Uterine wound healing after caesarean section: A systematic review

The rate of caesarean section (CS) is increasing worldwide. Defects in uterine healing have a major gynaecological and obstetric impact (uterine rupture, caesarean scar defect, caesarean scar pregnancy, placenta accreta spectrum). The complex process of cellular uterine healing after surgery, and specifically after CS, remains poorly understood in contrast to skin wound healing. This literature review on uterine wound healing was mainly based on histological observations, particularly after CS. The primary objective of the review was to examine the effects of CS on uterine tissue at the cellular level, based on histological observations. The secondary objectives were to describe the biomechanical characteristics and the therapies used to improve scar tissue after CS. This review was performed using PRISMA criteria, and PubMed was the data source. The study included all clinical and animal model studies with CS and histological analysis of the uterine scar area (macroscopic, microscopic, immunohistochemical and biomechanical). Twenty studies were included: 10 human and 10 animal models. In total, 533 female humans and 511 female animals were included. Review articles, meeting abstracts, case series, case reports, and abstracts without access to full-text were excluded. The search was limited to studies published in English. No correlation was found between cutaneous and uterine healing. The histology of uterine scars is characterized by disorganized smooth muscle, fibrosis with collagen fibres and fewer endometrial glands. As for skin healing, the initial inflammation phase and mediation of some growth factors (particularly connective tissue growth factor, vascular endothelial growth factor, platelet-derived growth factor, tumour necrosis factor α and tumour necrosis factor β) seem to be essential. This initial phase has an impact on the subsequent phases of proliferation and maturation. Collagen appears to play a key role in the initial granulation tissue to replace the loss of substance. Subsequent maturation of the scar tissue is essential, with a decrease in collagen and smooth muscle restoration. Unlike skin, the glandular structure of uterine tissue could be responsible for the relatively high incidence of healing defects. Uterine scar defects after CS are characterized by an atrophic disorganized endometrium with atypia and a fibroblastic highly collagenic stromal reaction. Concerning immunohistochemistry, one study found a decrease in tumour necrosis factor β in uterine scar defects. No correlation was found between biomechanical characteristics (particularly uterine strength) and the presence of a collagenous scar after CS. Based on the findings of this review, an illustration of current understanding about uterine healing is provided. There is currently no validated prevention of caesarean scar defects. Various treatments to improve uterine healing after CS have been tested, and appeared to have good efficacy in animal studies: alpha lipoic acid, growth factors, collagen scaffolds and mesenchymal stem cells. Further prospective studies are needed.

Effects of Using Barbed Suture in Myomectomy on Adhesion Formation and Adverse Pregnancy Outcome

Background: There is still concern regarding postoperative adhesion formation and adverse effects on pregnancy outcomes caused by barbed suture (BS) after myomectomy. The aim of this study was to compare the postoperative adhesion and pregnancy outcomes between conventional suture (CS) and BS after minimally invasive myomectomy (MIM) by robotic myomectomy (RM) or laparoscopic myomectomy (LM). Methods: The medical records of 94 women who had undergone MIM with CS and 97 who had undergone MIM with BS and achieved pregnancy were reviewed. Postoperative adhesion was evaluated following cesarean section. Results: The number of removed myomas was greater (5.3 ± 4.6 vs. 3.5 ± 3.1, p = 0.001) and the size of the largest myoma was larger (7.0 ± 2.2 vs. 5.8 ± 2.7 cm, p = 0.001) in the BS group relative to the CS group. A total of 98.9% of patients in the CS group and 45.4% in the BS group had undergone LM (p < 0.001), while the others underwent RM. There was no significant difference in the presence of postoperative adhesion at cesarean section between the BS and CS groups (45.5 vs. 43.7%, p = 0.095). Additionally, there were no intergroup differences in pregnancy complications such as preterm labor, placenta previa, accrete or abruption. Note also that in our logistic regression analysis, the suture type (BS or CS) was excluded from the independent risk factors regarding postoperative adhesion formation. Conclusions: Our data indicated that the incidence of postoperative adhesion after MIM with BS was similar when compared with CS. Also it seems that the suture type does not have a significant effect on pregnancy outcomes.

Comparison of fertility outcomes after laparoscopic myomectomy for barbed versus nonbarbed sutures

OBJECTIVE

To assess the impact on women's reproductive outcomes of barbed sutures to repair uterine breaches during laparoscopic myomectomy compared with traditional smooth sutures.

DESIGN

Retrospective, monocentric cohort study, with information on subsequent pregnancies prospectively acquired for some women.

SETTING

Tertiary-level academic referral center.

PATIENT(S)

Women older than 18 years who had undergone a laparoscopic myomectomy and had sought pregnancy afterward, divided into two groups based on type of suture used to repair the uterine wall: group A (nonbarbed) and group B (barbed).

INTERVENTION(S)

Laparoscopic removal of FIGO types 3, 4, 5, and 6 uterine leiomyomas by use of either only barbed sutures or only traditional smooth sutures to reconstruct the uterine defect.

MAIN OUTCOME MEASURE(S)

Pregnancy achievement rates, delivery modes, main pregnancy complications, perioperative complications for both kinds of suture, and the trend of the use of barbed sutures over time at our center.

RESULT(S)

Of 164 patients included, 83 were in group A and 81 in group B. Ninety-one patients (55.5%) experienced at least one postoperative pregnancy, with no differences between the groups (group A 60.5%; group B 50.6%). Of the 103 recorded postoperative pregnancies, 70 (68%) resulted in live births, 29 (28.1%) in first-trimester miscarriages, and 4 (3.9%) were ongoing.

CONCLUSION(S)

Barbed sutures have a similar impact on reproductive outcomes as smooth conventional threads, both in terms of pregnancy and obstetric complication rates, after laparoscopic myomectomy.

Unidirectional barbed suture for vaginal cuff closure without backward stitch in total laparoscopic hysterectomy

AIM

To evaluate the safety and efficacy of unidirectional barbed suture technique for vaginal cuff closure in total laparoscopic hysterectomy (TLH).

METHODS

In a retrospective chart review, data were analyzed from 165 patients who underwent a TLH with an unidirectional barbed suture technique for vaginal cuff closure from January 2012 to June 2016 at tertiary-care university-based teaching hospital and academic affiliated hospital. Vaginal cuff was closed by single layer 3/0 V-Loc unidirectional 9″, 180 day Absorbable Wound Closure Device (Covidien Healthcare, Mansfield, MA) and the suture was not stitched backward to secure distal end.

RESULTS

A total of 165 patients were included and the median age was 50 years (range, 35-84 years). The median completion time for hysterectomy time was 100 min (range, 40-240 min) and the median vaginal cuff closure time was 7 min (range, 4-15 min). The median estimated blood loss was 87.8 mL (range 30-250 mL) and the median uterine weight was 200 g (range, 40-900 g). Intraoperative complication included bladder perforation (1.2%) and postoperative complications were vaginal cuff dehiscence (1.8%), cuff cellulitis (0.6%), vesicovaginal fistula (0.6%) and unexplained fever (0.6%).

CONCLUSION

According to the results of current study, the use of unidirectional barbed suture without backward stitching appears to be safe for the vaginal cuff closure in TLH.

In Vivo Comparison of "V-Loc 90 Wound Closure Device" With "Vicryl" and "Monocryl" in Regard to Tissue Reaction in a Rabbit Bladder Model

OBJECTIVE

To compare the barbed polyglyconate suture (BPS) with 2 commonly used conventional sutures, this prospective randomized trial was designed. The sutures applied in the urinary collecting system, in terms of long-term histopathologic and macroscopic suture material features.

MATERIALS AND METHODS

Eight female and 6 male New Zealand rabbits were included in the study. Each animal served as its own control and was subjected to cystotomy. Watertight running cystorrhaphies were performed using 3 different sutures in a randomized fashion, namely Monocryl, Vicryl, and V-Loc 90. Seven animals were sacrificed after the third and 7 after the sixth week. Macroscopic and histopathologic examinations were performed. Tissue reaction, like inflammation and fibrosis, around the sutures were evaluated. Friedman and Wilcoxon signed ranks test was used for the statistical analysis.

RESULTS

The BPS demonstrated no adhesion. However, in the six-week group, stone formation was recorded on 4 BPS and 1 Vicryl thread, a difference being statistically significant (P = .039). Additionally, in the third- and in the sixth-week group, 1 (P = .368) and 3 (P = .050) BPS threads migrated, respectively. The histopathologic analysis revealed less inflammation and fibrosis associated with the BPS thread in both the third and the sixth-week groups (P = .010 and P = .002, respectively).

CONCLUSION

The BPS appears to be superior to conventional sutures in terms of local inflammation and fibrosis. However, suture migration and stone formation following collecting system closure could be potential predicaments.

Barbed suture tissue closure device in urological surgery – a comprehensive review

The development and implementation of barbed sutures has transformed the technique of tissue closure with increasing application across multiple surgical disciplines. Changes in design and handling such as the introduction of absorbable and non-absorbable bidirectional barbed sutures reflect an increasing applicability in tissues of varying qualities. We undertook a comprehensive review of available literature to provide an evidence-based rationale for the clinical use of barbed suture tissue closure devices. We summarise uses along with advantages and disadvantages reported across a number of surgical specialties such as urology, orthopaedics, gynaecology and plastic surgery. Tangible benefits noted were faster closure speed, maintenance of suture integrity, improved efficiency in closure, avoidance of knots and possibly a cost-benefit effect. In terms of complications, the barbed sutures compared equally with standard sutures with no significant differences. In conclusion, barbed sutures have demonstrated versatility and safety across surgical specialties and compares favourably with standard sutures. There appears to be an increasing popularity in the use of barbed sutures with clear advantages to both surgeon and patient.

Role of Barbed Sutures in Repairing Uterine Wall Defects in Laparoscopic Myomectomy: A Systemic Review and Meta-Analysis

As an innovative technology barbed sutures have demonstrated clinical and surgical benefits in several specialties. The purpose of this study was to systemically review the available evidence on the application of barbed sutures in repairing the uterine wall defects in laparoscopic myomectomy and to compare with conventional suture in clinical safety and efficacy. Medline, Embase, and Cochrane Database of Systematic Reviews were used for a systematic electronic search of published literature. Studies were selected that evaluate barbed sutures in surgical treatment for patients with benign myomas eligible for laparoscopic myomectomy in comparison with conventional sutures. Depending on the heterogeneity, either a fixed-effects model or random-effects model was used in this meta-analysis. Continuous variable data were showed as standard mean difference (SMD) and weighted mean difference with 95% confidence interval (CI). A total of 7 studies (n = 484) met inclusion criteria. Compared with conventional sutures, barbed sutures demonstrated significant reductions in suturing time (SMD, -1.26; 95% CI, -1.85 to -.67; p < .001), operating time (SMD, -.64; 95% CI, -.83 to -.44; p < .001), intraoperative blood loss (SMD, -.43; 95% CI, -.79 to -.06; p = .021), and postoperative hemoglobin drop (SMD, -.56; 95% CI, -1.01 to -.11; p = .014). The result was numerically lower in the barbed suture group for hospital length of study, although there was no significant difference. This meta-analysis demonstrates clear clinical advantages of time savings and blood loss reduction by using barbed sutures in close uterine wall defects in laparoscopic myomectomy compared with conventional sutures. Those benefits may reduce the surgical difficulty in laparoscopic myomectomy procedures.