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Wound Gap in Skin Closure After Caesarean Section: Subcuticular Vicryl vs. Vertical Mattress Ethilon

A Comparative Paper Presentation

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ABSTRACT

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1. INTRODUCTION

• Wound healing and integrity
• Risk of surgical site infection (SSI)
• Cosmetic outcome and scar quality
• Patient comfort and recovery

Key Definitions

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2. BACKGROUND AND RATIONALE

2.1 Current Evidence Base

2.2 The Two Techniques Under Study

Subcuticular Suture with Vicryl (2-0 or 3-0)

• Placed within the dermis, running continuously along the wound
• No visible suture marks on skin surface
• Vicryl is absorbable — no removal required
• Provides even tension distribution along the incision
• Excellent cosmetic result when done correctly
• Risk: if tension is too high or suture is placed too superficially, dehiscence can occur

Vertical Mattress with Ethilon (2-0 or 3-0)

• Interrupted technique with two levels of bites (deep and superficial)
• Everts wound edges, reducing dead space and tension
• Ethilon is non-absorbable — requires removal at day 5–7
• Excellent tensile strength
• Risk: suture marks ("railroad tracking"), patient discomfort, need for follow-up for removal
• Particularly effective in obese patients and those with high skin tension

2.3 Rationale for Comparison

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3. AIMS AND OBJECTIVES

Primary Objective

Secondary Objectives

1. To compare wound infection rates (SSI) between the two groups
2. To assess cosmetic outcome using the Manchester Scar Scale or Vancouver Scar Scale
3. To compare patient-reported pain scores at day 1, 3, and 7
4. To evaluate time taken for skin closure
5. To assess patient satisfaction with wound appearance at 6 weeks
6. To identify risk factors for wound gap in each group

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4. MATERIALS AND METHODS

4.1 Study Design

4.2 Study Setting

4.3 Sample Size

4.4 Inclusion Criteria

• Patients undergoing elective or emergency lower segment caesarean section (LSCS)
• Pfannenstiel incision used for skin entry
• Age 18–45 years
• Singleton or twin pregnancy
• Written informed consent

4.5 Exclusion Criteria

• Known allergy to suture materials
• Active skin or soft tissue infection at incision site
• Immune-compromised status (HIV, long-term steroids, chemotherapy)
• Morbid obesity (BMI > 45 kg/m²) — analyzed separately
• Previous keloid or hypertrophic scar
• Emergent situations where technique was dictated by clinical need

4.6 Randomization and Allocation

• Patients randomized using sealed opaque envelopes or computer-generated random numbers
• Group A (n=150): Skin closure by subcuticular continuous suture using Vicryl 2-0 on a round-body needle
• Group B (n=150): Skin closure by interrupted vertical mattress suture using Ethilon 2-0 on a cutting needle

4.7 Surgical Protocol (Standardized)

• All C-sections performed via Pfannenstiel / Joel-Cohen incision
• Peritoneal closure as per surgeon preference (standardized within study)
• Rectus sheath closed with loop PDS or Vicryl No. 1
• Subcutaneous fat approximated with interrupted Vicryl 2-0 if > 2 cm thickness
• Skin closure as per allocated group
• Standard perioperative antibiotics: IV Cefazolin 1–2g at induction

4.8 Outcome Measurement

• Defined as any separation of skin edges > 1 cm in length
• Assessed at: day 3, day 7, day 14, and day 30 post-operation
• Assessed by a blinded assessor (midwife/resident not involved in surgery)

• SSI graded per CDC/NHSN criteria (superficial incisional, deep incisional)
• Cosmetic score at 6 weeks using Patient Observer Scar Assessment Scale (POSAS)
• Pain by Visual Analogue Scale (VAS) at day 1, 3, 7
• Closure time measured in minutes
• Patient satisfaction questionnaire at 6 weeks

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5. RESULTS (Expected / Comparative Literature Findings)

5.1 Published Evidence Summary

Note: Direct RCT data specifically comparing subcuticular Vicryl vs. vertical mattress Ethilon in C-section is limited; most literature compares sutures vs. staples or absorbable vs. non-absorbable broadly.

5.2 Proposed Results Table (Template for Own Study)

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6. DISCUSSION

6.1 Mechanism of Wound Gap — Why Does It Occur?

• Obesity (BMI > 30) — increased adipose tissue reduces wound oxygenation and increases mechanical tension
• Diabetes mellitus — impaired collagen synthesis and neutrophil function
• Anaemia — reduced tissue perfusion and healing capacity
• Prolonged labour before LSCS — increased tissue oedema and bacterial load
• Corticosteroid use — suppresses fibroblast proliferation
• Malnutrition — reduced protein availability for wound matrix

• Inadequate tissue bites leaving dead space
• Excessive tension on suture line
• Suture cutting through fragile or oedematous tissue
• Haematoma formation in subcutaneous layer (more common without fat closure)

6.2 Subcuticular Vicryl — Advantages and Limitations

• Evenly distributes tension across the wound length
• Absorbable — eliminates need for suture removal visit
• Better cosmetic result (no external marks)
• Patient comfort superior (no protruding suture ends unless anchored externally)
• Faster closure time compared to interrupted sutures

• Technique-sensitive: superficial placement or excessive tightening leads to cheese-wiring through skin
• If infection occurs, the entire suture line may need to be removed
• Vicryl's braided structure may harbor bacteria if wound becomes contaminated
• Vicryl begins losing tensile strength at ~3 weeks, which coincides with the period of maximum wound remodeling

6.3 Vertical Mattress Ethilon — Advantages and Limitations

• Excellent wound eversion — reduces inversion-related dehiscence
• Eliminates dead space effectively with the deep bite
• Monofilament Ethilon resists bacterial colonization compared to braided sutures (Bailey & Love's, 28th Ed., p. 1099)
• If one suture breaks or is removed, remainder of suture line is intact
• Particularly valuable in: obese patients, poorly perfused tissues, high-tension wounds

• Requires removal (day 5–7) — adds patient visit and potential discomfort
• Creates suture track marks if left too long or tied too tightly
• More time-consuming to place than subcuticular technique
• Higher patient-reported pain due to external sutures
• If sutures are placed too tightly, they cause ischaemia and paradoxically increase dehiscence risk

6.4 The Tension Concept — Critical for Understanding Wound Gap

• In subcuticular closure: suture run that is too short (< 4:1 ratio) pulls edges tight and leads to ischaemia and gap
• In vertical mattress: ties that are too tight cause tissue strangulation; too loose fails to evert edges

6.5 Risk Factor Subgroup Analysis

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7. COMPLICATIONS SPECIFIC TO EACH TECHNIQUE

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8. CLINICAL RECOMMENDATIONS

1. For low-risk patients (normal BMI, no diabetes, elective LSCS, no prolonged labour):
   • Subcuticular Vicryl is the preferred technique
   • Superior cosmesis, no removal required, equivalent dehiscence rates
   • Consistent with NICE Caesarean Birth Guideline (2019, p. 24) recommending sutures over staples
2. For high-risk patients (obese, diabetic, emergency LSCS, prolonged labour, anaemia):
   • Vertical mattress Ethilon may offer advantage through superior edge eversion and dead-space elimination
   • Consider fat-layer closure (Scarpa's fascia/subcutaneous) before skin closure in patients with subcutaneous fat > 2 cm
   • Negative pressure wound therapy (NPWT) dressings should be considered in very high-risk cases
3. Universal measures to reduce wound gap:
   • Prophylactic antibiotics at induction
   • Subcutaneous fat closure when fat layer > 2 cm
   • Haemostasis before closure
   • Adequate nutrition and Hb optimization pre-operatively
   • Blood glucose control perioperatively

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9. CONCLUSION

• Subcuticular Vicryl offers better cosmesis, patient comfort, and no removal burden, making it ideal for standard-risk patients
• Vertical mattress Ethilon provides superior edge eversion, dead-space elimination, and monofilament resistance to infection, making it preferable in high-risk populations

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10. REFERENCES

1. NICE Guideline: Caesarean Birth (2019). National Institute for Health and Care Excellence. Recommendation 1.4.41, p. 24. "Consider using sutures rather than staples to close the skin after caesarean birth to reduce the risk of superficial wound dehiscence."
2. Bailey & Love's Short Practice of Surgery, 28th Edition. Norman S. Williams et al. CRC Press. Chapter on Wound Closure, p. 1099. Suture length to wound length ratio and principles of tension-free closure.
3. Rousseau JA, Girard K, Turcot-Lemay L, Thomas N. (2009). A randomized study comparing skin closure in cesarean sections: staple vs subcuticular suture. Am J Obstet Gynecol, 200(3):265.e1-4.
4. Basha SL, Rochon ML, Quiñones JN, Coassolo KM, Rust OA, Smulian JC. (2010). Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery. Am J Obstet Gynecol, 203(3):285.e1-8.
5. Clay FS, Walsh CA, Walsh SR. (2011). Staples vs subcuticular sutures for skin closure at cesarean delivery: a metaanalysis of randomized controlled trials. Am J Obstet Gynecol, 204(5):378-383.
6. Figueroa D, Jauk VC, Szychowski JM, et al. (2013). Surgical staples compared with subcuticular suture for skin closure after cesarean delivery: a randomized controlled trial. Obstet Gynecol, 121(1):33-38.
7. Chelmow D, Rodriguez EJ, Sabatini MM. (2004). Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol, 103(5 Pt 1):974-980.
8. Mackeen AD, Berghella V, Larsen ML. (2012). Techniques and materials for skin closure in caesarean section. Cochrane Database Syst Rev, (11):CD003577.

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APPENDIX: SUTURE TECHNIQUE ILLUSTRATIONS

Subcuticular Suture Technique

Skin surface ─────────────────────────────
                 →  →  →  →  →  →
Dermis      ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~  (suture runs intradermal)
Subcutis    ══════════════════════════════════

• Needle enters dermis at one end, passes horizontally through dermal layer
• Bites taken alternately from each side, advancing along wound
• Exits at opposite end; secured with knot or suture anchor

Vertical Mattress Technique

        Far-far bite         Near-near bite
            |                     |
Skin  ──────●─────────────────────●──────
           \|/                   \|/
Dermis  ────╬─────────────────────╬──────   (deep bite)
Subcutis  ──╬─────────────────────╬──────

• First pass: far bite (4–8 mm from edge), deep through dermis
• Second pass: near bite (1–2 mm from edge), superficial through dermis
• Tied on same side — everts wound edges

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SUMMARY SLIDE (Key Take-Home Messages)

1. NICE (2019) recommends sutures over staples for C-section skin closure to reduce wound dehiscence
2. Subcuticular Vicryl: better cosmesis, no removal, preferred in low-risk patients
3. Vertical mattress Ethilon: better edge eversion, dead-space elimination, preferred in high-risk (obese, diabetic) patients
4. Wound gap is multifactorial — technique alone cannot eliminate all risk; patient optimization is essential
5. High-quality RCT evidence directly comparing these two techniques specifically in C-section is still lacking — there is a gap in the literature your study can fill