Why is it important to close the subcutaneous fat layer during a cesarean section (C-section)?

From the Guidelines

Closing the subcutaneous fat layer during a cesarean section is crucial to prevent complications and promote optimal healing, particularly in patients with a thicker subcutaneous layer (>2 cm), as recommended by the Enhanced Recovery After Surgery Society 1. This recommendation is based on the guidelines for intraoperative care in cesarean delivery, which suggest that reapproximation of the subcutaneous tissue layer should be performed in women with 2 cm of subcutaneous tissue 1.

Key Points

• Proper closure of the fat layer reduces the risk of wound complications, including seromas, hematomas, and surgical site infections, by eliminating dead space where fluid can accumulate.
• Fat layer closure provides structural support to the incision, decreasing tension on the skin closure and minimizing the risk of wound dehiscence.
• The fat layer contains blood vessels and lymphatics, so proper closure helps control bleeding and lymphatic drainage.
• In patients with a thicker subcutaneous layer, closure of this layer becomes even more critical as these patients have higher rates of wound complications.

Recommendations

• The subcutaneous fat layer should be closed using absorbable sutures, such as Vicryl, in a continuous or interrupted fashion.
• The skin closure should be closed with subcuticular suture in most cases, as it reduces wound separation 1.
• The peritoneum does not need to be closed, as it is not associated with improved outcomes and increases operative times 1.

Evidence

The Enhanced Recovery After Surgery Society recommendations, published in the American Journal of Obstetrics and Gynecology in 2018, provide evidence-based guidelines for intraoperative care in cesarean delivery 1. While some studies suggest that the use of blunt needles may reduce glove perforations, there is no strong evidence to support a particular suture or needle type 1. Overall, the evidence suggests that closing the subcutaneous fat layer during a cesarean section is an important step in preventing complications and promoting optimal healing, particularly in patients with a thicker subcutaneous layer.

From the Research

Importance of Closing the Subcutaneous Fat Layer

• Closing the subcutaneous fat layer during a cesarean section (C-section) is important because it may reduce the risk of wound complications, such as hematoma, seroma, wound infection, and wound separation 2, 3.
• A study found that closure of the subcutaneous fat layer reduced the risk of hematoma or seroma by 48% and the risk of wound complication by 32% compared to non-closure 3.
• Another study found that the use of subcutaneous suture closure or subcutaneous drain reduced the incidence of wound complications in obese women undergoing cesarean delivery 4.

Reduction of Wound Complications

• Closure of the subcutaneous fat layer may protect against wound complications, including skin separation and seroma or hematoma formation 2.
• A systematic review and meta-analysis found that suture closure of the skin incision decreased composite wound complications by 50% compared to closure with staples, regardless of obesity status 5.
• The use of closed suction drainage in the subcutaneous space may also reduce the incidence of postoperative wound complications in obese women undergoing cesarean delivery 4.

Benefits of Subcutaneous Fat Layer Closure

• Closing the subcutaneous fat layer may reduce the risk of wound infection, although the evidence is not consistent across all studies 2, 3.
• The technique of closing the subcutaneous fat layer may be important in reducing wound complications, although further research is needed to determine the best technique and materials to use 3.
• Overall, the available evidence suggests that closing the subcutaneous fat layer during a C-section may be an important step in reducing the risk of wound complications and improving patient outcomes 2, 5, 3, 4.