Knotless barbed wire versus conventional suture for closing the uterine incision during cesarean section: a systematic review and meta-analysis


To compare perioperative outcomes between knotless barbed sutures (KBS) and conventional smooth sutures for closure of the uterine incision during caesarean section (CS).

The data source

MEDLINE, EMBASE, Web of Sciences, Scopus, the Cochrane Library, and were searched from inception through March 2021 with no language restrictions. The search terms were: [“Stratafix” OR “Quill” OR “V-Loc” OR “Barbs” OR “barbed”]
AND [“Cesarean” OR “Caesarean”] AND [“Suturing” OR “Suture” OR “Closure” OR “Repair”]. These terms were then combined to complete the search.

Study selection methods

Retrospective, randomized, peer-reviewed studies comparing the use of KBS and conventional sutures for uterine incision closure at CS were included. The quality of the studies was assessed by the Cochrane Risk of Bias tool. The primary endpoint was time to uterine incision closure in seconds. Secondary outcomes included total operative time (minutes), use of additional haemostatic sutures, blood transfusion rates, and postoperative complications.

Tabulation, integration and results

Of 20 identified reports, four representing 3332 women (1473 and 1859 with KBS and conventional sutures, respectively) were eligible. All were judged to be at low risk of bias. The time to close the uterine incision was significantly lower in the KBS group (p=0.001; mean difference -110.58; 95% CI: -127.37, -93.79). Similarly, the rate of use of additional haemostatic sutures was significantly lower in the KBS group (p=0.001; OR 0.14; 95% CI: 0.07, 0.26). Total operative time, blood transfusion rates, febrile morbidity and postoperative length of stay were comparable. The incidence of postoperative ileus was significantly lower in the KBS group (p=0.029; OR 0.31; 95% CI: 0.11, 0.89).


The use of KBS for uterine incision closure was associated with a decrease in hysterotomy closure time and a less frequent need for additional haemostatic sutures. Other perioperative outcomes were unaffected, although the risk of postoperative ileus was reduced.


This study is registered with PROSPERO, CRD42021219750.

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