No Closure vs Interrupted vs Continuous Subcutaneous Closure: Operative Time and Wound Outcomes

Postoperative wound morbidity after cesarean delivery, while relatively infrequent, contributes to maternal discomfort, delayed recovery, and increased health care utilization. Subcutaneous tissue management at closure is a potentially modifiable surgical step, and both the decision to approximate the subcutaneous layer and the suturing technique may influence early wound outcomes as well as operative efficiency. However, consensus is lacking regarding the optimal approach.

This prospective comparative study evaluates three standardized subcutaneous tissue closure strategies among adults undergoing elective cesarean delivery via Pfannenstiel incision with a subcutaneous adipose tissue thickness of at least two centimeters: (one) no subcutaneous suturing, (two) closure with three interrupted sutures, and (three) closure with a continuous non-locking single-layer suture. Participants are assigned in equal numbers to each strategy using a predefined sequential allocation based on operative order. The surgical technique and follow-up assessments are conducted according to a predefined protocol, and participants are blinded to group assignment.

The study focuses on two clinically relevant domains: operative duration and short-term wound outcomes. Operative efficiency is assessed using total surgery duration. Wound outcomes are assessed around postoperative day ten using both standardized clinical incision assessment (including signs suggestive of infection such as erythema, warmth, discharge, dehiscence, or separation) and incision-site ultrasonography to identify subcutaneous fluid collection and other wound-related findings. By comparing these commonly used closure strategies under standardized conditions, the study aims to determine whether subcutaneous closure technique meaningfully affects operative time and early wound morbidity following elective cesarean delivery.

Inclusion criteria

• Age 18 years or older
• Scheduled for elective cesarean delivery via Pfannenstiel incision at the study site
• Subcutaneous adipose tissue thickness 2 cm or greater (measured intraoperatively/at time of surgery per protocol)
• Able and willing to provide written informed consent
• Willing to return for postoperative day 10 follow-up assessment (clinical exam and incision-site ultrasonography)

Exclusion criteria

• Any condition associated with impaired wound healing (e.g., diabetes mellitus, autoimmune disease)
• Current systemic corticosteroid use
• Suspected or confirmed infection at the time of delivery, including chorioamnionitis
• Premature rupture of membranes
• Refusal or inability to provide informed consent