Barbed Versus Conventional Suture for Uterine Repair During Caesarean Section: A Randomized Controlled Study

Barbed Sutures and Their Potential Role in Reducing Inflammatory Reaction After Cesarean Delivery: A Single-Center Experience

Objectives The aim of this study was to investigate the short-term outcomes of knotless barbed sutures used for both closures of myometrium and subcuticular tissues in patients with various operative indications and who underwent cesarean delivery (CD) in a single tertiary center. Materials and methods A retrospective cohort study was conducted, and the patients were divided into two groups. The barbed suture group consisted of patients who underwent CD using barbed sutures for uterine closure (0 Stratafix® Spiral PDS Plus, Ethicon, Somerville, NJ, USA) and subcuticular closure (4-0 Stratafix® Spiral PDS Plus). The non-barbed group consisted of patients who underwent CD using monofilament sutures for uterine closure (0-Monocryl®, Ethicon) and subcuticular closure (3-0 Opepolyx®, Alfresa, Tokyo, Japan). Results White blood cell count on post-operative day 1 was statistically lower in the barbed suture group (p=0.01), while there were no other significant differences between the two groups. Conclusion Barbed sutures can be used without major complications in patients who have undergone CD, including high-risk pregnancies.

Suture type for hysterotomy closure: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Recent randomized controlled trials have demonstrated an association between uterine closure technique at the time of cesarean delivery and short- and long-term operative outcomes with varied results. This systematic review and meta-analysis aimed to examine types of suture material used for cesarean delivery.

DATA SOURCES

Scopus, PubMed, Cochrane Central Register of Controlled Trials, Ovid, and ClinicalTrials.gov were searched from inception of each database to October 2021.

STUDY ELIGIBILITY CRITERIA

All randomized controlled trials that compared types of suture materials used for hysterotomy closure during low-transverse cesarean delivery at ≥24 weeks' gestation and examined maternal outcomes were included for this review. The primary outcome was estimated blood loss. Secondary outcomes included additional surgical complications.

METHODS

Results were summarized as mean difference or risk ratio with associated 95% confidence intervals. The quality of studies was evaluated with the Cochrane Handbook for Systematic Reviews of Interventions for judging risk of bias. Heterogeneity was measured using I-squared (Higgins I2).

RESULTS

This review included 7 randomized controlled trials, of which 3 compared multifilament with barbed suture (136 vs 136 participants), 3 compared multifilament with conventional monofilament suture (245 vs 244 participants), and 1 trial compared multifilament with chromic suture (4590 vs 4595 participants). Primary analysis showed no difference in estimated blood loss between the multifilament and the barbed suture group (mean difference, 46.2 mL; 95% confidence interval, -13.6 to 105.9), nor in change in hemoglobin concentration between the multifilament and the conventional monofilament group (mean difference, -0.1%; 95% confidence interval, -0.5 to 0.3). Secondary outcomes showed a reduction in operative time with barbed vs multifilament suture (mean difference, 1.9 minutes; 95% confidence interval, 0.03-3.8). Analysis also demonstrated an increased uterine scar thickness with use of conventional monofilament vs multifilament suture (mean difference, -1.05 mm; 95% confidence interval, -1.9 to -0.2).

CONCLUSION

This meta-analysis does not support a specific type of suture material for uterine closure at cesarean delivery because of insufficient data. Although barbed suture was associated with an overall decrease in operative time, and use of conventional monofilament suture was associated with an increase in uterine scar thickness, the clinical utility of these differences is not clear. Further adequate randomized controlled trials are warranted for evaluation of different suture materials for hysterotomy closure.

Analysis of Study Designs and Primary Outcome Measures in Clinical Trials of Investigational Suture Materials

BACKGROUND

Clinical trials are a prerequisite for any investigational suture materials before a market approval application. The appropriate study designs and primary outcome measures are key to the validity and reliability of clinical trial results. This study aimed to characterize the study designs and primary outcome measures being applied in clinical trials of investigational suture materials.

METHODS

The systematic searches on PubMed, EMBASE, Web of Sciences, Scopus, and Cochrane databases were conducted to gather relevant studies published between January-2019 and May-2021. Data on general characteristics, suture intervention, study design, and primary outcome measures were extracted and analyzed.

RESULTS

Of 46 included studies, the majority of them were conducted with a randomized-controlled (93.5%), single-blind (50.0%), two-arm (84.8%), and parallel (76.1%) design with a 1:1 allocation ratio (95.7%). Through correlation network and heatmap analysis, the moderate-to-very strong correlations between some types of investigational suture materials and primary outcome measures were found including barbed vs non-barbed suture and suturing time, antibacterial-coated vs non-coated suture and wound infection, mono- vs multi-filament suture and wound healing index/markers, and different sizes of suture materials and scar assessment.

CONCLUSIONS

Our analysis provides guidance, with several key considerations, for designing a clinical trial evaluating investigational suture materials.

A comparison of barbed continuous suture versus conventional interrupted suture for fascial closure in total hip arthroplasty

A barbed suture is a self-anchoring knotless suture hypothesized to shorten suture time and reduce the tension point of the wound. The purpose of this study was to compare the barbed suture and the interrupted suture for fascial closure in total hip arthroplasty. We retrospectively reviewed patients who underwent total hip arthroplasty from March 2014 to June 2020. We evaluated 324 cases among 274 patients consisting of 188 males and 86 females. We collected the following data: demographics, time for wound closure, the number of threads used, hemoglobin level, surgical site pain, and wound complications. Variables were analyzed for their association with closure time using multiple regression analyses between the barbed suture (the SFX group) and the interrupted suture (the Vicryl group). Mean closure time was 5.8 min lower and the mean number of sutures used was 2.2 lower in the SFX group versus the Vicryl group (P < 0.01 and < 0.01, respectively). There were no statistical intergroup differences in the mean largest hemoglobin drop, the incidence of transfusion, surgical site pain, and the incidence of wound complications. The use of barbed sutures for fascial closure in total hip arthroplasty effectively reduces the surgical time without increasing wound complications.

Barbed vs conventional suture at cesarean delivery: A systematic review and meta-analysis

INTRODUCTION

Barbed sutures are used in cesarean delivery with the intended benefits of better tissue approximation, hemostasis, and strength, as well as reduced operative time. A systematic review and meta-analysis was undertaken to assess the safety and efficacy of the use of barbed suture compared with conventional sutures in cesarean delivery.

MATERIAL AND METHODS

MEDLINE, EMBASE, PubMed, Scopus, Cochrane CENTRAL, and three clinical trial registries, were searched from inception to December 2019, without restriction by language or publication year. Randomized controlled trials comparing the use of barbed suture with conventional sutures in closure of any layer (uterine/fascial/skin) during cesarean delivery were included. The safety outcomes included estimated blood loss, pain, mortality, and other morbidity including infection, re-operation or re-admission. Effectiveness outcomes included closure time, need for additional suture and scar integrity. Study selection, data extraction, risk-of-bias, and quality assessment were independently performed by two authors. Primary analysis compared outcomes for all layers of surgical closure, whereas subgroup analysis was performed by individual layer. Pooled mean differences (MD) and risk ratios (RR) with 95% CI were calculated using a random effects model. Level of evidence was assessed using GRADE criteria. PROSPERO registration number: CRD42020168859.

RESULTS

The review included four trials (three comparing uterine closure and one comparing skin closure), at high risk of bias, representing 460 participants. Primary analysis showed no morbidity differences between two groups. The use of barbed suture for uterine closure was associated with shorter incision closure time (MD 110.58 seconds, 95% CI 93.79-127.36 seconds), shorter total surgical time (MD 1.92 minutes, 95% CI 0.03-3.80 minutes), and a reduced need for additional hemostatic sutures (RR 0.39, 95% CI 0.28-0.54), with no difference in estimated blood loss (MD 46.17 mL, 95% CI 13.55 to -105.89 mL) or postoperative morbidity (RR 0.96, 95% CI 0.46-2.01). The level of evidence was deemed to be low to very low, based on inconsistency and imprecision of results.

CONCLUSIONS

Barbed sutures may be a suitable alternative to conventional sutures for uterine closure because they reduce uterine repair time, total surgical time, and the need for additional hemostatic sutures, without an increase in blood loss or maternal morbidity.