Fascia Closure
A number of studies have shown that a continuous running suture works well for fascia closure. Vicryl is an appropriate choice of suture material for a first delivery. Polydioxanone suture is a good choice for obese or diabetic patients. A loop is preferable, because it tends to reduce the number of knots.
The zone of optimal healing is 0.75 mm back from the incision edge. Dr. Ivester recommends working 1 cm back and 1 cm apart with sutures. This provides a balance between optimizing the strength of the repair and allowing space to promote angiogenesis and healing of the incision.
Avoid “postage-stamping” the incision. “You don't necessarily want to be neat. Frequently you'll see—especially in obese patients—it's not the sutures themselves that break. It's this line that's created from this perfectly approximated fascia that looks really beautiful and is really neat. You've basically just created a perforation line like a postage stamp that they rip open the first time they cough or have a good chuckle,” said Dr. Ivester.
The data are mixed on whether to use drains or subcutaneous closure. Some studies have shown significant reductions in wound complications by using drains or subcutaneous closure compared with patients who received neither. Other studies have shown no differences.
“In patients with low platelets or bleeding disorders, drains may be useful, while we tend toward subcutaneous closure in obese women,” Dr. Ivester said.
Antibiotic Use
The debate continues over when to give antibiotics. At Dr. Ivester's hospital antibiotics were previously given on the way to the operating room. Now they are given at cord clamping. The gynecology literature suggests that the best results are obtained when antibiotics are given 30–60 minutes preoperatively. Prophylactic antibiotics (first-generation cephalosporins) have reduced endometritis rates at his hospital.
Wound complications also appear to be lower in the literature for prophylactic antibiotics.