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And she’s pregnant…And she’s in early labor…And she’s breech…And your partners are nowhere to be found…
Objectives
• 1. What is the problem?
• 2. Incision choice in the obese patient
• 3. Closure techniques
• 4. Suture material
• 5. To drain or not to drain…
The Problem:Obesity is an independent risk factor for post-operative
infectious morbidityInfectionInfection No InfectionNo Infection
Emergent c/s BMI (kg/m2) 36.6 32.2 p<.001
Obesity % 81.8 57.3p<.001
Elective c/s BMI 38.9 32.2p<.003
Obesity % 89.5 58.0 p<.04
Thickness of SubcutaneousTissue 4.1 cm 2.3 cm p=.04
Myles Ob Gyn 2002;100:959
Vermillion Ob Gyn 2000;95:923
Transverse vs Vertical Incisions in Abdominal Surgery
11 randomized + 7 retrospective studiesProcedures: cholecystectomy, AAA, trauma,
major laparotomy:
Significant increase in pulmonary complications, burst abdomen, incisional hernia in vertical groupNo difference in exposureTime to open : V 9.9 min
T 13.9 min p<0.05
Grantcharov Eur J Surg 2001;167:260
Vertical vs Transverse in Obese C/S
Retrospective review of 239 women undergoing primary C/S with BMI > 35
Transverse(213) Vertical(26)
Wound breakdown 2% 15% p =0.003
Wound infection 7% 19% p = 0.04
Endometritis 15% 15% p = 0.98
Chorioamnionitis 15% 3% p = 0.11
Wall Ob Gyn 2003;102:952
High Transverse vs Low Transverse
Case-control retrospective review of C/S for women >150% ideal body weight
Supraumbilical Pfannenstiel
15 54
Avg wt lbs 329 + 60 246 + 34
No difference in infectious or non-infectious complications
Houston Am J Ob Gyn 2000;182:1033
The Baby Is Out…Now What?
Is there a need for visceral peritoneum closure?549 Randomized to closure vs nonclosureClosure group had significantly more:
Febrile episodesCystitisOperative timeLength of stay
Conclusion: do not close visceral peritoneum
Nagele Am J Ob Gyn 1996;174:1366
Fascial Closure
Meta-analysis of midline abdominal closures: 15 studies/6566 patients revealedContinuous suture vs interrupted had no difference in outcomesLowest incisional hernias with slowly absorbable
and non-absorbable vs rapidly absorbableNon-absorbable had increased wound pain and
suture sinus formation over slowly absorbable
Van ‘t Riet B J Surg 2002;89:1350
Wound Healing1st phase: 1-4 d exudative phase
no wound strength2nd phase: 5-20 d proliferative phase
connective tissue repairregains 15-30% strengthdelayed if infectionperiod of hernia initiation
3rd phase: 21 d-yrs tissue remodelingregains ~ 80% strength
What About SubQ?
245 women with at least 2 cm subcut fat were randomized to closure or non-closure of Camper fascia with running 3-0 polyglycolic acid
Closure Non-closure Seroma 5.1% 17.2% p=.002 Hematoma 3.4% 1.6% p=NS Infection 6.0% 7.8% p=NS Disruption 14.5% 26.6% RR 0.5
(CI=0.3-0.9)
Naumann Ob Gyn 1995;85:412
SubQ Closure vs Drainage76 women with > 2cm subcut randomized to running 3-0
vs drain vs nothing
Suture Drain NoneInfection 7.7% 0 3.9%Separation 15.4% 4.2% 26.9%
Drain group had significantly lower rate of complications compared to non-closure group
Allaire J Repro Med 2000;45:327
SubQ Closure vs Drainage 2
964 women with subcut > 2 cm s/p C/S randomized to subcut 3-0 running vs non-closure vs 7 mm closed drain.
Suture Drain None
Wound disruption 9.9% 9.7% 8.7%
No difference in seroma/hematoma/infection rate
Magann Am J Ob Gyn 2002;186:1119
Antibiotic Prophylaxis for C/S
Cochrane review: 81 trials with 12,000 women worldwide. Contained elective C/S and non-elective C/S.
Antibiotic treated women RR:
Endometritis 0.39 (0.31-0.43)
Wound infection 0.41 (0.29-0.43)
Smaill Cochrane Library 2004;4
Take-Home Conclusions:1. Obese C/S patients at significant risk for infection and
wound disruption2. Transverse incision has fewer complications at cost of
more time to entry3. Supraumbilical transverse incision is an option4. Do not need to close the visceral peritoneum5. Close the fascia with continuous slowly absorbable
suture6. There may be a benefit to subcutaneous closure vs
drainage in the obese patient7. Antibiotics should be used in these patients to reduce
post-operative incision complications
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