_____________________________________________________________________________________________________
*Corresponding author: E-mail: [email protected];
Non-suture Skin Closure Technique for Cesarean Section (Quek's Technique): A Case Series
Yek-Song Quek1*, Michelle Jia Ni Ling2 and Bt. Hassan Jamiyah3
1Columbia Asia Hospital Iskandar Puteri, Malaysia, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Malaysia.
2Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Malaysia.
3Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Malaysia.
Authors’ contributions
This work was carried out in collaboration among all authors. Author YSQ designed the study, performed the statistical analysis, wrote the protocol and wrote the first draft of the manuscript.
Authors MJNL and BHJ managed the analyses of the study. Author BHJ managed the literature searches. All authors read and approved the final manuscript.
Article Information
Editor(s):
(1)Dr. David Kitara Lagoro, Gulu University, Uganda.
Reviewers:
(1) Anil Patil, Bharati Vidyappeth Deemed to be University, India.
(2)Vijayata Sangwan, Bhagat Phool Singh Government Medical College, India.
Complete Peer review History:http://www.sdiarticle4.com/review-history/57161
Received 23 March 2020 Accepted 30 May 2020 Published 17 June 2020
ABSTRACT
Cesarean section (CS) is one of the most frequent abdominal procedures conducted in women worldwide. It is known that 5% of women who underwent CS would encounter wound complications. Several studies had been performed throughout the years to find the best option for skin closure in CS but to no avail, as none shows conclusive evidence. However, there is evidence showing that wound complications are reduced with the subcutaneous tissue closure technique.
This case report is presenting a new non-suture technique of skin closure by opposing the skin using steri-strip after the adipose tissue is sutured, following a standard CS to eliminate any foreign materials to reduce bacterial entrapment and vascular disruption at the dermis layer thus reduce keloid formation.
Keywords: Cesarean section; non-suture technique; skin closure; wound complications; case report.
Case Study
1. INTRODUCTION
Cesarean section (CS) is one of the most frequent abdominal procedures conducted in women worldwide [1,2]. A meta-analysis regarding the techniques and materials used for skin closure in CS shows no conclusive evidence about how the skin should be closed with the best outcome. Staples are associated with similar results in terms of wound infection, pain, and cosmesis when compared to sutures. Both of these skin closure techniques are the most commonly studied methods for skin closure during CS. If staples are removed on three days post-CS, it is found to have an increased incidence of skin separation and the need for reclosure compared to absorbable sutures [3].
A meta-analysis by V. Pergialiotis et al. which includes ten RCTs involving 3696 women, concluded that the subcutaneous tissue closure technique during CS results in lower wound complications [2].
Wound complications post CS are encountered by 5% of women who have undergone CS, which include hematomas, seromas, infection, and pain, that might further lead to wound dehiscence. It is believed that obesity or thick subcutaneous tissue (> 3 cm) might have a direct effect on the wound complication rate [2].
Thus, any modified skin closure technique that could reduce the incidence of wound complications and pain would have a significant impact on the national economic health plans.
Hence, a trial of a new non-suture technique of
skin closure for CS is being performed and presented.
2. PRESENTATION OF CASE
Ten young pregnant women opting for CS were selected, and consents are given for this new non-suture technique of skin closure. Only Malaysians who have consented for the procedure are included in the study; otherwise, they will be excluded. All surgeries were performed by the consultant who initiated this new skin closure technique. Their mean age is 29, with a BMI of 22. A summarized table, including the participants’ history [Table 1], is being provided. The intraoperative analgesics used is the standardized spinal anesthesia, which comprises of intrathecal heavy bupivacaine 10 – 12.5 mg, and morphine 100 - 150 mcg based on height and weight of the patient. A standard CS procedure is conducted and closed till rectus sheath with the absorbable 1/0 suture as usual. After that, the Z method is applied to close the deep subcutaneous tissue with the remaining suture continuously [Fig. 1,2].
The skin is not closed with any suture as usual but is opposed with a pack of steri-strip ½ inch [Fig. 3]. Post CS, the wound is covered with a waterproof dressing patch for 10 - 14 days [Fig.
4]. Patients are allowed to ambulate and bath with caution. The waterproof dressing patch can be replaced if necessary. The removal of the dressing patch and steri-strips as well as wound inspection, are performed on day 14 post- operation, which is then followed up by a second wound inspection a month later.
Fig. 1. Suturing of fat tissue layer [4]
Fig. 2. Complete closure of fat layer [4]
Fig. 3. Opposing the skin with steri- strip [4]
Table 1. Summarized participants’ histories
No. Age Parity BMI GEST. Past medical history NO.
Scar
Elective/
Emergency
1 35 G7P4+2 27 38 weeks - 1 Emergency
2 32 G1P0 19 38 weeks - - Emergency
3 32 G3P2 22 37 weeks GDM on D/C 1 Elective
4 34 G2P1 23 37 weeks GDM on D/C 1 Elective
5 22 G1P0 19 38 weeks - - Emergency
6 31 G3P2 22 37 weeks - 2 Elective
7 31 G1P0 22 40 weeks IDA - Elective
8 22 G3P2 19 37 weeks IDA 2 Elective
9 33 G1P0 22 38 weeks GDM on D/C - Elective
10 22 G1P0 20 38 weeks IDA - Elective
Abbreviation: Gest = Gestation, GDM on D/C = Gestational Diabetes Mellitus on Diet control, IDA = Iron deficiency anemia
Fig. 4. Post- operation 10-14 days scars [4]
The ten patients are followed up after a month for wound inspection, and none of them have developed any wound complications, namely hematoma, seromas, or infection. They are able to ambulate freely and carry out their daily life activities without complaining of any obvious pain at the wound site.
3. DISCUSSION
This non-suture technique of skin closure for CS avoids the introduction of any additional foreign material during the wound healing process. It also reduces vascular supply disruption at the dermis layer, which might lower the risk of infection, pain, and keloid formation. There are no visible or noticeable stitch lines as well as keloid formation when being observed at second follow up. The CS scars remained as thin as a line or 1mm width. The steri-strip and water-proof dressing patch play a role in providing double- layer protection against infection. This also allows blood to be drained out spontaneously and avoided any possibility of hematoma formation. Hence, this technique could be the most cost-effective when compared to other methods used in CS. An economic comparison of the various methods used in wound closure analysis performed by William T Zempsky et al.
concluded that the adhesive wound closure strip is cost-saving and cost-effective. It can be an
alternative to sutures and used as tissue adhesives in the closure of low-tension lacerations [5].
4. CONCLUSION
This new non-suture technique can be an alternative or even a better option in regard to the standard stapler, suture skin closure, and other methods used during CS. However, currently, the available data is still limited; thus, a larger randomized control trial is needed in the future.
CONSENT AND ETHICAL APPROVAL
As per university standard guideline, participant consent and ethical approval have been collected and preserved by the authors.
COMPETING INTERESTS
Authors have declared that no competing interests exist.
REFERENCES
1. Pfuntner A, Wier L, Stocks C. Most frequent procedures performed in U.S.
Hospitals. HCUP Statistical Brief #149.
February 2013. Agency for Healthcare
Research and Quality, Rockville, MD;
2010.
2. Pergialiotis V, Prodromidou A, Perrea DN, Doumouchtsis SK. The impact of subcutaneous tissue suturing at caesarean section on wound complications: A meta- analysis. BJOG. 2017;124(7):1018-25.
DOI: 10.1111/1471-0528.14593
3. A Dhanya Mackeen, Vincenzo Berghella, Mie-Louise Larsen. Techniques and materials for skin closure in caesarean
section. Cochrane Database Syst Rev.
2012;11(11):CD003577.
DOI: 10.1002/14651858.CD003577.pub3.
4. Quek, YS. “Quek Technique”. JPG file;
2019.
5. Zempsky WT, Zehrer CL, Lyle CT, Hedbloom EC. Economic comparison of methods of wound closure: Wound closure strips vs. sutures and wound adhesives. Int Wound J. 2005;2(3):272‐281.
DOI:10.1111/j.1742-4801.2005.00130.x _________________________________________________________________________________
© 2020 Quek et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Peer-review history:
The peer review history for this paper can be accessed here:
http://www.sdiarticle4.com/review-history/57161
