There is little hard evidence as to which is the best way to close the subcutaneous layer of incisions. With the increasing prevalence of obesity, the question of what to do when the fat layer is 3cm or more will be asked more frequently.
Cardosi et al from Florida (AJOG 2006;195:607-16) randomly allocated obese patients to three ways of dealing with the subcutaneous layer following vertical midline incisions for gynaecological procedures. The three methods were suturing the layer closed with an absorbable stitch, no stitching but placing a suction drain in situ, or no intervention.
All incisions had staples for skin closure that were left in place for at least 7 days. All patients received pre-operative antibiotic prophylaxis and the wounds were diligently observed in hospital and at 2 and 6 weeks post-operatively.
In the over 200 patients in the trial, the method of closure made no difference in terms of disruption, cellulitis, seroma or haematoma formation or abscess occurrence. It seems subcutaneous technique is irrelevant in these circumstances, so preference and resources can dictate practice.
