Skin is closed with a running subcuticular stitch of 4-0 delayed-absorbable suture, with adhesive glue, or with staples. In comparison, final cosmetic results and infection rates appear similar, skin suturing takes longer, but wound separation rates are higher with metal staples (Basha, 2010; Figueroa, 2013; Mackeen, 2014a, 2015). Poliglecaprone 25 (NIonocryl) or polyglactin 910 (Vieryl) are both suitable (Tuuli, 2016b). Outcomes with 2-octyl cyanoacrylate adhesive (Dermabond) were equivalent to sutures for Pfannenstiel incisions (Daykan, 2017; Siddiqui, 2013). A sterile thin abdominal wound dress ing is suicient. In morbidly obese women, application of a prophylactic negative-pressure device atop the closed skin incision to prevent seroma and subsequent infection does not appear to lower wound complication rates (Hussamy, 2018; Smid, 2017).
The Pfannenstiel-Kerr technique just described has been used for decades. More recently, Joel-Cohen and Misgav Ladach techniques have been added (Holmgren, 1999). These difer from traditional Pfannenstiel-Kerr entry mainly by their initial incision placement and greater use of blunt dissection.
he Joel-Cohen technique creates a straight 10-cm transverse skin incision 3 em below the level of the anterior superior iliac spines (Olofson, 2015). he subcutaneous tissue layer is opened sharply 2 to 3 em in the midline. This is carried down, without lateral extension, to the fascia. A small transverse incision is made in the fascia, and curved Mayo scissors are pushed laterally on each side and beneath intact subcutaneous fat to incise the fascia. With this incision completed, an index finger from each hand is inserted between the rectus abdominis muscle bellies and beneath the fascia. One finger is moved cranially and the other caudally, in opposition, to separate the bellies and further open the fascial incision. hen, a finger from each hand hooks under each belly to stretch the muscles laterally. The peritoneum is entered sharply, and this incision is sharply extended cephalocaudad. Entry with the Misgav Ladach technique difers in that the peritoneum is entered bluntly (Holmgren, 1999).
Modiications to the Joel-Cohen method abound. For emergency delivery, we begin along a line somewhat lower on the abdomen. For speed, we extend the fascial incision bluntly by hooking index fingers in the fascial incision's lateral angles and pulling laterally (Hofmeyr, 2009; Olofson, 2015). Index fingers insinuated between the rectus bellies then move cephalocaudad in opposition to stretch the incision. Blunt index-finger dissection enters the peritoneum, and again, cranial and caudad opposing stretch opens this layer. Last, all the layers of the abdominal wall are grasped manually and pulled laterally in opposition to further open the operating space.
These techniques have been associated with shorter operative times and with lower rates of intraoperative blood loss and postoperative pain (Mathai, 2013). They may, however, prove diicult for women with anterior rectus fibrosis and peritoneal adhesions (BoIze, 2013).