Classical versus double knots facia closure method during cesarean section; is there a difference in pain sensation or cosmetic satisfaction?

Öz

Aim: This study aimed to compare two rectus fascia closure techniques used during cesarean section and to evaluate their effects on postoperative pain, analgesic requirement, and cosmetic satisfaction. Methods: A prospective observational study was conducted including 218 women undergoing cesarean delivery. Participants were allocated into two groups according to the fascia closure method. In the classical continuous technique (Group 1), the fascial edges were grasped with a Kocher clamp and closed with a synthetic absorbable multifilament suture using a single-line knot. In the double-knot technique (Group 2), the fascia was closed with the same suture material beginning from the opposite direction, creating an additional loop, and the two sutures were tied together. Pain was assessed on postoperative days 1 and 10 using the Numeric Rating Scale (NRS). Analgesic consumption during hospitalization was recorded. Cosmetic satisfaction regarding the surgical incision was evaluated using a 10-point scale at 1 and 3 months after surgery. Results: Baseline demographic and clinical characteristics were comparable between the groups. Postoperative day-1 and day-10 NRS pain scores did not differ significantly (p>0.05). However, Group 1 required higher amounts of analgesics compared with Group 2 (NSAIDs: 2.6±1.2 vs. 1.7±0.8; paracetamol: 1.1±0.8 vs. 0.8±0.7; p<0.001). Cosmetic satisfaction scores were significantly higher in Group 2 at both the first and third postoperative months (p=0.03 and p=0.02, respectively). Conclusion: The double-knot fascia closure technique results in reduced analgesic requirement and higher cosmetic satisfaction compared with the classical continuous closure method, despite similar postoperative pain levels.

Anahtar Kelimeler

• Abdominal wound closure techniques
• cesarean section
• postoperative pain.

Sezaryen sırasında klasik ve çift düğümlü fasya kapatma yöntemleri arasında ağrı hissi veya kozmetik memnuniyet açısından fark var mıdır?

Öz

Amaç: Bu çalışmanın amacı, sezaryen sırasında kullanılan iki rektus fasya kapatma tekniğini karşılaştırmak ve bu tekniklerin postoperatif ağrı, analjezik gereksinimi ve kozmetik memnuniyet üzerindeki etkilerini değerlendirmektir. Yöntemler: Sezaryen doğum yapan 218 kadını kapsayan prospektif bir gözlemsel çalışma yürütülmüştür. Katılımcılar fasya kapatma yöntemine göre iki gruba ayrılmıştır. Klasik teknikte (Grup 1), fasya kenarları Kocher klempi ile tutularak sentetik emilebilir multifilament sütür ile tek sıra düğüm atılarak kapatılmıştır. Çift düğüm tekniğinde (Grup 2), fasya aynı sütür materyali ile karşı yönden başlanarak ek bir düğüm oluşturularak kapatılmış ve iki sütür birbirine bağlanmıştır. Ağrı, postoperatif 1. ve 10. günlerde Numerik Derecelendirme Ölçeği (NRS) kullanılarak değerlendirilmiştir. Hastanede yatış süresince analjezik ihtiyacı kaydedilmiştir. Cerrahi kesiye ilişkin kozmetik memnuniyet, ameliyattan 1 ve 3 ay sonra 10 puanlık bir ölçek kullanılarak değerlendirilmiştir. Bulgular: Gruplar arasında başlangıç demografik ve klinik özellikler benzerdi. Ameliyat sonrası 1. ve 10. gün NRS ağrı skorları anlamlı farklılık göstermedi (p>0,05). Ancak, Grup 1’deki hastalar, Grup 2'ye kıyasla daha fazla analjezik ihtiyacı duydu (NSAID'ler: 2,6±1,2'ye karşı 1,7±0,8; parasetamol: 1,1±0,8'e karşı 0,8±0,7; p<0,001). Kozmetik memnuniyet skorları, Grup 2'de hem birinci hem de üçüncü postoperatif ayda anlamlı derecede daha yüksekti (sırasıyla p=0,03 ve p=0,02). Sonuç: Çift düğüm fasya kapatma tekniği, benzer postoperatif ağrı seviyelerine rağmen, klasik kapatma yöntemine kıyasla daha az analjezik gereksinimi ve daha yüksek kozmetik memnuniyet ile sonuçlanmaktadır.

Anahtar Kelimeler

• Batın insizyonu kapatma teknikleri
• sezaryen
• posoperatif ağrı

Kaynakça

1. 1.Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in cesarean section rates: global, regional and national estimates. PLoS One. 2016;11(2):e0148343. [Crossref]
2. 2.Sigerist HE. A history of medicine. Vol II: Early Greek, Hindu, and Persian medicine. Oxford: Oxford University Press; 1961.
3. 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(4):294-306. [Crossref]
4. 4.Anderson ER, Gates S. Techniques and materials for skin closure in caesarean section. Cochrane Database Syst Rev. 2004;(2):CD003577. [Crossref]
5. 5.Mackeen AD, Berghella V, Larsen ML. Techniques and materials for cesarean section closure: a meta-analysis. Am J Obstet Gynecol. 2015;212(2):163.e1-9.
6. 6.Rahbari NN, Knebel P, Diener MK, Seidlmayer C, Ridwelski K, Stöltzing H, et al. Current practice of abdominal wall closure in elective surgery - Is there any consensus? BMC Surg. 2009 May 15;9:8. [Crossref]
7. 7.Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database Syst Rev. 2014;2014(7). [Crossref]
8. 8.Hofmeyr GJ, Mathai M, Shah A, Novikova N. Techniques for caesarean section. Cochrane Database Syst Rev. 2008;2008(1). [Crossref]

9. 9.CAESAR study collaborative group. Caesarean section surgical techniques: a randomised factorial trial (CAESAR). BJOG. 2010;117(11):1366-1376. [Crossref]
10. 10.CORONIS Collaborative Group; Abalos E, Addo V, Brocklehurst P, El Sheikh M, Farrell B, Gray S, et al. Caesarean section surgical techniques (CORONIS): a fractional, factorial, unmasked, randomised controlled trial. Lancet. 2013 Jul 20;382(9888):234-48. [Crossref]
11. 11.Fillingim RB. Individual differences in pain: understanding the mosaic that makes pain personal. Pain. 2017;158 Suppl 1(Suppl 1):S11-S18. [Crossref]
12. 12.Brown SR, Goodfellow PB. Transverse verses midline incisions for abdominal surgery. Cochrane Database Syst Rev. 2005;2005(4):CD005199. [Crossref]
13. 13.Dahlke JD, Mendez-Figueroa H, Maggio L, Sperling JD, Chauhan SP, Rouse DJ. The Case for Standardizing Cesarean Delivery Technique: Seeing the Forest for the Trees. Obstet Gynecol. 2020;136(5):972-980. [Crossref]
14. 14.Atılgan R, Pala Ş, Halisçelik M, Şenocak A. Comparison of the Effectiveness of Classical and Single-knot Fascia Closure Methods in Reducing Pain and Tenderness in the Incision Area After Cesarean Section: A Prospective Cohort Study. J Clin Obstet Gynecol. 2023;33(4):203-209. [Crossref]
15. 15.Chintamani. Editorial: Ten Commandments of Safe and Optimum Abdominal Wall Closure. Indian J Surg. 2018;80:105-108. [Crossref]
16. 16.Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg Oncol. 1992;18(9):785-795. [Crossref]
17. 17.Basson R, Bayat A. Skin scarring: Latest update on objective assessment and optimal management. Front Med (Lausanne). 2022;9:942756. [Crossref]
18. 18.Lari A, Alherz M, Hussain S, Burhamah W, Alabbad F, Jarragh A, et al. The Importance of Scar Cosmesis across the Surgical Specialties: Factors, Perceptions, and Predispositions. Plast Reconstr Surg Glob Open. 2022;10(3):e4219. [Crossref]
19. 19.Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol. 2004;103:974-80. [Crossref]
20. 20.Yang J, Kim KH, Song YJ, Kim SC, Sung N, Kim H, et al. Cosmetic outcomes of cesarean section scar; subcuticular suture versus intradermal buried suture. Obstet Gynecol Sci. 2018 Jan;61(1):79-87. [Crossref]
21. 21.Mackeen AD, Berghella V, Larsen ML. Techniques and materials for skin closure in caesarean section. Cochrane Database Syst Rev. 2012;11(11):CD003577. [Crossref]
22. 22.Bernabe RM, Madrigal P, Choe D, Pham C, Yenikomshian HA, Gillenwater J. Assessing Scar Outcomes Using Objective Scar Measurement Tools: An Adjunct to Validated Scar Evaluation Scales. Plast Reconstr Surg. 2024;154(5):885e-890e. [Crossref]