Cesarean section using the Misgav Ladach method

Added value of surgical interdisciplinarity- The Joel-Cohen's abdominal incision

Background

Surgical methods have profited from the exchange of knowledge among different specialties. Endoscopy which was introduced by gynecologists, surgeons, and internists is used now by all disciplines, and most of yesterday's laparotomies have now endoscopic alternatives. However, laparotomies are still needed, and there is no agreement among surgeons about what is the optimal abdominal incision. The Joel-Cohen incision which is used by gynecologists and obstetricians could become a valid alternative to the methods in use.

Method

The Joel-Cohen Method, which was evolved for abdominal hysterectomy is described here in detail. Only two instruments are used to open the abdomen, usually with no need for hemostasis.

Conclusion

The Joel-Cohen incision is suggested as a valid alternative for any emergency or elective surgical or urological abdominal operation. Its benefits are short operation time diminished blood loss and less need for analgesics.

Modified Stark's (Misgav Ladach) caesarean section: 15 - year experience of the own techniques of caesarean section

OBJECTIVE

A 15-year-experience of the personal modification of Misgav Ladach (ML) caesarean section in relation to the Dörffler method.

STUDY DESIGN

A retrospective clinical randomized observational study included 822 transperitoneal cesarean sections: 557 were performed via modified ML (without bladder catheterization, small transverse fascial incision with muscular stretching and non-preparation of vesicouterine plica) vs. 265 Dörffler (Pfannenstiel - Kerr) method.

RESULTS

Perioperative and postoperative complications were significantly more frequent in the Dörffler method (p < 0.0005) (perioperative hemorrhage, more frequent adhesions, plastic peritonitis in repeated caesarean sections, as well as two bladder lesions). Postoperative febrility, dehiscence and wound seroma were more frequent in the first study group (p < 0.0005). More frequent paralytic ileus, uroinfections and bladder atony, which we did not observe in our own technique (p < 0.0005). The use of antibiotics and analgesics was prolonged until the fifth postoperative day in the first group compared to the second group where it was reduced to only 10 % on the second day (p < 0.0005). Also, the incidence of anemia and the need for blood transfusions were higher in the first study group, as well as the need for revision behind caesarean section and two hysterectomies due to massive postoperative intraperitoneal and retroperitoneal bleeding (p < 0.0005).

CONCLUSION

Our fifteen-year study highlighted the importance of our own published modified ML caesarean section in minimizing technique of surgery and the reduction of perioperative morbidity and significantly faster recovery of operated patients in the current era of enormous caesarean section increase.

Can prepartum thromboelastometry-derived parameters and fibrinogen levels really predict postpartum hemorrhage?

BACKGROUND

Decreased postpartum rotational thromboelastometric parameters of coagulation (ROTEM®) and fibrinogen levels have been associated with postpartum hemorrhage (PPH). However, the predictive power of prepartum ROTEM® parameters and fibrinogen levels (Fbgpre) for PPH remains unknown.

METHODS

This prospective observational pilot study included 217 healthy pregnant women. Maximum clot firmness (FIBTEM-MCF), fibrinogen levels and standard coagulation parameters were measured upon admission to the delivery room for labor and within 1 h after vaginal delivery. Blood loss was measured with a calibrated collecting drape during the third stage of labor. PPH was defined as blood loss ≥500 mL. Predictors for bleeding were identified via receiver operating characteristic analyses and bivariate and multivariate regression analyses.

RESULTS

Women with and without PPH did not differ in median FIBTEM-MCF [23 mm (25th percentile 20 mm, 75th percentile 26 mm) vs. 23 mm (19 mm, 26 mm), respectively; P=0.710] or mean Fbgpre (4.57±0.77 g/L vs. 4.45±0.86 g/L, respectively; P=0.431). Blood loss and prepartum coagulation parameters were not correlated (FIBTEM-MCF, rs=-0.055, P=0.431; Fbgpre, rs=-0.017, P=0.810). The areas under the curves (predictive power for PPH) for FIBTEM-MCF and Fbgpre and were 0.52 (0.41-0.64, P=0.699) and 0.53 [95% confidence interval (95% CI) 0.40-0.65, P=0.644], respectively. Neither FIBTEM-MCF nor Fbgpre was associated with PPH. However, primiparity [odds ratio (OR) 4.27, 95% CI 1.32-13.80, P=0.015) and urgent cesarean section (2.77, 1.00-7.67, P=0.050) were independent predictors of PPH.

CONCLUSIONS

ROTEM® parameters, Fbgpre and postpartum blood loss were not associated, nor did these factors predict PPH. Sufficiently powered prospective studies are needed to confirm these results.

Comparative study of Misgav-Ladach and Pfannenstiel-Kerr cesarean techniques: a randomized controlled trial

AIM

To compare Pfannenstiel-Kerr (PKM) and Misgav-Ladach (MLM) methods in terms of operation-related features and neonatal outcome in primary cesarean deliveries.

METHODS

A total of 180 pregnant women randomized into PKM (n = 90) or MLM (n = 90) groups were included in this study. Primary outcome measures were total operative and extraction times, Apgar score, blood loss, wound complications, and the suture use. Secondary outcome measures were wound seroma and infection incidence, time of bowel restitution, and the perceived pain.

RESULTS

Total operation and extraction times were significantly shorter and less suture material was used in the MLM group than the PKM group (p < 0.001). Initially, higher scores obtained for 6 h-VAS in the MLM group (p < 0.05) were normalized after 24 h of the operation. PKM and MLM were similar in terms of preoperative and postoperative levels of hemoglobin and hematocrit, wound complication, bowel restitution, fever, seroma, infection, wound dehiscence and the need for transfusion, antibiotic, and analgesics.

CONCLUSION

The operation-related morbidity of the MLM and PKM for primary C/S seem to be comparable; however, the MLM seems to be superior in terms of operation time and the amount of suture usage but inferior in pain scores in the early postoperative period.

Cesarean techniques in cases with one previous cesarean delivery: comparison of modified Misgav-Ladach and Pfannenstiel-Kerr

AIM

To compare the effectiveness of the Pfannenstiel-Kerr method (PKM) or modified Misgav-Ladach method (MMLM) in previous cesarean sections (C/Ss).

METHODS

Hundred and fifteen gravidas were included with previous one C/S, using either a PKM or MMLM. Demographic characteristics, operative outcomes, surgical complications, and neonatal outcomes were compared in two groups.

RESULTS

The mean operative time (18.0 ± 3.5 vs. 23.5 ± 5.7 min; p < 0.0001) and mean extraction time (90.1 ± 41.2 vs. 208.1 ± 79.1 s; p < 0.0001) were significantly shorter in the MMLM group than the PKM group. Postoperative recovery (mobilization, normalization of bowel function, need for analgesics, time to oral feeding, and intra-operative blood loss) was similar between the MMLM and PKM groups.

CONCLUSION

The MMLM appears to be a faster alternative to PKM for previous C/Ss, with similar results as in previous studies with primary CSs.

Incidence of post-operative adhesions following Misgav Ladach caesarean section--a comparative study

AIM

To evaluate the incidence of peritoneal adhesions as a post-operative complication after caesarean section following the Misgav Ladach method and compare it with peritoneal adhesions following traditional caesarean section methods (Pfannenstiel-Dörffler, low midline laparotomy-Dörffler).

METHODS

The analysis is retrospective and is based on medical documentation of the Clinic for Gynecology and Obstetrics, University Clinical Centre, Tuzla, Bosnia and Herzegovina (data from 1 January 2001 to 31 December 2005). We analysed previous caesarean section dependent on caesarean section method (200 by Misgav Ladach method, 100 by Pfannenstiel-Dörffler method and 100 caesarean section by low midline laparotomy-Dörffler). Adhesion scores were assigned using a previously validated scoring system.

RESULTS

We found statistically significant difference (p < 0.05) in incidence of peritoneal adhesions in second and third caesarean section between Misgav Ladach method and the Pfannestiel-Dörffler and low midline laparotomy-Dörffler method. Difference in incidence of peritoneal adhesions between low midline laparotomy-Dörffler and Pfannenstiel-Dörffler method was not statistically different (p > 0.05). The mean pelvic adhesion score was statistically lower in Misgav Ladach group (0.43 +/- 0.79) than the mean score in the Pfannestiel-Dörffler (0.71 +/- 1.27) and low midline laparotomy-Dörffler groups (0.99 +/- 1.49) (p < 0.05).

CONCLUSIONS

Our study showed that Misgav Ladach method of caesarean section makes possible lower incidence of peritoneal adhesions as post-operative complication of previous caesarean section.

Modified Misgav Ladach method for cesarean section: clinical experience

OBJECTIVE

To determine the advantages of modified a Misgav Ladach method over conventional (Pfannenstiel-Dorffler) cesarean section.

STUDY DESIGN

From October 2002 to March 2005, 217 cesarean sections performed according to a modified Misgav Ladach method (without routine preoperative urinary catheterization, blunt separation of the fascia after a small incision, and unprepared plica vesicouterina) were prospectively compared with 153 randomly selected conventional cesarean sections. Maternal age, parity, gestational age, neonatal birth weight, procedure duration, operative complications and postoperative course were analyzed.

RESULTS

The incidence of postoperative fever was 2.30 and 4.57% (p = 0.001), wound seroma 0.46 and 1.96% (p = 0.01), local wound infection 0.92 and 1.96% (p = 0.01), wound dehiscence 0 and 0.65% (NS), anemia 3.68 and 7.84% (p = 0.001), and need of blood transfusion 1.38 and 1.96% (NS) in the modified Misgav Ladach and conventional group, respectively. The mean duration of the operation was 26.24 min with the Misgav Ladach versus 39.41 min with the conventional operation (p < 0.001). The postoperative use of antibiotics and analgesics/antipyretics was significantly lower in the modified Misgav Ladach group (p = 0.001).

CONCLUSION

Study results demonstrated that the modified Misgav Ladach method of cesarean section is associated with faster postoperative recovery, lower morbidity and blood loss, shorter length of operative procedure, lower incidence of operative complications, lesser postoperative use of antibiotics and analgesics/antipyretics, and lower utilization of surgical material. The modified Misgav Ladach method of cesarean section is suitable for emergency and elective procedures, justifying its use in daily routine.

Comparison of intrathecal bupivacaine and levobupivacaine combined with opioids for Caesarean section

OBJECTIVE

To date, racemic bupivacaine is the most popular local anaesthetic for spinal anaesthesia in parturients undergoing elective Caesarean delivery. However, data suggests that S-enantiomers like levobupivacaine may produce differential sensory and motor blockade. The aim of the present study was to compare fixed doses of intrathecal hypertonic levobupivacaine 0.5% (10 mg) and bupivacaine 0.5% (10 mg) combined with either intrathecal fentanyl (10 and 20 microg), or sufentanil (5 microg) in terms of sensory and motor block characteristics.

RESEARCH DESIGN AND METHODS

60 parturients with singleton pregnancy and > 34 weeks of gestation who underwent elective Caesarean delivery participated in this randomized, double-blinded clinical trial. They received spinal anaesthesia with either levobupivacaine or bupivacaine and the above mentioned opioids added (n = 10 parturients/group). Sensory block was assessed bilaterally by loss of cold sensation, and the degree of motor block was determined according to the Bromage scale every minute until delivery, subsequently at 5-min intervals until the end of surgery, and at 15-min intervals thereafter until complete resolution of spinal anaesthesia. A visual analogue scale was used postoperatively to measure duration of analgesia at 15-min intervals.

MAIN OUTCOME MEASURES

Levobupivacaine produced a significantly shorter and less pronounced motor blockade than racemic bupivacaine regardless of the kind and dose of opioid added. Duration of motor block Bromage 3 was 53 +/- 14 min, 23 +/- 18 min and 41 +/- 8 min compared to 65 +/- 25 min, 70 +/- 19 min and 65 +/- 22 min in the bupivacaine groups. Also, only n = 5/30 parturients reached Bromage 3 in the levobupivacaine groups versus n = 21/30 parturients in the bupivacaine groups. No parturient experienced intraoperative pain. Adding sufentanil 5 microg to either local anaesthetic significantly prolonged duration of effective analgesia compared to supplemental fentanyl 10 or 20 microg.

CONCLUSIONS

Based on our data, 10 mg of hypertonic levobupivacaine 0.5% combined with sufentanil 5 microg was the most appropriate anaesthetic regimen in parturients undergoing elective Caesarean delivery in spinal anaesthesia.

The modified Misgav-Ladach versus the Pfannenstiel-Kerr technique for cesarean section: a randomized trial

BACKGROUND

Modifications to the classic cesarean section technique described by Pfannenstiel and Kerr have been proposed in the last few years. The objective of this trial was to compare intraoperative and short-term postoperative outcomes between the Pfannenstiel-Kerr and the modified Misgav-Ladach (MML) techniques for cesarean section.

METHODS

This prospective randomized trial involved 162 patients undergoing transverse lower uterine segment cesarean section. Patients were allocated to one of the two arms: 88 to the MML technique and 74 to the Pfannenstiel-Kerr technique. Main outcome measures were defined as the duration of surgery, analgesic requirements, and bowel restitution by the second postoperative day. Additional outcomes evaluated were febrile morbidity, postoperative antibiotic use, postpartum endometritis, and wound complications. Student's t, Mann-Whitney, and Chi-square tests were used for statistical analysis of the results, and a p < 0.05 was considered as the probability level reflecting significant differences.

RESULTS

No differences between groups were noted in the incidence of analgesic requirements, bowel restitution by the second postoperative day, febrile morbidity, antibiotic requirements, endometritis, or wound complications. The MML technique took on average 12 min less to complete (p = 0.001).

CONCLUSION

The MML technique is faster to perform and similar in terms of febrile morbidity, time to bowel restitution, or need for postoperative medications. It is likely to be more cost-effective.

The Misgav Ladach method--a step forward in operative technique in obstetrics

AIM

To investigate the advantage of performing cesarean section using the Misgav-Ladach method and to justify its use in everyday practice.

METHODS

In a prospective study we analyzed over a two year period (2000-01) cesarean sections carried out using the Misgav-Ladach method at our clinic. We compared both 550 cases of Misgav-Ladach (ML) and 100 cases of Pfannenstiel (PH) cesarean section. In the group that had undergone the Misgav-Ladach method we sutured the uterus in one layer and left the peritoneum non-sutured, and in the group who had undergone Pfennenstiel we sutured the uterus in two layers and also sutured the visceral and parietal peritoneum. In every case we analyzed: maternal age, gestational age, duration of operation, consumption of suture material, duration of hospitalization, and surgical complications.

RESULTS

Incidence of postoperative febrile morbidity was 5.45%, in the Misgav-Ladach group compared with 13.2% in the Pfannenstiel group (p < 0.05). Local infection of the wound in the Misgav-Ladach group was found in 4.54% and in the Pfannenstiel group in 9% (p < 0.05). Mean time of extraction of the newborn in the Misgav-Ladach group was 1.25 minutes, and in the Pfannenstiel group 4.10 minutes (P < 0.05). Mean duration of operation in the Misgav-Ladach group was 10.98 min, and in the Pfannenstiel group 25 min (p < 0.05). Mean duration of hospitalization in the Misgav-Ladach group was 4.75 days, and in the Pfannenstiel group 6.32 days (p > 0.05). Mean consumption of suture material in the group Misgav-Ladach was 3.10 sutures per operation, and in the Pfannenstiel group was 9.5 sutures.

CONCLUSION

Our study shows that the Misgav-Ladach method of cesarean section enables fast recovery and shorter hospitalization, and reduces the length of the operation, the incidence of surgical complication and the consumption of surgical materials.

The history of cesarean technique

Cesarean section has been practiced since ancient times. Unfortunately, no ancient medical documents describing the techniques for cesarean section are extant. In the early medieval period, cesarean section was usually performed by midwives. One of the first explicit instructions in medical literature on cesarean technique dates from about 1480 ce from southern Germany. We discuss the evolution of cesarean surgical technique and point up the contribution of many giants in the field of obstetrics and gynecology, such as Blundell, Frank, Harris, Joel-Cohen, Kehrer, Kerr, Lebas, Levret, Maylard, Pfannenstiel, Porro, Portes, and Sanger.

Intraoperative surgical complication during cesarean section: an observational study of the incidence and risk factors

BACKGROUND

The study was intended to estimate the incidence of intraoperative surgical complications with the impact of the educational level of the surgeon and a history of previous cesarean section on intraoperative complications at cesarean childbirth.

METHODS

In the period between August 1st 1995 and July 30th 1996, 7782 women gave birth at the three Obstetric Departments in Copenhagen County, Denmark, of which 929 (11.9%) were delivered by cesarean section. These women served as the study population, and their medical records were reviewed and data obtained immediately after delivery.

RESULTS

The overall intraoperative complication rate was 12.1%. The rate of complications in emergency cesarean sections was 14.5% compared with 6.8% in the elective group. The educational level of the surgeon and a history of previous cesarean section were not found to be significantly associated to intraoperative complications. Low station of the presenting part of the fetus, high fetal birth weight, fetal distress and dystocia as indications and increasing maternal age were significant risk factors of lacerations. Placenta previa and placental abruption as indications, increasing prepregnancy body mass index, as well as low and high birth weight were significant risk factors for intraoperative blood loss more than 1 l. Duration of regular painful contractions had a preventive effect.

CONCLUSION

Utero-cervical lacerations and blood loss of more than 1 l were the most frequent intraoperative complications in cesarean section in the present study. The educational level of the surgeon or history of a previous cesarean section were not significantly related to these complications.

Intrathecal fentanyl, sufentanil, or placebo combined with hyperbaric mepivacaine 2% for parturients undergoing elective cesarean delivery

Worldwide, long-acting bupivacaine is the most popular local anesthetic for spinal anesthesia in parturients undergoing elective cesarean delivery. With advances in surgical techniques, e.g., the Misgav Ladach method, and shorter duration of surgery, the local anesthetic mepivacaine, with an intermediate duration of action, may be a reasonable alternative. Our aim in the present study was to evaluate the effects of 2% hyperbaric mepivacaine alone, or combined with either intrathecal fentanyl (5 and 10 microg), or sufentanil (2.5 and 5 microg), on sensory, motor, and analgesic block characteristics, hemodynamic variables, and neonatal outcome in a randomized, prospective, and double-blinded study (n = 100, 20 parturients per group, singleton pregnancy, >37 wk of gestation). No parturient experienced intraoperative pain. The average duration of motor block Bromage 3 in all groups was 68 min, and resolution time to Bromage 0 was 118 min. Maximal cephalad sensory block level was T3-6 and could be established within 6 min. Complete analgesia was significantly prolonged in all groups receiving intrathecal opioids, yet, with sufentanil 5 microg, even the duration of effective analgesia was significantly extended. Neonatal outcome was not affected by intrathecal opioid administration. In conclusion, 2% hyperbaric mepivacaine is a feasible local anesthetic for spinal anesthesia in parturients undergoing elective cesarean delivery, particularly with short duration of surgery.

IMPLICATIONS

Sensory, motor, and analgesic block characteristics of the local anesthetic mepivacaine alone or combined with intrathecal opioids were studied in parturients undergoing elective cesarean delivery in a randomized, double-blinded clinical trial. Mepivacaine was found to be an acceptable local anesthetic for spinal anesthesia in parturients undergoing cesarean delivery. In combination with sufentanil 5 microg, complete and effective analgesia were significantly prolonged.

Prospective, randomized, comparative study of Misgav Ladach versus traditional cesarean section at Nazareth Hospital, Kenya

Cesarean section (CS) is the commonest major operation carried out in many low income countries. A new technique for CS, called the Misgav Ladach procedure, was evaluated in a randomized trial in Nazareth Hospital (Kiambu District, Kenya). A total of 160 patients were assigned to the Misgav Ladach procedure (n = 80) or to the traditional CS as performed in most rural hospitals in low income countries (n = 80). The two groups were analyzed by operating time, presence of infection and febrile morbidity, grade of postoperative pain, starting of fluid and solid alimentation, and development of incisional hernia and hypertrophic scar. The operating time of the Misgav Ladach procedure was significantly shorter. 20.4 (SD 6.1) minutes versus 30.4 (SD 6.1) minutes (p < 0.001). A total of 5 wound infections (6.2%) were seen with the Misgav Ladach procedure versus 16 (20.0%) in the control group (p = 0.01). The number of analgesic doses required during the postoperative period were significantly less in the Misgav Ladach group: 1.3 (SD 0.6) versus 1.9 (SD 0.7) ampuls of pethidine (p < 0.001) and 15.1 (SD 2.0) versus 16.4 (SD 1.8) tablets of ibuprofen (p < 0.001). Incisional pain was significantly less in the Misgav Ladach group: Visual Analogue Scale score 3.0 (SD 1.5) versus 4.9 (SD 2.0), p < 0.01. The patients in the Misgav Ladach group began drinking fluids voluntarily [19.1 (SD 4.5) hours versus 20.6 (SD 4.0) hours; p = 0.01] and eating solid food [41.2 (SD 9.3) hours versus 46.1 (SD 9.0) hours; p < 0.01] significantly before than those in the control group. At the 6-week follow-up, the presence of hypertrophic scar was significantly associated with the traditional procedure (2.1% vs. 48.8%; p < 0.001). We conclude that the Misgav Ladach operation should become the standard method for performing CS in low income countries, particularly in rural hospitals.

Can Joel-Cohen incision and single layer reconstruction reduce cesarean section morbidity?

OBJECTIVE

To compare an innovative cesarean section based on Joel-Cohen incision with the traditional Pfannenstiel technique in terms of operative data and post-operative recovery.

METHOD

Out of 158 randomized patients, 83 patients underwent the innovative cesarean section (Joel-Cohen incision, one-layer locked uterine suture, no peritoneization) and 75 the traditional operative approach (Pfannenstiel incision, double layer closure of the uterus, visceral and parietal peritoneization). Operative data and post-operative morbidity were compared; sample size was calculated to detect a 13% difference in the occurrence of post-operative fever with a statistical power of 80%.

RESULT

Post-operative fever was not different in the two groups. Total operating time was shorter with the innovative technique: 31.6 +/-1.38 min vs. 44.4+/-1.44 (P=0.0001) and fewer sutures were used: 3.6+/-0.13 vs. 6+/-0.13 (P=0.001). Patients operated by the new technique began moving sooner and intestinal function restarted earlier.

CONCLUSION

The proposed technique made for shorter operating times and faster recovery but no decrease in puerperal morbidity.

Study on modification of the Misgav Ladach method for cesarean section

172 cases of pregnant women scheduled for delivery by cesarean section were randomly assigned to 59 cases in modification group with modified Misgav Ladach technique, 57 cases in Misgav Ladach group with Misgav Ladach technique and 56 cases in Pfannenstiel group with Pfannenstiel technique from May to Dec. 1999. The modified points included: transversely incising the fascia 2 to 3 cm, then dividing it bluntly; without opening and dissociating the visceral peritoneum; two layers suturing of low transverse uterine incision; closing the skin by continuous suturing. Results showed the average delivery time in the modification group was (3.6 +/- 2.6) min and (5.7 +/- 2.9) min in the Misgav Ladach group (P < 0.05). Median operating time was (28.3 +/- 5.4) min in modification group compared with (27.5 +/- 6.5) min in the Misgav Ladach group (P > 0.05). Average blood loss was (128 +/- 35) ml in modification group compared with (212 +/- 147) ml in the Pfannenstiel group (P < 0.05). It was concluded that the modified Misgav Ladach technique not only preserved all advantages of Misgav Ladach method, but also had additional advantages, such as faster in delivering the fetus, less damage, easier mastering for obstetricians.