Adhesive Glue vs Subcuticular Sutures for Cesarean Section Skin Closure: A Double Blind Randomized Controlled Trial
Objectives: The objectives of the study were to compare the wound complication rate, postoperative pain and overall patient satisfaction between adhesive glue and subcuticular suture in women undergoing elective Caesarean Section (CS).
Methods: A double blind Randomized Controlled trial was conducted among pregnant women undergoing an elective CS, who were randomly assigned to skin closure with adhesive glue or with a Polyglactin 3-0 subcuticular suture. In both groups after closure of the rectus fascia, the subcutaneous fat layer was closed with 3-4 interrupted catgut or Vicryl 1-0. In the adhesive glue group, 2 layers of adhesive glue were used to close the outer skin layer. In the suture group, the skin was closed with Polyglactin 3-0 suture under the skin using a continuous suture technique. A sample of 52 in each group was needed to achieve any significant finding with a power of 80%. Primary outcome assessed were parenteral analgesic use, daily subjective pain scores while in hospital, 6 week postoperative subjective pain score and scar cosmetic score 6 weeks post-operatively. Secondary outcome assessed were surgeons satisfaction, duration of surgery, duration of hospitalization after the caesarean, and wound complications.
Results: Two hundred pregnant women at term for elective caesarean were assessed for eligibility of which 132 fulfilled the criteria and were randomized into two groups. Sixty women in each group completed the required follow up. Patients’ baseline demographic and clinical backgrounds were similar in both the groups. Postoperative day 3 subjective pain score was significantly lower in adhesive glue group (p=0.023) compared to suture group. Skin closure time with glue required less time compared to suture (glue 2.57±.67 minute vs suture 3.2±1.18 minute, p=0.001). Total operative time was also less in adhesive glue group though the difference was not significant (39.52±8.24 minute vs 42.1±6.10, p=0.054). Scar assessment by the modified patient and observer scar assessment scale (POSAS) at 6 weeks postpartum showed similar cosmetic outcome between the two groups. Patient Scar cosmetic score was 11.8 for glue group and 12.7 for suture group (p=0.330) while the Observer Scar cosmetic score was 10.8 for glue group and 11.7 for suture (p=0.252). No significant differences were observed between the groups in blood loss, surgical site infection, length of hospitalization, or wound breakdown.
Conclusion: Adhesive glue may be a useful option for skin closure of Pfannenstiel skin incisions after caesarean delivery. It has the advantages like shorter skin closure and operating time, less postoperative pain and similar cosmesis and satisfaction among surgeons with no increases in wound complication rates.
1.Blanchette H. The rising cesarean deliveryrate in America: what are the consequences? Obstet Gynecol 2011;118:687- 90.
2. Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery. Am J Obstet Gynecol 2005;193:1607–17.
3. Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol 2013;209:294–306.
4. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med 1997;16:1142–8.
5. Kwon JY, Yun HG, Park IY. n-Butyl-2-cyanoacrylate tissue adhesive (Histoacryl) vs. subcuticular sutures for skin closure of Pfannenstiel incisions following cesarean delivery. PLoS One 2018;13:e0202074.
6. Clay FSH, Walsh CA, Walsh SR. Staples vs subcuticular sutures for skin closure at cesareandelivery: A metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2011;204:378– 83.
7. Bhende S, Rothenburger S, Spangler DJ, Dito M. In vitro assessment of microbial barrier properties of Dermabond topical skin adhesive. Surg Infect (Larchmt) 2002;3:251–7.
8. Siddiqui DS, Lacuna EM, Chen HY, Chauhan SP. Skin closure of Pfannenstiel incision with Dermabond, staples, or suture during cesarean delivery: experience of a single attending. Am J Perinatol 2013;30:219–24.
9. Coulthard P, Worthington H, Esposito M, Elst M, Waes OJ. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev 2004;2:CD004287.
10. Shapiro AJ. Dinsmore RC, North JH Jr. Tensile strength of wound closure with cyanoacrylate glue. Am Surg 2001;67:1113–5.
11. Gordon CA. Reducing needle-stick injuries with the use of 2-octyl cyanoacrylates for laceration repair. J Am Acad Nurse Pract 2001;13:10–2.
12. Mertz PM, Davis SC, Cazzaniga AL, Drosou A, Eaglstein WH. Barrier and antibacterial properties of 2-octyl cyanoacrylate-derived wound treatment flms. J Cutan Med Surg 2003;7:1–6.
13. Lin M, Coates WC, Lewis RJ. Tissue adhesive skills study: the physician learning curve. Pediatr Emerg Care 2004;20:219– 23.
14. Blondeel PN, Murphy JW, Debrosse D, Nix JC 3rd, Puls LE, Theodore N, et al. Closure of long surgical incisions with a new formulation of 2-octylcyanoacrylate tissue adhesive versus commercially available methods. Am J Surg 2004;188:307– 13.
15. Gennari R, Rotmensz N, Ballardini B, et al. A prospective, randomized, controlled clinical trial of tissue adhesive (2-octylcyanoacrylate) versus standard wound closure in breast surgery. Surgery 2004;136:593–9.
16. Pronio A, Di Filippo A, Narilli P, Caporilli D. Closure of cutaneous incision after thyroid surgery: a comparison between metal clips and cutaneous octyl-2-cyanoacrylate adhesive. A prospective randomized clinical trial. Eur J Plast Surg 2011;34:103–10.
17. Hancock NJ, Samuel AW. Use of Dermabond tissue adhesive in hand surgery. J Wound Care 2007;16:441–3
18. Singer AJ, Thode HC Jr. A review of the literature on octylcyanoacrylate tissue adhesive. Am J Surg 2004;187:238–48.
19. Cheng HH, Hui P,Leung KY, Chai JJ, Cheng M and Chan Y. Comparing the use of tissue adhesive (2-Octyl cyanoacrylate) and interrupted sutures for caesarean section wound: a prospective randomised controlled trial. HKJGOM 2015;15:39–45.
20. Daykan Y, Sharon-Weiner M, Pasternak Y, Tzadikevitch-Geffen K, Markovitch O, Sukenik-Halevy R, et al. Skin closure at cesarean delivery, glue vs subcuticular sutures: a randomized controlled trial. Am J Obstet Gynecol 2017;216:406.e1–e5.
21. Fearmonti RM, Bond JE, Erdmann D, Levin LS, Pizzo SV, Levinson H. The modified patient and observer scar assessment scale: a novel approach to defining pathologic and nonpathologic scarring. Plast Reconstr Surg 2011;127:242–7.
22. Cromi A, Ghezzi F, Gottardi A, Cherubino M, Uccella S, Valdatta L. Cosmetic outcomes of various skin closure methods following cesarean delivery: a randomized trial. Am J Obstet Gynecol 2010;203:36.e1–8.
23. Coulthard P, Esposito M, Worthington HV, van der Elst M, van Waes O, Darcey J. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev 2010;5:CD004287.
24. Nipshagen MD, Hage JJ, Beekman WH. Use of 2-octylcyanoacrylate skin adhesive (Dermabond) for wound closure following reduction mammaplasty: a prospective, randomized intervention study. Plast Reconstr Surg 2008;122:10–8.
25. Duncan JAL, Bond JS, Mason T, Ludlow A, Cridland P, O'Kane S, Ferguson MWJ. Visual analogue scale scoring and ranking: a suitable and sensitive method for assessing scar quality? Plast Reconstr Surg 2006;118:909–18.
26. Hollander JE, Singer AJ, Valentine S, Henry MC. Wound registry: development and validation. Ann Emerg Med 1995;25:675–85.
27. Cromi A, Ghezzi F, Gottardi A, Cherubino M, Uccella S, Valdatta L. Cosmetic outcomes of various skin closure methods following caesarean delivery: a randomized trial. Am J Obstet Gynecol 2010;203:36.e1–8
28. Dumville JC, Coulthard P, Worthington HV, et al. Tissue adhe-sives for closure of surgical incisions. Cochrane Database Syst Rev 2014;11:CD004287.
29. Ong J, Ho KS, Chew MH, Eu KW. Prospective randomised study to evaluate the use of DERMABOND ProPen (2-octylcyanoacrylate) in the closure of abdominal wounds versus closure with skin staples in patients undergoing elective colectomy. Int J Colorectal Dis 2010;25:899–905.
30. Mackeen AD, Berghella V, Larsen M-L. Techniques and materials for skin closure in cesarean section. Cochrane Database Syst Rev 2012;11:CD003577. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003577. pub3/information. Accessed Nov 29, 2021.
31. Sebesta MJ, Bishoff JT. Octylcyanoacrylate skin closure in laparoscopy. JSLS 2004;8:9–14.
32. Halstead LS, Dang T, Elrod M, Convit RJ, Rosen MJ, Woods S. Teleassessment compared with live assessment of pressure ulcers in a round clinic: a pilot study. Adv Skin Wound Care 2003;16:91–6.