Download Cesarean Delivery in the Obese Patient

Cesarean Delivery in the
Obese Patient
Alexander F. Burnett, MD
Division Gyn Oncology
UAMS
And she’s pregnant…
And she’s in early labor…
And she’s breech…
And your partners are
nowhere to be found…
Objectives
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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…
The Problem:
Obesity is an independent risk factor for post-operative
infectious morbidity
Infection
No Infection
Emergent c/s
BMI (kg/m2)
36.6
32.2
p<.001
Obesity %
81.8
57.3
p<.001
Elective c/s
BMI
38.9
32.2
p<.003
Obesity %
89.5
58.0
p<.04
Myles Ob Gyn 2002;100:959
Thickness of Subcutaneous
Tissue
4.1 cm
2.3 cm
p=.04
Vermillion Ob Gyn 2000;95:923
Decisions…decisions…
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
Vertical vs Transverse in Obese
C/S
Retrospective review of 239 women undergoing primary C/S with
BMI > 35
Transverse(213)
Vertical(26)
Wound breakdown
2%
15% p =0.003
Wound infection
7%
19% p = 0.04
Endometritis
15%
15% p = 0.98
Chorioamnionitis
15%
3% p = 0.11
Wall Ob Gyn 2003;102:952
High Transverse vs Low
Transverse
Case-control retrospective review of C/S for
women >150% ideal body weight
Supraumbilical
Pfannenstiel
15
54
Avg wt lbs
329 + 60
246 + 34
No difference in infectious or non-infectious
complications
Houston Am J Ob Gyn 2000;182:1033
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
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
Wound Healing
1st phase: 1-4 d
exudative phase
no wound strength
2nd phase: 5-20 dproliferative phase
connective tissue repair
regains 15-30% strength
delayed if infection
period of hernia initiation
3rd phase: 21 d-yrs
tissue remodeling
regains ~ 80% strength
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
Closure
Non-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
SubQ Closure vs Drainage
76 women with > 2cm subcut randomized to running 3-0
vs drain vs nothing
Infection
Separation
Suture
7.7%
15.4%
Drain
0
4.2%
None
3.9%
26.9%
Drain group had significantly lower rate of complications
compared to non-closure group
Allaire J Repro Med 2000;45:327
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.
Suture
Drain
None
Wound disruption 9.9%
9.7%
8.7%
No difference in seroma/hematoma/infection rate
Magann Am J Ob Gyn 2002;186:1119
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:
Endometritis
0.39 (0.31-0.43)
Wound infection 0.41 (0.29-0.43)
Smaill Cochrane Library 2004;4
Take-Home Conclusions:
1.
2.
3.
4.
5.
6.
7.
Obese C/S patients at significant risk for infection and
wound disruption
Transverse incision has fewer complications at cost of
more time to entry
Supraumbilical transverse incision is an option
Do not need to close the visceral peritoneum
Close the fascia with continuous slowly absorbable
suture
There may be a benefit to subcutaneous closure vs
drainage in the obese patient
Antibiotics should be used in these patients to reduce
post-operative incision complications