[Caesarean section: closure or non-closure of peritoneum? A randomized trial of postoperative morbidity]

Laparoscopic Management of Adhesions Developed after Peritoneal Nonclosure in Primary Cesarean Section Delivery

OBJECTIVE

The aim of the current study was to laparoscopically investigate the effects of peritoneal nonclosure on the sites, types, and degrees of adhesions developed after primary caesarean section (CS) in women complaining of secondary infertility after first CS delivery.

STUDY DESIGN

This was a cross-sectional study, where 250 women suffering from secondary infertility after their first CS had been recruited. They had been classified into group I (n = 89), where both the visceral and parietal peritoneum had been left opened; group II (n = 75), where only the parietal peritoneum had been closed; and group III (n = 86), where both peritoneal layers had been closed. Laparoscopy had been used to classify those adhesions according to the location, severity, and their adverse impact on the reproductive capacity.

RESULTS

Both adnexal and nonadnexal adhesions had been found significantly higher in group I, while adnexal types of adhesions were significantly higher after nonclosure of the visceral peritoneum in group II. Laparoscopic tubal surgery performed included tubo-ovariolysis, fimbrioplasty, and neosalpingostomy. Pregnancy rate was found correlating with the adnexal adhesion location and score.

CONCLUSION

Nonclosure of the peritoneum in CS is associated with more adhesion formation, which might adversely affect the future women reproduction.

Adhesion prevention after cesarean delivery: evidence, and lack of it

In spite of the recognized occurrence of cesarean-attributable adhesions, its clinical significance is uncertain. The presence of adhesions during a repeat cesarean section can make fetal extraction lengthy and the procedure challenging and may increase the risk of injury to adjacent organs. Two methods for adhesion prevention are discussed, peritoneal closure and use of adhesion barriers. Peritoneal closure appears to be safe in the short term. In the long term, conflicting evidence arise from reviewing the literature for possible adhesion reduction benefits. A systematic review of the literature on the use of adhesion barriers in the context of cesarean section yielded only a few studies, most of which are lacking in methodology. For now, it appears that the available evidence does not support the routine use of adhesion barriers during cesarean delivery.

Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes

BACKGROUND

Caesarean section is a very common surgical procedure worldwide. Suturing the peritoneal layers at caesarean section may or may not confer benefit, hence the need to evaluate whether this step should be omitted or routinely performed.

OBJECTIVES

The objective of this review was to assess the effects of non-closure as an alternative to closure of the peritoneum at caesarean section on intraoperative and immediate- and long-term postoperative outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 November 2013).

SELECTION CRITERIA

Randomised controlled trials comparing leaving the visceral or parietal peritoneum, or both, unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked it for accuracy.

MAIN RESULTS

A total of 29 trials were included in this review and 21 trials (17,276 women) provided data that could be included in an analysis. The quality of the trials was variable. 1. Non-closure of visceral and parietal peritoneum versus closure of both parietal layersSixteen trials involving 15,480 women, were included and analysed, when both parietal peritoneum was left unclosed versus when both peritoneal surfaces were closed. Postoperative adhesion formation was assessed in only four trials with 282 women, and no difference was found between groups (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.76 to 1.29). There was significant reduction in the operative time (mean difference (MD) -5.81 minutes, 95% CI -7.68 to -3.93). The duration of hospital stay in a total of 13 trials involving 14,906 women, was also reduced (MD -0.26, 95% CI -0.47 to -0.05) days. In a trial involving 112 women, reduced chronic pelvic pain was found in the peritoneal non-closure group. 2. Non-closure of visceral peritoneum only versus closure of both peritoneal surfacesThree trials involving 889 women were analysed. There was an increase in adhesion formation (two trials involving 157 women, RR 2.49, 95% CI 1.49 to 4.16) which was limited to one trial with high risk of bias.There was reduction in operative time, postoperative days in hospital and wound infection. There was no significant reduction in postoperative pyrexia. 3. Non-closure of parietal peritoneum only versus closure of both peritoneal layersThe two identified trials involved 573 women. Neither study reported on postoperative adhesion formation. There was reduction in operative time and postoperative pain with no difference in the incidence of postoperative pyrexia, endometritis, postoperative duration of hospital stay and wound infection. In only one study, postoperative day one wound pain assessed by the numerical rating scale, (MD -1.60, 95% CI -1.97 to -1.23) and chronic abdominal pain d by the visual analogue score (MD -1.10, 95% CI -1.39 to -0.81) was reduced in the non-closure group. 4. Non-closure versus closure of visceral peritoneum when parietal peritoneum is closed.There was reduction in all the major urinary symptoms of frequency, urgency and stress incontinence when the visceral peritoneum is left unsutured.

AUTHORS' CONCLUSIONS

There was a reduction in operative time across all the subgroups. There was also a reduction in the period of hospitalisation post-caesarean section except in the subgroup where parietal peritoneum only was not sutured where there was no difference in the period of hospitalisation. The evidence on adhesion formation was limited and inconsistent. There is currently insufficient evidence of benefit to justify the additional time and use of suture material necessary for peritoneal closure. More robust evidence on long-term pain, adhesion formation and infertility is needed.

Caesarean section surgical techniques (CORONIS): a fractional, factorial, unmasked, randomised controlled trial

BACKGROUND

Variations exist in the surgical techniques used for caesarean section and many have not been rigorously assessed in randomised controlled trials. We aimed to assess whether any surgical techniques were associated with improved outcomes for women and babies.

METHODS

CORONIS was a pragmatic international 2×2×2×2×2 non-regular fractional, factorial, unmasked, randomised controlled trial that examined five elements of the caesarean section technique in intervention pairs. CORONIS was undertaken at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Each site was assigned to three of the five intervention pairs: blunt versus sharp abdominal entry; exteriorisation of the uterus for repair versus intra-abdominal repair; single-layer versus double-layer closure of the uterus; closure versus non-closure of the peritoneum (pelvic and parietal); and chromic catgut versus polyglactin-910 for uterine repair. Pregnant women were eligible if they were to undergo their first or second caesarean section through a planned transverse abdominal incision. Women were randomly assigned by a secure web-based number allocation system to one intervention from each of the three assigned pairs. All investigators, surgeons, and participants were unmasked to treatment allocation. The primary outcome was the composite of death, maternal infectious morbidity, further operative procedures, or blood transfusion (>1 unit) up to the 6-week follow-up visit. Women were analysed in the groups into which they were allocated. The CORONIS Trial is registered with Current Controlled Trials: ISRCTN31089967.

FINDINGS

Between May 20, 2007, and Dec 31, 2010, 15 935 women were recruited. There were no statistically significant differences within any of the intervention pairs for the primary outcome: blunt versus sharp entry risk ratio 1·03 (95% CI 0·91-1·17), exterior versus intra-abdominal repair 0·96 (0·84-1·08), single-layer versus double-layer closure 0·96 (0·85-1·08), closure versus non-closure 1·06 (0·94-1·20), and chromic catgut versus polyglactin-910 0·90 (0·78-1·04). 144 serious adverse events were reported, of which 26 were possibly related to the intervention. Most of the reported serious adverse events were known complications of surgery or complications of the reasons for the caesarean section.

INTERPRETATION

These findings suggest that any of these surgical techniques is acceptable. However, longer-term follow-up is needed to assess whether the absence of evidence of short-term effects will translate into an absence of long-term effects.

FUNDING

UK Medical Research Council and WHO.

Closure or non-closure of peritoneum in cesarean section: outcomes of short-term complications

Background

Cesarean section (CS) is one of the most frequently performed surgical procedures worldwide. The complications following a CS include fever, wound infection, post-operative pain and bleeding which are not usually found in a normal vaginal delivery. Traditionally, suturing of peritoneal layers for CS patients has been done, but in some studies it has been shown that this procedure could be eliminated without affecting the rate of morbidity.

Objectives

The objective of this study was to assess the short-term outcomes of two different cesarean delivery techniques.

Patients and Methods

A total of 100 cases who underwent CS were randomly assigned equally to either closure of both the visceral and parietal peritoneum or no peritoneum closure. Duration of operation, pain scores, analgesic requirements, alterations in hemoglobin levels and febrile morbidity were assessed accordingly.

Results

Pain scores, analgesic requirements assessed at 24 hours and operation duration were significantly lower in the non-closure group as compared to the closure group. Febrile conditions and changes in hemoglobin levels were similar in both groups.

Conclusions

Non-closure of both visceral and the parietal peritoneum when performing a CS produces a significant reduction in pain, fewer analgesic requirements and a shorter operation duration without increasing the febrile morbidity and changes in hemoglobin levels as compared to the standard methods.

[Two observations of evisceration after caesarean section performed according the so-called Stark procedure]

Two cases of evisceration after caesarean sections performed according the Misgav Ladach General Hospital procedure (Stark's procedure) are reported. In these cases, omentum was sutured between the edges of fascia recti, creating a weakness of the abdominal sheath. These cases claim about a strict procedure for fascia suture. Also, these cases question about the parietal peritoneal closure and the drawing of rectus muscles, which are vertical breaks; so, these sutures close transversal incision of the abdominal wall with cross sutures, which are very secure.

Incidence of adhesions at repeat cesarean delivery

OBJECTIVE

To compare the incidence and severity of adhesions at repeat cesarean delivery based on the closure at primary section.

STUDY DESIGN

A retrospective chart review was conducted for 62 cases of repeat cesarean sections. A score was assigned based on the severity of adhesions. The primary operative report was reviewed, and the closure type recorded. Statistical analysis was performed with a t test, chi2, and ANOVA.

RESULTS

Forty-nine and eight-tenths percent of cases had extensive adhesions. Closure of the peritoneal or rectus abdominis muscle resulted in significantly fewer extensive adhesions than nonclosure (31.2% vs 70.0%; P = .013). The mean adhesion score for the nonclosure group was 2.67, compared with 1.91 for the parietal peritoneal closure group (P = .044) and 1.73 for the rectus muscle group (P = .009), where 1 is no adhesions and 4 is the most severe).

CONCLUSION

Closure of the rectus muscle or the parietal peritoneum at primary section resulted in significantly fewer adhesions at repeat cesarean delivery.

Closure versus non-closure of the peritoneum at caesarean section

BACKGROUND

Caesarean section is a very common surgical procedure world wide. Suturing the peritoneal layers at caesarean section may or may not confer benefit, hence the need to evaluate whether this step should be omitted or not.

OBJECTIVES

The objective of this review was to assess the effects of non-closure as an alternative to closure of the peritoneum at caesarean section on intra-operative, immediate and long-term postoperative and long-term outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (November 2002).

SELECTION CRITERIA

Controlled trials comparing leaving the visceral and/or parietal peritoneum unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted by two reviewers.

MAIN RESULTS

Nine trials involving 1811 women were included and analysed. The methodological quality of the trials was variable. Non-closure of the peritoneum reduced operating time whether both or either layer was not sutured. For both layers, the operating time was reduced by 7.33 minutes, 95% confidence interval (CI) -8.43 to -6.24. There was significantly less postoperative fever and reduced postoperative stay in hospital for visceral peritoneum and for both layer non-closure. There were no other statistically significant differences. The trend for analgesia requirement and wound infection tended to favour non-closure, while endometritis results were variable. Long-term follow up in one trial showed no significant differences. The power of the study to show differences was low.

REVIEWER'S CONCLUSIONS

There was improved short-term postoperative outcome if the peritoneum was not closed. Long-term studies following caesarean section are limited, but data from other surgical procedures are reassuring. There is at present no evidence to justify the time taken and cost of peritoneal closure.