**2.4 Subcutaneous tissue and skin closure**

Suturing of the subcutaneous tissue has always been debated. Level one evidence says that suture closure of the subcutaneous fat at the time of CS reduces the risk of wound disruption in women with a subcutaneous tissue larger than two centimeters. Doing so will not only reduce collection in this space but also decrease wound tension. Though studies do show that it does not affect long-term cosmetic outcome [30].

A basic need of skin closure is good approximation. Apart from cosmetically good scars it is also necessary that the skin closure technique should be technically easy, acceptable, speedy and economical. Good tissue union and cosmetically acceptable scars are vital for ideal surgical practice.

Technique of skin closure in a cesarean section can be continuous subcuticular stitch, interrupted mattress stitch, staples or adhesive compounds.

With a plethora of skin closure materials currently available, choosing a solution that combines excellent and rapid cosmetic results with practicality and costeffectiveness can be difficult, if not tricky. Suture materials currently available are natural, synthetic, absorbable, or non-absorbable, single filament or braided.

Mattress sutures have an advantage of occluding dead space and keeping the skin edges everted without tension. This is useful especially in older women where skin tends to get inverted.

The disadvantage with this type of suture is that there can be difficulty in approximation and prominent suture marks as sutures tend to be removed later.

To overcome the disadvantage of traditional interrupted mattress suture, Hohenleutner et al., described the intradermal buried vertical mattress suture [31]. This suture technique is safe, easy and fast to perform, everts skin edges and achieves good cosmetic results without leaving suture marks.

Subcuticular suture was first described by Halsted [32]. It is a cosmetic stitch, more difficult, but a good choice especially in younger women whose skin is soft and supple, hence making approximation easy. It is preferable to use absorbable suture for this stitch as the ends are also buried and suture removal is not required.

Though subcuticular stitch has better patient compliance than mattress stitch, the post-operative scar assessment at 6 weeks have yielded similar results in both.

Staples are attractive because of the speed of application.

An RCT study of staples with subcuticular stitch by Figueroa D showed that surgical staples were significantly associated with a higher incidence wound disruptions among those randomized to staples. This observation persisted when the outcome is restricted to disruptions >1 cm in length or > 0.5 cm in depth and typically led to additional scheduled clinic follow-up visits [33].

Another RCT by Madsen AM, comparing absorbable subcuticular staples with suture showed that wound complications, and cosmesis were similar [34]. So if one wants to use staples for closure then the absorbable one would be preferred, as metal staples though faster, has more wound morbidity.

There are many advantages of tissue adhesives over suturing and other methods of wound closure, such as a lower infection rate, less operating room time, good cosmetic results, lower costs, ease of use, immediate wound sealing, faster return to work, elimination of needle-stick injuries and eliminating the need for post-operative suture removal [35]. An RCT by Daykan Y, says that skin closure with glue or synthetic subcuticular suture have similar outcomes with respect to surgical site infection and wound disruptions [36]. The commonly used adhesive is octyl-2-cyanoacrylat.
