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Cierre subcutáneo versus ningún cierre subcutáneo después de los procedimientos quirúrgicos no relacionados con la cesárea

Appendices

Appendix 1. Classification of surgical wounds

Clean wound

  • Uninfected operative wounds

  • No inflammation is encountered

  • Respiratory, alimentary, genital or uninfected urinary tracts are not entered

  • Primarily closed

Clean‐contaminated wound

  • Respiratory, alimentary, genital or urinary tract is entered under controlled conditions

  • Without unusual contamination

  • No evidence of infection or major break in sterile technique is encountered

Contaminated wound

  • Open, fresh accidental wounds or operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract or incisions in which acute, non‐purulent inflammation is encountered

Dirty wound

  • Old traumatic wounds with retained devitalised tissue or those that involve existing clinical infection or perforated viscera (i.e. the organisms causing postoperative infection were present in the operative field before the operation)

Appendix 2. Ovid MEDLINE, Ovid EMBASE and EBSCO CINAHL Search Strategies

Ovid Medline

1 exp Wound Closure Techniques/ (38162)
2 exp Sutures/ (12060)
3 (closure or close or closing or sutur*).tw. (300829)
4 or/1‐3 (324065)
5 exp Subcutaneous Tissue/ (1703)
6 (((subcutaneous or sub‐cutaneous) adj5 (fat or adipose or tissue*)) or superficial fascia or hypdermis).tw. (18170)
7 or/5‐6 (19321)
8 4 and 7 (937)
9 randomized controlled trial.pt. (338195)
10 controlled clinical trial.pt. (85043)
11 randomized.ab. (241810)
12 placebo.ab. (134534)
13 clinical trials as topic.sh. (162087)
14 randomly.ab. (173722)
15 trial.ti. (103477)
16 or/9‐15 (782338)
17 (animals not (humans and animals)).sh. (3663525)
18 16 not 17 (720068)
19 8 and 18 (66)

Ovid Embase

1 exp wound closure/ (8769)
2 exp suture/ (28180)
3 (closure or close or closing or sutur*).tw. (400571)
4 or/1‐3 (412703)
5 exp subcutaneous tissue/ (22275)
6 (((subcutaneous or sub‐cutaneous) adj5 (fat or adipose or tissue*)) or superficial fascia or hypdermis).tw. (25061)
7 or/5‐6 (37394)
8 4 and 7 (1710)
9 Randomized controlled trials/ (26220)
10 Single‐Blind Method/ (16988)
11 Double‐Blind Method/ (115513)
12 Crossover Procedure/ (36187)
13 (random$ or factorial$ or crossover$ or cross over$ or cross‐over$ or placebo$ or assign$ or allocat$ or volunteer$).ti,ab. (1213080)
14 (doubl$ adj blind$).ti,ab. (140490)
15 (singl$ adj blind$).ti,ab. (13290)
16 or/9‐15 (1268250)
17 exp animals/ or exp invertebrate/ or animal experiment/ or animal model/ or animal tissue/ or animal cell/ or nonhuman/ (19613926)
18 human/ or human cell/ (14178567)
19 and/17‐18 (14131914)
20 17 not 19 (5482012)
21 16 not 20 (1091425)
22 8 and 21 (133)

EBSCO CINAHL

S22 S9 AND S21
S21 S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20
S20 MH "Quantitative Studies"
S19 TI placebo* or AB placebo*
S18 MH "Placebos"
S17 TI random* allocat* or AB random* allocat*
S16 MH "Random Assignment"
S15 TI randomi?ed control* trial* or AB randomi?ed control* trial*
S14 AB ( singl* or doubl* or trebl* or tripl* ) and AB ( blind* or mask* )
S13 TI ( singl* or doubl* or trebl* or tripl* ) and TI ( blind* or mask* )
S12 TI clinic* N1 trial* or AB clinic* N1 trial*
S11 PT Clinical trial
S10 MH "Clinical Trials+"
S9 S4 AND S8
S8 S5 OR S6 OR S7
S7 TI ( "superficial fascia" or hypdermis ) OR AB ( "superficial fascia" or hypdermis )
S6 TI ( (subcutaneous or sub‐cutaneous) N5 (fat or adipose or tissue*) ) OR AB ((subcutaneous or sub‐cutaneous) N5 (fat or adipose or tissue*) )
S5 (MH "Abdominal Fat")
S4 S1 OR S2 OR S3
S3 TI ( closure or close or closing or sutur* ) OR AB ( closure or close or closing or sutur* )
S2 (MH "Suture Techniques")
S1 (MH "Sutures")

Study flow diagram
Figuras y tablas -
Figure 1

Study flow diagram

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 1 Superficial surgical site infection.
Figuras y tablas -
Analysis 1.1

Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 1 Superficial surgical site infection.

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Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 2 Superficial wound dehiscence.
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Analysis 1.2

Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 2 Superficial wound dehiscence.

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Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 3 Deep wound dehiscence.
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Analysis 1.3

Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 3 Deep wound dehiscence.

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Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 4 Hospital stay.
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Analysis 1.4

Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 4 Hospital stay.

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Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 5 Superficial surgical site infection (sensitivity analysis ‐ missing data imputation).
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Analysis 1.5

Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 5 Superficial surgical site infection (sensitivity analysis ‐ missing data imputation).

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Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 6 Hospital stay (sensitivity analysis).
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Analysis 1.6

Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 6 Hospital stay (sensitivity analysis).

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Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 7 Superficial surgical site infection (sensitivity analysis ‐ > 30 days).
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Analysis 1.7

Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 7 Superficial surgical site infection (sensitivity analysis ‐ > 30 days).

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Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 8 Superficial wound dehiscence (sensitivity analysis ‐ > 30 days).
Figuras y tablas -
Analysis 1.8

Comparison 1 Subcutaneous closure versus no subcutaneous closure, Outcome 8 Superficial wound dehiscence (sensitivity analysis ‐ > 30 days).

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Summary of findings for the main comparison. Subcutaneous closure compared to no subcutaneous closure for non‐caesarean surgery

Subcutaneous closure compared to no subcutaneous closure for non‐caesarean surgery

Patient or population: participants having non‐caesarean surgery
Settings: secondary
Intervention: subcutaneous closure of incision
Comparison: no subcutaneous closure of incision

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

No subcutaneous closure

Subcutaneous closure

Superficial surgical site infection

83 per 1000

70 per 1000
(44 to 110)

RR 0.84
(0.53 to 1.33)

815
(6 studies)

⊕⊝⊝⊝
very low1,2

Superficial wound dehiscence

103 per 1000

58 per 1000
(23 to 145)

RR 0.56
(0.22 to 1.41)

215
(2 studies)

⊕⊝⊝⊝
very low1,2

Deep wound dehiscence

133 per 1000

33 per 1000
(4 to 281)

RR 0.25
(0.03 to 2.11)

60
(1 study)

⊕⊝⊝⊝
very low1,2

Hospital stay

The mean hospital stay in the control groups was
6 days

The mean hospital stay in the intervention groups was
0.1 higher
(0.45 lower to 0.64 higher)

434
(3 studies)

⊕⊝⊝⊝
very low1,3

*The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: we are very uncertain about the estimate

1 The trial(s) was (were) of high risk of bias
2 The confidence intervals overlapped 1 and either 0.75 or 1.25 or both. The number of events in the intervention and control group was fewer than 300
3 There was severe heterogeneity as noted by the I2 statistic and the lack of overlap of confidence intervals

Figuras y tablas -
Summary of findings for the main comparison. Subcutaneous closure compared to no subcutaneous closure for non‐caesarean surgery
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Comparison 1. Subcutaneous closure versus no subcutaneous closure

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Superficial surgical site infection Show forest plot

6

815

Risk Ratio (M‐H, Fixed, 95% CI)

0.84 [0.53, 1.33]

2 Superficial wound dehiscence Show forest plot

2

215

Risk Ratio (M‐H, Fixed, 95% CI)

0.56 [0.22, 1.41]

3 Deep wound dehiscence Show forest plot

1

60

Risk Ratio (M‐H, Fixed, 95% CI)

0.25 [0.03, 2.11]

4 Hospital stay Show forest plot

3

434

Mean Difference (IV, Fixed, 95% CI)

0.10 [‐0.45, 0.64]

5 Superficial surgical site infection (sensitivity analysis ‐ missing data imputation) Show forest plot

6

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Best‐best analysis

6

824

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.52, 1.32]

5.2 Best‐worst analysis

6

824

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.47, 1.16]

5.3 Worst‐best analysis

6

824

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.63, 1.52]

5.4 Worst‐worst analysis

6

824

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.57, 1.33]

6 Hospital stay (sensitivity analysis) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

7 Superficial surgical site infection (sensitivity analysis ‐ > 30 days) Show forest plot

3

434

Risk Ratio (M‐H, Fixed, 95% CI)

0.54 [0.25, 1.19]

8 Superficial wound dehiscence (sensitivity analysis ‐ > 30 days) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 1. Subcutaneous closure versus no subcutaneous closure
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