Knotless Barbed versus Conventional Suture for Closure of the Uterine Incision at Cesarean Delivery: A Systematic Review and Meta-analysis

To compare perioperative outcomes between knotless barbed sutures (KBSs) and conventional smooth sutures for uterine incision closure at cesarean section. MEDLINE, EMBASE, Web of Sciences, Scopus, the Cochrane Library, and ClinicalTrials.gov were searched from the inception of the study to March 2021 without language restriction. The search terms were as follows: [“Stratafix” OR “Quill” OR “V-Loc” OR “Barbs” OR “barbed”] AND [“Cesarean” OR “Caesarean”] AND [“Suturing” OR “Suture” OR “Closure” OR “Repair”]. Moreover, these terms were combined to complete the search. Retrospective and randomized peer-reviewed studies comparing the use of KBSs and conventional sutures for uterine incision closure at cesarean section were included. The studies’ quality was assessed by the Cochrane risk-of-bias tool. The primary outcome was the time of uterine incision closure in seconds. The secondary outcomes included total operating time (minutes), use of additional hemostatic sutures, rates of blood transfusion, and postoperative complications. Of 20 reports identified, 4 representing 3332 women (1473 with KBSs and 1859 with conventional sutures) were eligible. All studies were judged to be at low risk of bias. The uterine incision closure time was significantly lower in the KBS group (mean difference, −110.58; 95% confidence interval [CI], −127.37 to −93.79; p = .001). Furthermore, the rate of use of additional hemostatic sutures was significantly lower in the KBS group (odds ratio, 0.14; 95% CI, 0.07–0.26; p = .001). Total operative time, rates of blood transfusion, febrile morbidity, and length of postoperative stay were comparable. The incidence of postoperative ileus was significantly lower in the KBS group (odds ratio, 0.31; 95% CI, 0.11–0.89; p = .029). The use of KBSs for uterine incision closure was associated with decreased hysterotomy closure time and less frequent need for the placement of additional hemostatic sutures. Other perioperative outcomes were not affected, although the risk of postoperative ileus was reduced.