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Does Suture Material Affect Uterine Scar Healing After Cesarean Section?
Results from a Randomized Controlled Trial

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DOI: 10.1080/08941939.2018.1458926

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ISSN: 0894-1939 (Print) 1521-0553 (Online) Journal homepage: http://www.tandfonline.com/loi/iivs20

Does Suture Material Affect Uterine Scar

Healing After Cesarean Section? Results from a
Randomized Controlled Trial

Alper Başbuğ, Ozan Doğan, Aşkı Ellibeş Kaya, Çiğdem Pulatoğlu & Mete
Çağlar

To cite this article: Alper Başbuğ, Ozan Doğan, Aşkı Ellibeş Kaya, Çiğdem Pulatoğlu
& Mete Çağlar (2018): Does Suture Material Affect Uterine Scar Healing After Cesarean
Section? Results from a Randomized Controlled Trial, Journal of Investigative Surgery, DOI:
10.1080/08941939.2018.1458926

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Journal of Investigative Surgery, 0, 1–7, 2018
Copyright  C 2018 Taylor & Francis Group, LLC

ISSN: 0894-1939 print / 1521-0553 online

DOI: 10.1080/08941939.2018.1458926

Does Suture Material Affect Uterine Scar Healing After

Cesarean Section? Results from a Randomized Controlled
Trial
Alper Başbuğ ,1 Ozan Doğan ,2 Aşkı Ellibeş Kaya ,1 Çiğdem Pulatoğlu ,3 Mete Çağlar4

1
Department of Obstetrics and Gynecology, Duzce University Hospital, Duzce, Turkey, 2 Department of Obstetrics and
Gynecology, Sisli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey, 3 Department of Obstetrics and
Gynecology, Bayburt Government Hospital, Bayburt, Turkey, 4 Department of Obstetrics and Gynecology, Akdeniz
University Faculty of Medicine, Antalya, Turkey

ABSTRACT
Background: Impaired healing of the uterine scar after cesarean has been associated with adverse gynecologi-
cal and obstetric outcomes. Although a large number of studies have been conducted on the events leading to
this, information obtained from prospective randomized studies examining the role of suture material in the
formation of cesarean scar defect (CSD) is lacking. Objective: To evaluate the effects of synthetic suture materi-
als on CSD formation. Study design: We performed a two-arm 1:1 randomized study in women with singleton
pregnancies undergoing elective primary cesarean delivery after the 38th week of gestation. Uterine scar closure
was performed using synthetic absorbable monofilament and multifilament sutures. The primary outcome was
residual myometrial thickness (RMT) in the area of the scar, measured by transvaginal ultrasound 6–9 months
after birth. Secondary outcomes included differences in mean operative time, mean estimated blood loss at the
time of surgery, and the rates of postoperative gynecological sequelae. Results: Complete follow-up was obtained
from 94 (88%) of 107 participants. RMT was thicker in the monofilament compared to the multifilament suture
group (5.5 ± 2.24 vs. 4.18 ± 1.76, p = 0.01). Hemoglobin delta was higher in the monofilament suture group
(1.59 ± 0.96 vs. 1.25 ± 0.60, p = 0.04). There was no statistically significant difference between the monofilament
suture and multifilament suture groups in terms of gynecological sequelae. Conclusion: Closure of the uterine scar
with monofilament suture has a positive effect on scar healing and increases RMT thickness.
Keywords: cesarean; isthmocele; scar defect; suture material

INTRODUCTION many short and long-term complications of CS, includ-

Cesarean section (CS) is the most common type of
obstetric surgery,1 with substantial increases in the
number of CS deliveries in middle- and high-income
countries in recent years.2 The rates of cesarean sec-
tion vary by region, accounting for 3.3% of deliv-
eries in Africa, 33.7% in Latin America, 27.3% in
Asia, and 40.5% in China, with a global average
of 15.9%.3 In Turkey, the rate of CS is considerably
higher, at 53% of deliveries.4 When medically justi-
fied, CS can effectively prevent maternal and peri-
natal mortality and morbidity5,6 ; however, there are
ing effects on other surgical procedures, as well as on
subsequent CS operations.7,8 One of the most com-
mon complications is the CS scar defect, which is
noted more frequently with increasing CS operations.
CS scar defects can develop after transverse incision
of the lower uterine segment, which may result in
prolonged postmenstrual bleeding, spotting, pelvic
pain, and infertility. This pouch-like structure, first
described by Morris in 1995, also called isthmocele,
niche, or cesarean scar dehiscence, is located at the
site of the old cesarean scar on the anterior uterine
isthmus.9,10

Received 19 January 2018; accepted 26 March 2018.

Address correspondence to Hamidiye Etfal Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey. Email:
ozandogan02@hotmail.com
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iivs.

1
2 A. Basbug et al.
Sutures are an essential part of any major surgery,
serving to hold opposing tissues together and acceler-
ate the healing process, resulting in decreased scarring
of the affected areas.11,12 In the past, gold, silver, iron,
and steel wires, dried animal gut, silk, and plant
fibers (e.g., linen, cotton) have been used as suture
materials,13 though nowadays, obstetricians typi-
cally prefer synthetic absorbent sutures for CS. Many
authors have investigated possible risk factors related
to cesarean scar defect (CSD), particularly those related
to uterine closure, number of cesarean births, uterine
position, and labor before cesarean delivery14 ; how-
ever, studies examining the role of the suture material
in formation of cesarean scar defects are limited. Here,
we sought to evaluate the effects of different synthetic
absorbable suture materials on cesarean scar defect
formation.
MATERIALS AND METHODS
This single-center, prospective randomized controlled
trial was conducted in Duzce Medical Faculty, Duzce,
Turkey, between December 2016 and December 2017.
The study was approved by the Ethics Committee of
Duzce Medical Faculty (approval number: 2016/003).
All patients provided informed written consent prior
to enrollment. This study followed the Consolidated
Standards of Reporting Trials (CONSORT) guidelines.
The study included women older than 18 years
who had elective cesarean birth and singleton preg-
nancy after 38 weeks of gestation and who had no
gynecological sequelae such as postmenstrual spot-
ting, dysmenorrhea, and chronic pelvic pain before
pregnancy. The indications for cesarean delivery were
maternal request, Cephalopelvic disproportion, breech
presentation, and macrosomic baby. Exclusion cri-
teria were gestational diabetes, gestational hyper-
tension/preeclampsia, multiple pregnancies, previous
cesarean or uterine scar, active labor (with regular uter-
ine contractions and cervical dilatation ࣙ4 cm) dur-
ing cesarean, failure of labor to progress, unsuccess-
ful induction of labor, and cesarean delivery before 38
weeks of gestation.
Surgical Technique
All surgical procedures were performed by two senior
surgeons experienced in obstetric surgery (A.B. and
A.E.K.), with the different suture materials divided
equally between surgeons. Povidone iodine was used
for surgical cleansing of the skin. For patients with
a body mass index (BMI) <30 kg/m2 , 1 g cefazolin
sodium (İESpor, İ.E.Ulagay) was administered intra-
venously 1 h before the skin incision was made; for
patients with BMI >30 kg/m2, 2 g cefazolin sodium
was used. The cesarean section was performed with a
Pfannenstiel abdominal incision and a transverse inci-
sion of the lower uterine segment. Next, we performed
a slight and sharp dissection of the vesicouterine peri-
toneal fold, followed by a blunt dissection of the plane
between the uterus and bladder using a finger. Closure
of the low transverse uterine incision was made using a
single-layer locked suture, including decidua, with the
visceral peritoneum open and the parietal peritoneum
closed. Estimated blood loss was calculated accord-
ing to the formula, delta hemoglobin concentration =
baseline hemoglobin concentration – postoperative 6th
hour hemoglobin concentration.
Suture Materials
Suture Material 1: Multifilament synthetic absorbable
suture composed of a copolymer made of glycolide
and L-lactide (glycolide-co-lactide), size no: 1. At 2
weeks, 75% of the original tensile strength remained;
full absorption between 56 and 70 days (Pegelak,
Trabzon, Turkey, equivalent of Vicryl ).®
Suture Material 2: Monofilament synthetic
absorbable suture composed of a copolymer made
of glycolide and epsilon-caprolactone (glycolide-co-
caprolactone). size no: 1. At 2 weeks, 30% of the original
tensile strength remained; full absorption between 90
and 120 days (Tekmon, Trabzon, Turkey, equivalent of
®
Monocryl ).
Follow-up
The following baseline characteristics were collected:
maternal age, BMI, gravidity, parity, previous vagi-
nal birth, cesarean birth cause, prenatal cervical
dilatation, estimated blood loss, and duration of the
operation.
Considering that uterine wound healing is typi-
cally completed within 6 months after birth, ultra-
sound examination of uterine scars was performed
6–9 months after cesarean birth.15 At their appointment
for this procedure, respondents first completed a sur-
vey consisting 26 questions that have been developed
to discover and interpret the signs assessing gyneco-
logical sequelae associated with CS scar defects. Then,
transvaginal ultrasonography (TVS) was performed to
evaluate the uterine scar, as previously described.16 All
ultrasound examinations were performed by an expe-
rienced doctor (A.B.) using 5–9 MHz transducer (Volu-
son 730 Expert, GE Healthcare, Milwaukee, WI, USA).
The position of the uterus (anteverted or retroverted),
the residual myometrial thickness (RMT, thickness of
the residual myometrium over the cesarean scar), and
the total myometrial thickness (TMT, myometrial thick-
ness above the uterine scar) of the uterine scar were
recorded. CSD was defined as an RMT score <2.3.15
Journal of Investigative Surgery

Sample Size
No previous prospective randomized controlled
studies were available for comparison, so to estimate
the necessary sample size, we performed a pilot study
that included 20 patients with 10 patients in each
group. RMT varied by 30% between groups (6 mm to
4 mm). Based on these data, for an alpha level value
of 0.5 and a power value of 80%, we calculated a
minimum sample size of 43 per group, for a total of
86 patients. Considering a potential risk of 10% loss to
follow-up, we intended to randomize 94 patients.
For this study, a total of 179 women were screened,
with 130 deemed eligible for inclusion, of whom 107
were enrolled. Five patients in the multifilament suture
group and six in the monofilament suture group were
lost to the follow-up after 6 months, leaving a total of
96 patients.
Outcomes
The primary outcome was the relationship between
RMT and suture material. Secondary outcomes
included differences between groups in the mean
operative time, mean estimated blood loss at the
time of the cesarean, and prevalence of postoperative
gynecological sequelae.
Statistical Analysis
Descriptive statistics for continuous variables are
expressed as mean ± standard deviation or median
(minimum–maximum), and nominal variables are
expressed as the number and percentage (%). Differ-
ences in mean values for each group were evaluated
using the Student’s t-test, and differences in median
values were evaluated using the Mann–Whitney
U-test. Categorical data were compared using the Chi-
square distribution. p-values ࣘ0.05 were considered
statistically significant. Statistical analysis was per-
formed using SPSS for Windows version 22 software
(SPSS, Inc., Chicago, IL, USA).
RESULTS
Figure 1 shows the CONSORT flow chart accounting
for all patients, including those lost to follow-up, those
who discontinued intervention, and those who did not
meet the inclusion criteria. Two patients became preg-
nant after the initial CS and were therefore excluded
from the study. The groups were similar in terms of age,
body mass index, gravidity, parity, gestational week at
delivery, cervical dilatation, uterine position, and indi-
cations for CS. (Table 1).

C 2018 Taylor & Francis Group, LLC
İmpact of Suture Material on Uterine Scar Healing 3
Overall operating time was shorter in the multifil-
ament compared to the monofilament suture group
(35.62 ± 6.64 vs. 38.33 ± 5.86, respectively; p = 0.08),
though this shorter duration was accompanied by sig-
nificantly higher blood loss in the monofilament suture
group (1.25 ± 0.60 vs. 1.59 ± 0.96, p = 0.04; Table 2).
Although differences in blood loss were statistically
significant, no patients included in this study experi-
enced hemorrhage requiring transfusion. There was no
intraoperative complication in either group.
Between CS and transvaginal ultrasound examina-
tion, there was a mean interval of 27.9 weeks in multifil-
ament suture group and 27.75 weeks in monofilament
suture group. this difference was not statistically signif-
icant (p = 0.77). The residual myometrial thickness was
significantly greater in the monofilament compared to
the multifilament suture group (5.50 ± 2.24 vs. 4.18
± 1.76, respectively; p = 0.001). The total myometrial
thickness was also greater in the monofilament suture
group; however, this difference was not statistically
significant (9.46 ± 2.06 vs. 8.42 ± 1.89, respectively;
p = 0.18). CSD was lower in the monofilament suture
group compared to the multifilament suture group
in cases where residual myometrial thickness was
<2.3 mm, though this difference was not statistically
significant (23.9 vs. 14.6%, respectively; p = 0.33).
Postoperative gynecological sequelae such as post-
menstrual spotting, dysmenorrhea, and chronic pelvic
pain were less common in the monofilament than in
the multifilament suture group, though these differ-
ences were not statistically significant (21.7% vs. 8.3%,
p = 0.13; 13.04 vs. 6.25%, p = 0.39; and 13.04% vs. 6.25%,
p = 0.39, respectively) (Table 3).
DISCUSSION
The results of this randomized study showed that
when the uterine defect after transposition of the lower
segment was repaired by monofilament suture, the
residual myometrial thickness was greater. There was
no relationship between suture type and CSD and post-
operative gynecological sequelae. Intraoperative blood
loss was sufficiently minimized in both groups that
blood transfusion was not required for any patient.
A cesarean scar defect, niche, or isthmocele is a coin-
cidental finding on TVS and is usually asymptomatic.
While the exact prevalence of symptomatic isthmocele
is unclear, as the number of recurrent cesarean sec-
tions increases, there is no doubt that the number of
women with known uterine scar defects will also rise.17
The prevalence of isthmocele ranges from 6% to 88%
depending on the diagnostic method used, diagnostic
criteria, and postoperative evaluation time.18–20 In our
study, CSD incidence was 14.6% in the monofilament
suture group and 23.9% in the multifilament suture
group.
4 A. Basbug et al.

FIGURE 1. Flow diagram of the selection, enrollment, and randomization of the

participants.

TABLE 1. Characteristics of the patients.

Multifilament suture group (n = 46) Monofilament suture group (n = 48) p-value

Age (year) 29.57 ± 5.60 29.43 ± 6.70 0.65

BMI 26.61 ± 3.87 25.79 ± 4.34 0.27
Nulliparity 27 (58.7%) 25 (52.1%) 0.078
Previous vaginal birth 19 (41.3%) 23 (47.9) 0.53
Gestational age at delivery (week) 39.19 ± 1.08 39.47 ± 1.23 0.24
Cervical dilatation (cm) 0 (0-4) 0 (0-4) 0.56
Uterine Position
Anteverted 41 (89.13%) 40 (83.37%) 0.81
Retroverted 5 (10.87%) 8 (16.63%) 0.46
Indications for CS
Maternal request 24 (52.19%) 23 (47.9%) 0.88
Cephalopelvic disproportion 6 (13.04%) 7 (14.60%) 0.56
Breech presentation 5 (10.86%) 9 (18.75%) 0.28
Macrosomic baby 11 (23.91%) 9 (18.75%) 0.78

TABLE 2. Intraoperative data.

Multifilament suture group (n = 46) Monofilament suture group (n = 48) p-value

Operation time (min) 35.62 ± 6.64 38.33 ± 5.86 0.08

Delta hemoglobin concentration (g/dL) 1.25 ± 0.60 1.59 ± 0.96 0.04
Intraoperative complication (%) 0 0 1.00

Journal of Investigative Surgery


TABLE 3. Comparison of the residual myometrial thickness and postoperative gynecological sequelae.
Multifilament
suture group
(n = 46)
Time from CS to transvaginal 27.94 ± 3.33
ultrasound examination (weeks)
Residual myometrial thickness (mm) 4.18 ± 1.76
Total myometrial thickness (mm) 8.42 ± 1.89
Thickness <2.3 mm (%) 12 (23.9%)
Postmenstrual spotting 10 (21.7%)
Dysmenorrhea 6 (13.04%)
Chronic pelvic pain 6 (13.04%)
Several mechanisms have been implicated in the for-
mation of CSD, with most cases attributed, at least
in part, to the surgical procedure used. A study by
Vervoort et al. directly attributed the formation of
CSD to use of a lower segment transverse incision.
The authors hypothesized that surgical incisions per-
formed during active labor are often made more prox-
imal to the cervix due to the difficulty of distinguish-
ing between the effaced cervix and uterus. In these
cases, the mucus-producing glands of the lower seg-
ment become included in the defect, which can disrupt
wound healing due to accumulation of secretions in
the wound.21 However, this hypothesis fails to explain
cases of CSD after cesarean section performed prior
to the initiation of active labor. Another hypothesis
regarding CSD formation is related to uterine wall clo-
sure techniques. Closing the uterine wall in either sin-
gle or double layers, use of a locked or unlocked suture
technique, and the inclusion or exclusion of decidua
may affect the development of CSD.22 In a review by
Tulandi et al., closing the uterus using a single layer
was shown to reduce the risk of CSD defects compared
with double-layer closure, though this difference was
not statistically significant.17 In our study, we closed the
uterine defect using a single-layer approach with con-
tinuous locking sutures, which included the decidua.
Using this approach, the mean CSD in the monofila-
ment suture group was lower than that in the multifila-
ment suture group (23.9 vs. 14.6), though the difference
was not statistically significant.
A number of studies have been published that sup-
port the notion of surgical processes as a determi-
nant CSD. However, these analyses fail to address the
importance of scar healing in CSD development, in
which suture materials are a main component. His-
torically, many materials have been used to heal scars
due to traumas or surgeries, with modern surgeries
typically relying on an array of advanced synthetic
suture materials. The task of any suture material is
to bring the wound lips together by positioning them
face to face and to control bleeding from the wound.
For this purpose, during cesarean section, multifila-
ment sutures are preferred by 95% of obstetricians in

C 2018 Taylor & Francis Group, LLC
İmpact of Suture Material on Uterine Scar Healing 5
Monofilament
suture group
(n = 48) p-value
27.75 ± 2.95 0.77
5.5 ± 2.24 0.01
9.46 ± 2.06 0.18
7 (14.6%) 0.33
4 (8.33%) 0.13
3 (6.25%) 0.39
3 (6.25%) 0.39
general practice.23 Although the exact reasons behind
this preference may vary, we suspect that the pri-
mary reason underlying a preference for multifilament
suture materials is that they provide better hemosta-
sis. In the CORONIS study, researchers found no differ-
ence in postpartum blood loss when catgut, a monofil-
ament suture, was compared to glycolide-co-lactide
(PG-910, Vicryl), a multifilament suture.24 Although
we did observe significantly higher blood loss in the
monofilament suture group, this loss was not enough
to require blood transfusion. The exact relationship
between monofilament sutures and blood loss remains
uncertain, although the greater number of knotting
throws, low tensile strength, and longer operation time
with monofilament sutures does appear to be less ben-
eficial for hemostasis.
The wound healing process consists of four major
phases: hemostasis, inflammation, proliferation, and
maturation. The inflammatory phase begins immedi-
ately after hemostasis and can be seen histologically
in the trauma caused by bacterial penetration and sat-
uration. If an absorbable suture is left in place for
more than 2 weeks after wound closure, an acute
inflammatory reaction occurs. This event is produced
by the penetration of bacteria into the stitch channel
and their entrance into the suture material, which is
more frequent in multifilament suture materials due to
their structure.25,26 Multifilament suture materials also
aid in bacterial migration, allowing bacteria to enter
via the interior of the suture material, impairing the
host’s immunologic response and adversely affecting
wound healing.27 We therefore believe that the pro-
longed inflammatory phase in patients treated using
multifilament sutures, as well as immunologic changes
that occur in host cells, play a role in the formation of
CSD.
The strengths of our study include a homogeneous
population with nonactive labor, primary cesarean
delivery without a prior uterine scar, high follow-
up rates, and a sufficiently long recovery period of
6–9 months for CSD assessment. The main limita-
tions of this study are the use of only glycolide-co-
caprolactone-containing material as the monofilament
6 A. Basbug et al.
suture material and glycolide-co-lactide as the multi-
filament suture material. Plain or cromic catgut, poly-
®
dioxanone (PDS ), and antibacterial coated sutures are
not used. The use of only the single-layer continu-
ous locking closure technique, including the decidua;
and the lack of short and long-term follow-up for
endometritis and chorioamnionitis , secondary infertil-
ity, and complications in subsequent pregnancies could
also be considered a study limitation.
While the discussions of the last few years have
been largely focused on uterine closure methods, this
study emphasized the importance of other factors that
affect uterine scar healing, such as suture materials.
Our results showed that monofilament sutures reduced
pathological inflammation during wound healing
without increasing costs, operation time, or intraoper-
ative complication rates; resulting in improved uter-
ine scar recovery; and potentially reduced CSD. These
findings suggest means by which gynecological seque-
lae due to CSD and serious obstetric complications that
may occur in subsequent pregnancies can be reduced.
DECLARATION OF INTEREST
No potential conflicts of interest were disclosed.
AUTHORSHIP CREDITS
The authors declare that are qualified for authorship
and have participated sufficiently in the work to take
public responsibility for appropriate portions of the
content. The authors declare that they made a substan-
tial contribution to the concept or design of the work; or
acquisition, analysis, or interpretation of data, drafted
article or revised it critically for important intellectual
content, approved the version to be published, and
each author has participated sufficiently in the work
and taken public responsibility for appropriate por-
tions of the content.
ACKNOWLEDGMENT
The English in this document has been checked
by at least two professional editors, both native
speakers of English. For a certificate, please see:
http://www.textcheck.com/certificate/IbfNSq
ORCID
Alper Başbuğ http://orcid.org/0000-0003-1825-9849
Ozan Doğan http://orcid.org/0000-0002-0016-8749
Aşkı Ellibeş Kaya http://orcid.org/0000-0002-1323-
7416
Çiğdem Pulatoğlu http://orcid.org/0000-0002-7595-
3629
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