1. Cesarean Delivery in the Obese Patient Alexander F. Burnett, MD Division Gyn Oncology UAMS

2. And she’s pregnant… And she’s in early labor… And she’s breech… And your partners are nowhere to be found…

3. Objectives 1. What is the problem? 2. Incision choice in the obese patient 3. Closure techniques 4. Suture material 5. To drain or not to drain…

4. The Problem: Obesity is an independent risk factor for post-operative infectious morbidity InfectionNo Infection Emergent c/s BMI (kg/m 2 )36.6 32.2 p<.001 Obesity %81.8 57.3 p<.001 Elective c/s BMI38.9 32.2 p<.003 Obesity %89.5 58.0 p<.04 Thickness of Subcutaneous Tissue4.1 cm 2.3 cm p=.04 Myles Ob Gyn 2002;100:959 Vermillion Ob Gyn 2000;95:923

5. Decisions…decisions…

6. Transverse vs Vertical Incisions in Abdominal Surgery 11 randomized + 7 retrospective studies Procedures: cholecystectomy, AAA, trauma, major laparotomy: Significant increase in pulmonary complications, burst abdomen, incisional hernia in vertical group No difference in exposure Time to open:V 9.9 min T 13.9 min p<0.05 Grantcharov Eur J Surg 2001;167:260

7. Vertical vs Transverse in Obese C/S Retrospective review of 239 women undergoing primary C/S with BMI > 35 Transverse(213) Vertical(26) Wound breakdown2% 15% p =0.003 Wound infection7% 19% p = 0.04 Endometritis15% 15% p = 0.98 Chorioamnionitis15% 3% p = 0.11 Wall Ob Gyn 2003;102:952

8. High Transverse vs Low Transverse Case-control retrospective review of C/S for women >150% ideal body weight SupraumbilicalPfannenstiel 1554 Avg wt lbs329 + 60246 + 34 No difference in infectious or non-infectious complications Houston Am J Ob Gyn 2000;182:1033

11. The Baby Is Out…Now What? Is there a need for visceral peritoneum closure? 549 Randomized to closure vs nonclosure Closure group had significantly more: Febrile episodes Cystitis Operative time Length of stay Conclusion: do not close visceral peritoneum Nagele Am J Ob Gyn 1996;174:1366

12. Fascial Closure Meta-analysis of midline abdominal closures: 15 studies/6566 patients revealed Continuous suture vs interrupted had no difference in outcomes Lowest incisional hernias with slowly absorbable and non-absorbable vs rapidly absorbable Non-absorbable had increased wound pain and suture sinus formation over slowly absorbable Van ‘t Riet B J Surg 2002;89:1350

13. Wound Healing 1 st phase: 1-4 dexudative phase no wound strength 2 nd phase: 5-20 dproliferative phase connective tissue repair regains 15-30% strength delayed if infection period of hernia initiation 3 rd phase: 21 d-yrstissue remodeling regains ~ 80% strength

15. What About SubQ? 245 women with at least 2 cm subcut fat were randomized to closure or non-closure of Camper fascia with running 3-0 polyglycolic acid ClosureNon-closure Seroma 5.1% 17.2%p=.002 Hematoma 3.4% 1.6%p=NS Infection 6.0% 7.8%p=NS Disruption 14.5% 26.6%RR 0.5 (CI=0.3-0.9) Naumann Ob Gyn 1995;85:412

16. SubQ Closure vs Drainage 76 women with > 2cm subcut randomized to running 3-0 vs drain vs nothing SutureDrainNone Infection 7.7% 0 3.9% Separation15.4% 4.2%26.9% Drain group had significantly lower rate of complications compared to non-closure group Allaire J Repro Med 2000;45:327

17. SubQ Closure vs Drainage 2 964 women with subcut > 2 cm s/p C/S randomized to subcut 3-0 running vs non-closure vs 7 mm closed drain. SutureDrainNone Wound disruption 9.9% 9.7% 8.7% No difference in seroma/hematoma/infection rate Magann Am J Ob Gyn 2002;186:1119

18. Antibiotic Prophylaxis for C/S Cochrane review: 81 trials with 12,000 women worldwide. Contained elective C/S and non-elective C/S. Antibiotic treated women RR: Endometritis0.39 (0.31-0.43) Wound infection0.41 (0.29-0.43) Smaill Cochrane Library 2004;4

19. Take-Home Conclusions: 1.Obese C/S patients at significant risk for infection and wound disruption 2.Transverse incision has fewer complications at cost of more time to entry 3.Supraumbilical transverse incision is an option 4.Do not need to close the visceral peritoneum 5.Close the fascia with continuous slowly absorbable suture 6.There may be a benefit to subcutaneous closure vs drainage in the obese patient 7.Antibiotics should be used in these patients to reduce post-operative incision complications