**2.3 Rectus sheath closure**

Different techniques and suture materials are used in cesarean section for closure of the rectus sheath. Few general principles are to be followed while closing the abdominal wall to achieve good healing and reduce complications. All sutures used to close the musculofascial wall must be tied with enough tension to approximate the edges of the incision. If greater tension is applied, the tissue will become ischemic and necrosis will develop. The sutures should be placed at least 1 to 1.5 cm from the wound edge. In patients at increased risk of wound disruption, sutures should be placed 2 cm from the edge [28].

The commonly used technique is to put continuous sutures without any locking. Continuous suture when used in one layer avoids high tension on suture and does not compress the wound edges. This prevents devascularization of the sheath and formation of a good quality collagen, i.e., type I [29]. Running sutures have the advantage of speed, since knots need only be tied at two or three points. Interrupted and figure-of-eight sutures can be used for reinforcing in thin rectus sheath and has an advantage, of not coming apart if insecurely tied.

Rectus sheath closure is routinely performed with non-absorbable or delayed absorbable sutures. It is generally accepted that non-absorbable sutures cause less tissue reaction and are more resistant to infection than the absorbable sutures. However, these sutures are associated with higher incidence of buttonhole hernias and sinus formation leading to increased wound pain. Care should be taken while tying the knots to avoid slippage. The commonly used suture materials for rectus sheath closure are polyglactin-910 number 1 and polypropylene number 1. Cochrane review found no studies examining different suture techniques or material for rectus sheath closure.
