Barbed versus conventional suture at cesarean delivery: a systematic review and meta-analysis.

Agarwal, Sugandha; D'Souza, Rohan; Ryu, Michelle; Maxwell, Cynthia

INTRODUCTION Barbed sutures are used in cesarean delivery with the intended benefits of better tissue approximation, hemostasis and strength, as well as reduced operative time. A systematic review and meta-analysis was undertaken to assess the safety and efficacy of the use of barbed suture compared to conventional sutures in cesarean delivery. MATERIAL AND METHODS MEDLINE, EMBASE, PubMed, Scopus, Cochrane CENTRAL, and three clinical trial registries, were searched from inception to December 2019, without restriction by language or publication year. Randomised controlled trials comparing the use of barbed suture with conventional sutures in closure of any layer (uterine/ fascial/ skin) during cesarean delivery were included. The safety outcomes included estimated blood loss, pain, mortality, other morbidity including infection, re-operation or re- admission. Effectiveness outcomes included closure time, need for additional suture and scar integrity. Study selection, data extraction, risk-of-bias and quality assessment were independently performed by two authors. Primary analysis compared outcomes for all layers of surgical closure, while subgroup analysis was performed by individual layer. Pooled mean differences (MD) and risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random effects model. Level of evidence was assessed using GRADE criteria. PROSPERO registration number: CRD42020168859 RESULTS: The review included four trials (three comparing uterine closure and one comparing skin closure), at high risk-of-bias, representing 460 participants. Primary analysis showed no morbidity differences between two groups. The use of barbed suture for uterine closure was associated with shorter incision closure time [MD 110.58 seconds (95% CI 93.79 - 127.36)], total surgical time [MD 1.92 minutes (95% CI 0.03 - 3.80)], and a reduced need for additional hemostatic sutures [RR 0.39 (95% CI 0.28 - 0.54)], with no difference in estimated blood loss [MD 46.17 ml (95% CI 13.55 to -105.89)] or postoperative morbidity [RR 0.96 (95% CI 0.46 - 2.01)]. The level of evidence was deemed to be low-to-very-low, based on inconsistency and imprecision of results. CONCLUSIONS Barbed sutures may be a suitable alternative to conventional sutures for uterine closure as they reduce uterine repair time, total surgical time and the need for additional haemostatic sutures, without an increase in blood loss or maternal morbidity.