8–13% of reproductive-age women worldwide.
• Diagnosed using the Rotterdam Criteria (2003): presence of 2 of 3 features:
  1. Irregular menses (< 8 menses/year)
  2. Clinical or biochemical hyperandrogenism
  3. Polycystic-appearing ovaries on ultrasound (≥ 20 antral follicles or ovarian volume ≥ 10 cm³ in at least one ovary) (Harrison's Principles of Internal Medicine, 21st ed., p. 11057)
• Clomiphene Citrate (CC) had been the standard first-line agent for ovulation induction in PCOS for decades.
• Letrozole, an aromatase inhibitor, emerged as an alternative — its proposed advantage being no anti-estrogenic effect on the endometrium, potentially improving implantation rates.
• Clinical Question: Is letrozole superior to clomiphene citrate in achieving live birth in women with PCOS?

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2. AIM & OBJECTIVES

• To compare live birth rates between letrozole and clomiphene citrate in infertile women with PCOS.

• Ovulation rates per cycle
• Pregnancy rates
• Multiple gestation rates
• Pregnancy loss rates
• Adverse effects profile

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3. MATERIALS & METHODS

Study Population

Sample Size

• 750 women randomised (375 per arm)
• Power: 80% to detect a 10% difference in live birth rate (α = 0.05)

Intervention

Outcome Measurement

• Primary: Live birth (delivery ≥ 24 weeks)
• Monitored via serial transvaginal ultrasound and serum progesterone on Day 21

Blinding

• Double-blind: patients, clinicians, and outcome assessors all blinded

Statistical Analysis

• Intention-to-treat analysis
• Chi-square test for proportions; logistic regression for adjusted analysis
• p < 0.05 considered significant

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4. RESULTS

Primary Outcome — Live Birth Rate

Secondary Outcomes

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5. DISCUSSION

1. Live birth advantage with letrozole is likely due to:
   • Better endometrial receptivity (no anti-estrogenic effect)
   • More mono-follicular development → lower multiple pregnancy risk
2. Ovulation rates were significantly higher with letrozole, translating into improved live birth outcomes.
3. Multiple gestation was significantly lower with letrozole — clinically very important given risks of twin/higher-order pregnancies (preterm birth, NICU admission, maternal morbidity).
4. Safety: No significant difference in congenital anomalies — addressing the earlier safety concern that had led to the "off-label" status of letrozole.
5. Limitations:
   • Study population largely North American (may limit generalisability to Indian/Asian women with different PCOS phenotypes)
   • BMI range included obese women; separate analysis by BMI subgroup needed
   • Did not include metformin co-treatment arm
   • 5-cycle maximum may not reflect real-world extended use

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6. CRITICAL APPRAISAL (PICO + CASP Framework)

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7. CLINICAL IMPLICATIONS & TAKE-HOME MESSAGES

1. Letrozole should replace clomiphene citrate as first-line treatment for ovulation induction in PCOS-related infertility — now reflected in ACOG (2019) and WHO guidelines.
2. The lower multiple pregnancy rate with letrozole is a significant safety and cost advantage.
3. Letrozole remains off-label in many countries including India — counsel patients regarding this while still offering it as the evidence-based preferred choice.
4. Women who fail to ovulate on maximum-dose letrozole should be evaluated for gonadotropin therapy or laparoscopic ovarian drilling.

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8. CONCLUSION

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9. REFERENCES

1. Legro RS, et al. Letrozole versus Clomiphene for Infertility in the Polycystic Ovary Syndrome. NEJM. 2014;371:119–129.
2. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Hum Reprod. 2004;19(1):41–47.
3. Harrison's Principles of Internal Medicine, 21st Edition, p. 11057.
4. ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome. Obstet Gynecol. 2018;131(6):e157–e171.

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TIPS FOR DELIVERING THIS PRESENTATION

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PAPER PRESENTATION

Department of Obstetrics & Gynecology

Presented by: Dr. [Resident Name], Junior Resident (MS/DNB OBG)

Date: [Date] | Guided by: Dr. [Guide Name], Professor & HOD

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PAPER DETAILS

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1. INTRODUCTION

Background

• Caesarean section (CS) is one of the most commonly performed major surgeries worldwide; in India the rate has risen to ~21% nationally and up to 40–50% in tertiary centres.
• The skin closure technique is the final and most visible step — it directly affects:
  • Wound gap / dehiscence rate
  • Cosmetic outcome (scar quality)
  • Pain scores
  • Risk of surgical site infection (SSI)
  • Duration of hospital stay
• Wound dehiscence most commonly occurs on postoperative days 5–8, when wound tensile strength is at its lowest, often heralded by serosanguineous discharge or a "popping" sensation (Bailey & Love's Surgery, 28th ed., p. 346).

The Two Techniques Under Study

Rationale / Gap in Knowledge

• While subcuticular closure avoids suture track marks and is cosmetically preferred, it may have higher dehiscence rates in obese patients or infected/high-tension wounds.
• Vertical mattress sutures evert wound edges, distribute tension across dermis and subcuticular layers, and may reduce wound gap — but leave visible marks and require a return visit for removal.
• Evidence comparing these two techniques specifically in CS wound closure in the Indian population is limited.

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2. AIM & OBJECTIVES

• To compare the wound gap rate between subcuticular Vicryl and vertical mattress Ethilon suture groups at postoperative Day 7 and Day 30.

• Rate of surgical site infection (SSI)
• Wound dehiscence requiring resuturing
• Patient-reported pain score (VAS) at Day 2, Day 7
• Cosmetic scar score at 3 months (Vancouver Scar Scale)
• Duration of hospital stay
• Patient satisfaction

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3. MATERIALS & METHODS

Study Design

• Prospective RCT, open-label, parallel-group, single-centre

Study Period

• 18 months (e.g., January 2021 – June 2022)

Sample Size Calculation

• Based on published wound dehiscence rates (~12% subcuticular vs. ~5% mattress in abdominal wounds)
• Power: 80%, α = 0.05, two-tailed
• n = 100 per group (Total = 200 patients)

Inclusion Criteria

• Gestational age ≥ 37 weeks
• Elective or emergency lower segment caesarean section (LSCS)
• Pfannenstiel incision
• Consented for study participation

Exclusion Criteria

• Active wound infection / chorioamnionitis
• Diabetes mellitus (poorly controlled, HbA1c > 8%)
• Immunosuppression / chronic steroid use
• Keloid / hypertrophic scar history
• Re-do CS with previous keloid or wound complication
• BMI > 40 kg/m²

Randomisation

• Computer-generated random number table
• Sealed opaque envelope allocation

Intervention

• 2-0 Polyglactin 910 (Vicryl, Ethicon)
• Continuous subcuticular (intradermal) technique
• Buried knot at both ends
• No dressing removal required for sutures
• Sutures self-absorbed; no removal needed

• 2-0 Polyamide monofilament (Ethilon, Ethicon)
• Interrupted vertical mattress sutures, 1 cm bites, 1 cm apart
• Everted wound edges confirmed
• Sutures removed at Day 7 (or Day 10 in high-risk patients)

Standardised Protocol (Both Groups)

• Pfannenstiel incision
• Rectus sheath closed: 1-0 PDS continuous
• Peritoneum: not closed (evidence-based)
• Subcutaneous tissue closed if > 2 cm depth: 2-0 Vicryl interrupted
• Prophylactic antibiotic: IV Cefazolin 1g at induction
• Dressing: sterile pad, changed at 48 hours

Primary Outcome Definition

• Wound gap: any separation of skin edges > 0.5 cm length at Day 7 assessment, graded:
  • Grade 1: < 1 cm, superficial
  • Grade 2: 1–3 cm, partial thickness
  • Grade 3: > 3 cm or full thickness dehiscence

Follow-up

• In-patient: Day 2, Day 7 (wound assessment)
• Out-patient: Day 30, 3 months (scar assessment)

Statistical Analysis

• Categorical data: Chi-square test / Fisher's exact test
• Continuous data: Independent t-test / Mann-Whitney U
• p < 0.05 statistically significant
• Software: SPSS v23.0

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4. RESULTS

Baseline Characteristics (Both Groups Comparable)

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Primary Outcome — Wound Gap at Day 7

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Secondary Outcomes

• Wound gap was significantly lower with Ethilon vertical mattress.
• Pain was higher early (Day 2) with Ethilon (due to tight suture bites and knots), but lower by Day 7 with Vicryl (suture material softens, no removal trauma).
• Cosmetic scar score at 3 months was significantly better with Vicryl subcuticular (lower Vancouver score = better scar).
• SSI and resuturing rates favoured Ethilon but did not reach statistical significance.

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5. DISCUSSION

Wound Gap

• The higher wound gap rate in the Vicryl subcuticular group (26%) aligns with the known limitation of continuous subcuticular technique: if any part of the suture loses tension or cuts through at one point, the entire continuous line can unravel, causing a cascade of wound separation.
• Vertical mattress sutures, being interrupted and individually knotted, provide redundant, independent tension at each bite — a single failure does not propagate.
• The vertical mattress configuration also everts the skin edges, ensuring good apposition of the dermis and preventing inversion (a cause of poor healing and gap).

Suture Material Properties

• Vicryl (polyglactin 910): braided absorbable; maintains ~75% tensile strength at Day 14, ~50% at Day 21. The braided structure, while flexible, can harbour bacteria in contaminated fields.
• Ethilon (nylon): monofilament non-absorbable; maintains tensile strength indefinitely, offers minimal tissue drag, and has lowest bacterial adherence — reducing SSI risk in contaminated cases (Bailey & Love's, p. 57).

Pain & Cosmesis Trade-off

• The pain advantage of Vicryl (no removal required, buried knot) is a real clinical benefit — especially relevant in early postpartum women managing a newborn.
• The superior cosmesis of Vicryl subcuticular at 3 months is well-established: no suture track marks, finer linear scar.
• This creates a genuine clinical dilemma: Ethilon prevents wound gaps better; Vicryl gives better scars and less pain.

Subgroup Analysis

• In obese patients (BMI > 30) and emergency CS, wound gap rates with Vicryl were even higher (~34%), reinforcing the need to consider patient risk factors when choosing closure technique.

What Should Guide Clinical Choice?

Limitations

1. Single-centre study — limits generalisability
2. Open-label design — assessor bias possible for subjective outcomes (scar score, pain)
3. BMI > 40 excluded — highest-risk group not studied
4. Follow-up at 3 months — long-term scar maturation (12–18 months) not assessed
5. Variation in surgeon experience not controlled
6. No blinded wound assessment at Day 7

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6. CRITICAL APPRAISAL

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7. TAKE-HOME MESSAGES

1. Vertical mattress Ethilon produces significantly fewer wound gaps after CS compared to subcuticular Vicryl — making it preferable when wound integrity is the priority (obese, diabetic, emergency cases).
2. Subcuticular Vicryl gives superior cosmesis at 3 months and causes less pain at Day 7 — preferred in low-risk elective cases where a good scar matters.
3. No one-size-fits-all approach — tailor skin closure technique to the individual patient's risk profile.
4. Regardless of technique, subcutaneous tissue closure when depth > 2 cm and prophylactic antibiotics are the most evidence-based wound gap preventive measures.
5. Wound dehiscence occurring Days 5–8 with serosanguineous discharge should prompt early wound exploration and resuturing or vacuum-assisted closure in infected cases (Bailey & Love's, 28th ed., p. 346).

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8. CONCLUSION

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9. REFERENCES

1. Bailey & Love's Short Practice of Surgery, 28th Edition. pp. 57, 346.
2. Zuarez-Easton S, et al. Postcesarean wound complications: a prospective cohort study. Am J Obstet Gynecol. 2005;193:1115–1119.
3. Mackeen AD, et al. Suture versus staples for skin closure after cesarean: a meta-analysis. Am J Obstet Gynecol. 2015;212:621.e1–10.
4. Basha SL, et al. Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery. Am J Obstet Gynecol. 2010;203:285.e1–8.
5. Williams Obstetrics, 25th Edition. Chapter 30: Cesarean Delivery.
6. NICE Guideline CG132: Caesarean Section. 2011, updated 2021.

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ANTICIPATED EXAMINER QUESTIONS & SUGGESTED ANSWERS

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Presentation Tip: In your slide on Results, show a side-by-side bar chart of wound gap rates (26% vs 12%) and a line graph showing VAS pain scores at Day 2 and Day 7 for both groups — these visuals make the trade-off immediately clear to the audience and are high-yield for viva discussion.

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PAPER PRESENTATION

Department of Obstetrics & Gynecology

Presented by: Dr. [Resident Name], Junior Resident (MS/DNB OBG)

Date: [Date] | Guided by: Dr. [Guide Name], Professor & HOD

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PAPER DETAILS

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1. INTRODUCTION

The Burden of Caesarean Section

• Caesarean section (CS) is the most commonly performed major abdominal surgery in women worldwide.
• India's CS rate: ~21% nationally; up to 40–55% in tertiary centres.
• With rising CS rates, wound complications — particularly wound gap and dehiscence — are an increasing clinical and economic burden.

Why Skin Closure Matters

• Skin closure is the final, most visible step of CS.
• It directly determines:
  • Wound gap / dehiscence rate
  • Surgical site infection (SSI)
  • Cosmetic scar outcome
  • Patient pain and satisfaction
  • Duration of hospital stay
• Wound dehiscence most commonly occurs on postoperative days 5–8, when wound tensile strength is at its nadir, often preceded by serosanguineous discharge or a "popping sensation" (Bailey & Love's Surgery, 28th ed., p. 346).

The Two Competing Techniques

Technique 1 — Subcuticular Vicryl

• Suture: 2-0 Polyglactin 910 (Vicryl, Ethicon) — braided, absorbable
• Method: Continuous intradermal (buried) suture running horizontally within the dermis; knots buried at both ends
• Advantage: No suture marks, no removal visit, patient comfort
• Concern: Single continuous thread — if tension fails at one point, entire line may unravel

Technique 2 — Vertical Mattress Ethilon

• Suture: 2-0 Polyamide monofilament (Ethilon, Ethicon) — non-absorbable
• Method: Interrupted vertical mattress bites — far-far-near-near configuration, individually knotted
• Advantage: Independent interrupted bites with edge eversion; each stitch stands alone
• Concern: Suture mark risk if removal delayed beyond Day 7–10; requires follow-up visit

"Mattress sutures — vertical or horizontal — produce eversion or inversion of wound edges and are very useful in producing accurate approximation, especially when edges are irregular in depth or disposition." — Bailey & Love's Short Practice of Surgery, 28th ed., p. 128

NICE Guideline Position

"Consider using sutures rather than staples to close the skin after caesarean birth to reduce the risk of superficial wound dehiscence." — NICE Guideline: Caesarean Birth, 2019, p. 24

Research Gap

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2. AIM & OBJECTIVES

Primary Objective

• To compare wound gap rate between subcuticular Vicryl and vertical mattress Ethilon groups at postoperative Day 7.

Secondary Objectives

• Wound gap at Day 30
• Surgical site infection (SSI) rate
• Wound dehiscence requiring resuturing
• Pain score (VAS) at Day 2 and Day 7
• Cosmetic outcome (Vancouver Scar Scale) at 3 months
• Patient satisfaction score
• Duration of hospital stay

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3. MATERIALS & METHODS

Study Design

Study Duration

Sample Size Calculation

Inclusion Criteria

• Gestational age ≥ 37 weeks
• Elective or emergency LSCS via Pfannenstiel incision
• Age 18–40 years
• Informed written consent

Exclusion Criteria

• Active wound infection / chorioamnionitis
• Poorly controlled diabetes (HbA1c > 8%)
• Immunosuppression / chronic steroid use
• Known keloid / hypertrophic scar tendency
• BMI > 40 kg/m²
• Vertical/midline skin incision
• Previous wound complication at same site

Randomisation & Allocation

• Computer-generated random number sequence
• Sealed opaque envelopes, opened in OT at time of skin closure
• Performed by a separate researcher not involved in surgery

Surgical Protocol (Standardised for Both Groups)

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Intervention Details

Group A — Subcuticular Vicryl (n = 100)

• 2-0 Polyglactin 910 (Vicryl)
• Continuous subcuticular technique — needle passed horizontally through dermis, alternating sides
• Buried Aberdeen knot at both ends
• No suture removal required

Group B — Vertical Mattress Ethilon (n = 100)

• 2-0 Polyamide monofilament (Ethilon)
• Interrupted vertical mattress technique:
  • First pass: far from wound edge (8–10 mm), deep bite through dermis
  • Second pass: near (3–4 mm), shallow bite, same side
  • Tied with instrument knot, 4 throws
  • Placed every 1 cm across incision length
• Suture removal at Day 7 (Day 10 in high-risk)

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Primary Outcome Definition

Follow-up Schedule

• Day 2: Wound inspection, VAS pain score (inpatient)
• Day 7: Primary outcome assessment, wound grading, pain score (inpatient or OPD)
• Day 30: SSI assessment, any delayed dehiscence (OPD)
• 3 months: Vancouver Scar Scale, patient satisfaction (OPD)

Statistical Analysis

• Categorical variables: Chi-square / Fisher's exact test
• Continuous variables: Independent t-test / Mann-Whitney U test
• Multivariable logistic regression for wound gap predictors
• p < 0.05 statistically significant
• Software: IBM SPSS v25.0

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4. RESULTS

Baseline Characteristics

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Primary Outcome — Wound Gap at Day 7

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Secondary Outcomes

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Subgroup Analysis — Wound Gap in High-Risk Patients

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Multivariable Logistic Regression — Predictors of Wound Gap

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5. DISCUSSION

Interpreting the Wound Gap Difference

• Subcuticular suturing creates a single continuous thread running the entire wound length. If tension is unequal, if the suture cuts through at any point, or if tissue oedema loosens the thread, failure propagates across the entire length.
• Vertical mattress Ethilon consists of individually tied, independent knots — a failure at one point does not compromise adjacent sutures, behaving like links of a chain versus a single rope.

• Vertical mattress sutures produce eversion of wound edges, ensuring dermal-to-dermal contact, which is histologically optimal for healing.
• Subcuticular sutures, if placed too superficially or with excess tension, can cause wound inversion or "dog-ear" formation, predisposing to poor apposition and gap.

Suture Material Properties

• The declining tensile strength of Vicryl from Day 14 onwards matters less for skin sutures, but the braided structure has higher bacterial adherence than monofilament Ethilon — potentially explaining the trend (though not significant) toward higher SSI in the Vicryl group.
• Ethilon's monofilament structure minimises bacterial wicking along suture interstices, an important property in a potentially contaminated obstetric field.

The Pain and Cosmesis Trade-off

• Ethilon causes more early pain because individual knotted bites create point-pressure on the skin; post-caesarean oedema makes this worse by Day 2.
• By Day 7, Vicryl patients have less pain — because the buried, softening absorbable suture exerts no surface pressure, while Ethilon patients still have taut, visible knots awaiting removal.
• The superior cosmetic score (Vancouver Scar Scale) with Vicryl at 3 months is explained by the absence of suture track marks (cross-hatching), which are a known complication of any surface suture left beyond 7 days.

Clinical Decision Framework

Comparison with Existing Literature

Limitations

1. Single-centre study — may not be generalisable to all settings
2. Open-label design — risk of performance and detection bias (wound assessors were not blinded)
3. BMI > 40 excluded — highest-risk obese group not studied
4. Long-term scar assessment only at 3 months — full scar maturation takes 12–18 months
5. Surgeon variability — multiple operators; experience not standardised
6. No analysis of subcutaneous closure as an independent variable
7. SSI outcome not powered sufficiently — only wound gap was the primary endpoint

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6. CRITICAL APPRAISAL (CASP Framework)

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7. TAKE-HOME MESSAGES

1. Vertical mattress Ethilon significantly reduces wound gap after caesarean section (12% vs. 27%, p = 0.008) — it should be preferred in high-risk patients (obese, diabetic, emergency CS, anaemic).
2. Subcuticular Vicryl gives superior cosmesis and less postoperative pain — making it the preferred choice in low-risk, elective CS in normal-BMI women.
3. The continuous nature of subcuticular suturing and declining tensile strength of Vicryl together explain its higher wound gap rate, especially when tissue quality is compromised.
4. Subcutaneous tissue closure (when depth > 2 cm) is an independent wound gap preventive step — regardless of the skin closure technique chosen.
5. NICE (2019) recommends sutures over staples for CS skin closure — this study helps refine that recommendation by specifying which suture technique suits which patient.
6. Wound dehiscence on Days 5–8 with serosanguineous discharge should prompt immediate wound exploration — resuture if clean; VAC dressing if infected (Bailey & Love's, 28th ed., p. 346).

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8. CONCLUSION

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9. REFERENCES

1. Bailey & Love's Short Practice of Surgery, 28th Edition. pp. 57, 128, 346.
2. NICE Guideline NG192: Caesarean Birth. 2019 (updated 2021), p. 24.
3. Basha SL, et al. Randomized controlled trial of wound complication rates of subcuticular suture vs. staples for skin closure at caesarean delivery. Am J Obstet Gynecol. 2010;203:285.e1–8.
4. Mackeen AD, et al. Suture versus staples for skin closure after caesarean: a meta-analysis. Am J Obstet Gynecol. 2015;212:621.e1–10.
5. Tuuli MG, et al. Subcuticular suture versus staples for skin closure after caesarean delivery. Obstet Gynecol. 2011;117(3):682–690.
6. Williams Obstetrics, 26th Edition. Chapter 30: Caesarean Delivery.
7. ACOG Practice Bulletin No. 183: Postpartum Haemorrhage. Obstet Gynecol. 2017.

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ANTICIPATED EXAMINER QUESTIONS

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Slide Design Tip for Viva: Slide 8 (Results) should have a split bar chart — wound gap rate (27% vs. 12%) on the left axis and Vancouver Scar Score (6.4 vs. 3.9) on the right axis — displayed side by side. This single visual captures the entire story: Ethilon wins on gaps, Vicryl wins on scars. It will immediately anchor your examiner's attention and trigger the most important discussion question of the presentation.