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Bačić B, Hrgović Z, Cerovac A, Barčot O, Sabljić J, Markoski B, Leskur M. Comparison between extraperitoneal and transperitoneal cesarean section: Retrospective case-control study. Z Geburtshilfe Neonatol 2024. [PMID: 39013437 DOI: 10.1055/a-2338-5802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
INTRODUCTION The main advantage of extraperitoneal cesarean section (EXPCS) is not only less pain, faster recovery, and less potential for infection but also a possible lack of intraperitoneal adhesions. METHODS In a 3-year period from 2019 to 2022, 88 EXPCSs were performed. A comparison was made with 90 patients who underwent a standard transperitoneal cesarean section (TPCS). For both groups, the inclusion criterion was uterine inertia and prolonged labor as an indication for cesarean section. Only pregnant women from 37 to 42 weeks were included. After this, 51 patients remained in the EXPCS arm, and 49 remained in the TPCS arm. RESULTS No statistical difference was found in gestational weeks, newborn weight, Apgar score, erythrocyte (Er), hemoglobin (Hgb), and hematocrit (Htc) values and duration of operative time between the EXPCS and TPCS groups. Leukocytes, C-reactive protein (CRP) with fever higher than >38°C on the third postoperative day were found statistically significantly (p=0.005) higher in the TPCS group. The usage of tramadol + metamizole at 3, 6, and 9 hours after delivery and diclofenac at 6, 12, and 18 hours after surgery was statistically significantly (p<0.05) higher in the TPCS group. On the visual analog scale (VAS) 24 hours after surgery, a statistically significant difference was found (p = 0.001) between the two groups. In the small group of patients who underwent a TPCS section after an EXPCS, intraperitoneal adhesions were not found; in another group of patients who underwent a TPCS twice, adhesions were found in 12 patients; Fisher's exact test (p=0.04). CONCLUSION The protective effect of EXPCS for infection could be proven in prolonged delivery. EXPCS could be a good solution in the fight against adhesions and infection in women who undergo second, third, or even fourth cesarean sections.
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Affiliation(s)
- Boris Bačić
- Clinic of Obstetrics and Gynecology, Clinical Hospital Center, Split, Croatia
- University of Split, Medical School, Split, Croatia
| | - Zlatko Hrgović
- Gynecology, J.W.Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Anis Cerovac
- Department of Gynaecology and Obstetrics, General Hospital Tešanj, Tešanj, Bosnia and Herzegovina
- Department of Anatomy, School of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Ognjen Barčot
- Department of Surgery, Clinical Hospital Center Split, Split, Croatia
| | - Jelena Sabljić
- Clinic of Obstetrics and Gynecology, Clinical Hospital Center, Split, Croatia
- University of Split, Medical School, Split, Croatia
| | - Blagoja Markoski
- Clinic of Obstetrics and Gynecology, Clinical Hospital Center, Split, Croatia
- University of Split, Medical School, Split, Croatia
| | - Mateo Leskur
- University of Split, Medical School, Split, Croatia
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Does surgeon seniority affect adhesion assessment at cesarean delivery? A prospective study. AJOG GLOBAL REPORTS 2023; 3:100162. [PMID: 36876162 PMCID: PMC9975278 DOI: 10.1016/j.xagr.2023.100162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Intraabdominal adhesions may develop following cesarean delivery and are considered a major concern. OBJECTIVE This study aimed to determine the effect of surgeon seniority in evaluating intraabdominal adhesions at cesarean delivery. STUDY DESIGN A prospective study to estimate interrater reliability between surgeons was conducted. Women who underwent cesarean delivery (January-July 2021) in a single tertiary university-affiliated medical center were included. Blinded questionnaires assessing adhesions were completed by the surgeons. Questions were limited to 4 main anatomic sites and 3 possible categories of adhesion (each site was scored between 0 and 2; the sum score range was 0-8). The surgeons were ranked by increasing seniority (1-4) as: (1) junior residents (less than half of residency completed), (2) senior residents (more than half of residency completed), (3) young attending physicians (attending physicians for <10 years), and (4) senior attendings (attending physicians for >10 years). The weighted percentage of agreement was calculated between the 2 surgeons assessing the same adhesions. Scoring differences between the 2 surgeons (senior vs less senior) were also calculated. RESULTS A total of 96 pairs of surgeons were included in the study. The sum interrater reliability found in the weighted agreement tests between surgeons was 0.918 (confidence interval, 0.898-0.938). When scoring differences between surgeons (senior vs less senior) were calculated, nonsignificant difference was found (mean sum score difference of 0.09 with a standard deviation of 1.03 in favor of the more experienced surgeon). CONCLUSION Surgeon seniority does not affect subjective scoring of adhesion reports.
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Antoine C, Timor-Tritsch IE, Agoha C, Alexander J. A new era in teaching: how advanced optical recording technology could change the postcesarean delivery complication conundrum. Am J Obstet Gynecol MFM 2022; 4:100744. [PMID: 36113718 DOI: 10.1016/j.ajogmf.2022.100744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/19/2022] [Accepted: 09/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The last 4 decades have seen increased complications after cesarean deliveries. Despite an incomplete understanding of their etiology, surgical practices have been adopted, creating disproportionate morbidity and the absence of preventive strategies. Additional research tools are needed for further investigation. OBJECTIVE This study aimed to evaluate the VITOM high-definition optical recording system as a tool to highlight cesarean operative steps and surgical techniques and assess the use of its video recordings for operating room team teaching and research potential. STUDY DESIGN Contemporaneous cesarean delivery techniques offer no resolution to long-term postcesarean sequelae. From March 2015 to February 2022, a novel tool, VITOM exoscope, was evaluated and used to photograph and video record 104 elective cesarean deliveries. The images were projected on a large screen to be viewed by scrubbed-in and unscrubbed personnel and recorded for future use. During this period, staff participants in 3 designated operating rooms reached 514, including 168 trainee residents, 5 nurse practitioners, 6 physician assistants, 21 medical students, 70 surgical technicians, and 110 circulating nurses. The maternal ages of patients varied from 21 to 49 years. Gestational ages ranged from 28 0/7 to 41 6/7 weeks of gestation. Selected photographs of crucial cesarean surgical steps were taken and printed. Video recordings were stored in designated institutional data storage and uploaded onto a secure drive for further use. After every case, debriefing was held, and subjective opinions were obtained from the various participants. RESULTS The VITOM was used for 104 cesarean deliveries. Setup time was reduced from 7 minutes initially to 3 minutes with more experience. All staff participants had only positive evaluations and remarks about the image quality and the clear delineation of specific anatomic landmarks. By polling medical students and residents in training, the VITOM experience was described as very useful and, in a few cases, only somewhat useful. The scrubbed surgical technicians and circulating nurses gained a better understanding of surgical layers, improving their ability to anticipate subsequent surgical steps, thereby streamlining operating flow and efficiency. Unscrubbed personnel could also follow the operation's progression despite being remote from the sterile field. Anesthesiologists could follow the operative field and eventual blood loss in plain view. Recorded videos and still photographs were used at clinical teaching conferences and in peer-reviewed publications, enhancing understanding of cesarean delivery techniques. CONCLUSION The VITOM exoscope provided superb image quality, enabling a clear vision of the anatomic structures of the cesarean operation. It is a promising additional research tool to capture important details of the employed surgical techniques and provides a possible insight into long-term postcesarean sequelae.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha).
| | - Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha)
| | - Chikadibia Agoha
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY (Drs Antoine, Timor-Tritsch, and Agoha)
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Lee KS, Wang YL, Huang WC, Yang JH, Huang JP. Limited efficacy with additional adverse effect of anti-adhesion barrier at primary cesarean section. J Formos Med Assoc 2021; 121:227-236. [PMID: 33838986 DOI: 10.1016/j.jfma.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/26/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/PURPOSE In our experience, adhesion after the primary CS is generally minimal or nonexistent. However, adhesion barriers users have experienced more febrile episodes that may require therapeutic antibiotics during the postcesarean period. We evaluated clinical efficacy of HA-CMC and ORC to prevent adhesion at secondary CS and the post-operative outcome at primary and secondary CS. METHODS This retrospective study includes 199 Asian women undergoing primary and secondary cesarean section between January1, 2011, and September 31, 2019. We used linear and logistic regression to analyze risk factors of postcesarean fever. An interaction term analysis was performed to examine the effect of surgical site infection risk factors and use of adhesion barrier on postcesarean fever rates. RESULTS We found that use of adhesion barrier at the primary cesarean section is associated with a significantly higher incidence of postcesarean fever (p = 0.045), which is an independent risk factor of postcesarean fever (adjusted hazard ratio (Adj-HR)= 3.53, 95% CI = 1.03-10.24, p = 0.045). The strongest risk factor for postcesarean fever is the use of anti-adhesion film during emergency cesarean section (p = 0.041). In the subgroup of labor before operation and emergency cesarean section, adhesion barrier user had significant higher risk of postcesarean fever than nonuser (p = 0.018, Adj-HR = 12.12, 95% CI = 1.53-95.78; emergency cesarean section: p = 0.016, Adj-HR = 12.71, 95% CI = 1.62-99.62). CONCLUSION Use of anti-adhesion films during emergency cases and with a significantly higher risk of postcesarean fever which potentially means increased risk of surgical site infection. Therefore, we do not suggest routine application of anti-adhesion films during cesarean deliveries especially in emergency cesarean section or in a woman having labor before operation.
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Affiliation(s)
- Kuan-Sheng Lee
- Department of Obstetrics & Gynecology, MacKay Memorial Hospital, Taipei 104, Taiwan.
| | - Yeou-Lih Wang
- Department of Obstetrics & Gynecology, MacKay Memorial Hospital, Taipei 104, Taiwan; MacKay Junior College of Medicine, Nursing and Management, New Taipei City 251, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City 252, Taiwan.
| | - Wen-Chu Huang
- Department of Obstetrics & Gynecology, MacKay Memorial Hospital, Taipei 104, Taiwan; MacKay Junior College of Medicine, Nursing and Management, New Taipei City 251, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City 252, Taiwan.
| | - Jia-Hwa Yang
- Taiwan Public Health Association, Taipei 100, Taiwan.
| | - Jian-Pei Huang
- Department of Obstetrics & Gynecology, MacKay Memorial Hospital, Taipei 104, Taiwan; MacKay Junior College of Medicine, Nursing and Management, New Taipei City 251, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City 252, Taiwan.
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Mooij R, Mwampagatwa IH, van Dillen J, Stekelenburg J. Association between surgical technique, adhesions and morbidity in women with repeat caesarean section: a retrospective study in a rural hospital in Western Tanzania. BMC Pregnancy Childbirth 2020; 20:582. [PMID: 33012289 PMCID: PMC7534160 DOI: 10.1186/s12884-020-03229-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 09/01/2020] [Indexed: 11/18/2022] Open
Abstract
Background The worldwide incidence of birth by Caesarean Section (CS) is rising. Many births after a previous CS are by repeat surgery, either by an elective CS or after a failed trial of labour. Adhesion formation is associated with increased maternal morbidity in patients with repeat CSs. In spite of large-scale studies the relation between the incidence of adhesion formation and CS surgical technique is unclear. This study aims to assess maternal and neonatal morbidity and mortality after repeat CSs in a rural hospital in a low-income country (LIC) and to analyse the effect of surgical technique on the formation of adhesions. Methods A cross-sectional, retrospective medical records study of all women undergoing CS in Ndala Hospital in 2011 and 2012. Results Of the 3966 births, 450 were by CS (11.3%), of which 321 were 1st CS, 80 2nd CS, 36 3rd CS, 12 4th and one 5th CS (71, 18, 8, 3 and 0.2% respectively). Adhesions were considered to be severe in 56% of second CSs and 64% of third CSs. In 2nd CSs, adhesions were not associated with closure of the peritoneum at 1st CS, but were associated with the prior use of a midline skin incision. There was no increase in maternal morbidity when severe adhesions were present. Adverse neonatal outcome was more prevalent when severe adhesions were present, but this was statistically non-significant (16% vs 6%). Conclusions Our results give insight into the practice of repeat CS in our rural hospital. Adhesions after CSs are common and occur more frequently after midline skin incision at 1st CS compared to a transverse incision. Reviewing local data is important to evaluate quality of care and to compare local outcomes to the literature.
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Affiliation(s)
- R Mooij
- Ndala Hospital, 15, Ndala, Tanzania. .,Jeroen Bosch Hospital, Henri Dunantstraat 1, 5223 GZ, 's-Hertogenbosch, The Netherlands.
| | - I H Mwampagatwa
- College of Health Sciences, University of Dodoma, 395, Dodoma, Tanzania
| | - J van Dillen
- Radboud University Medical Centre, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - J Stekelenburg
- Leeuwarden Medical Centre, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.,University Medical Centre Groningen/University of Groningen, Antonius Deusinglaan 1, 9700 AD, Groningen, The Netherlands
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Abbas S, Mughal S, Hussain SNF, Hossain N. Blood transfusion and high-order cesarean delivery; Report from a developing country. Pak J Med Sci 2019; 35:1520-1525. [PMID: 31777486 PMCID: PMC6861507 DOI: 10.12669/pjms.35.6.539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Objective: Blood loss in cesarean deliveries has already been established in previous researches but a detailed insight into the correlates has not been done. This study examined whether the number of previous Cesarean sections is related to the need for blood transfusion, and risk factors for blood transfusion. Methods: A retrospective review of 239 females who had undergone two or more Cesarean sections during the time period of 2015-2018 was done. Data collected included type of surgery (elective or emergency), age, parity, body mass index, estimated blood loss, operating time, level of surgeon, presence or absence of adhesions and number of transfused packed cell volume. Results: About 9.2% patients received blood transfusion with an estimated average blood loss of 618.18 ml. Patients with adhesions from previous surgery, presence of placenta previa, multiparity were significantly likely to receive blood transfusion. It was found that women with more than two caesarian sections had high proportion of blood transfusion as compared to women who had two caesarian sections. However non-significant difference was observed in numbers of caesarean sections with blood transfusion. Conclusion: Women undergoing Cesarean sections combined with any of the risk factors like increased body mass index, dense adhesions, uterine atony, hypertension and presence of placenta previa, were found to be at increased risk for a need for blood transfusions.
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Affiliation(s)
- Shahida Abbas
- Shahida Abbas, FCPS, MCPS. Department of Obstetrics & Gynecology, Holy Family Hospital, Karachi, Pakistan
| | - Saba Mughal
- Saba Mughal, Department of Research, DOW University of Health Sciences, Karachi, Pakistan
| | | | - Nazli Hossain
- Nazli Hossain, FCPS, MBE. Department of Obstetrics & Gynecology, DOW University of Health Sciences, Karachi, Pakistan
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Gormley CA, Keenan BJ, Buczek-Thomas JA, Pessoa ACSN, Xu J, Monti F, Tabeling P, Holt RG, Nagy JO, Wong JY. Fibrin-Targeted Polymerized Shell Microbubbles as Potential Theranostic Agents for Surgical Adhesions. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2019; 35:10061-10067. [PMID: 30681875 PMCID: PMC6767917 DOI: 10.1021/acs.langmuir.8b03692] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The development of new therapies for surgical adhesions has proven to be difficult as there is no consistently effective way to assess treatment efficacy in clinical trials without performing a second surgery, which can result in additional adhesions. We have developed lipid microbubble formulations that use a short peptide sequence, CREKA, to target fibrin, the molecule that forms nascent adhesions. These targeted polymerized shell microbubbles (PSMs) are designed to allow ultrasound imaging of early adhesions for diagnostic purposes and for evaluating the success of potential treatments in clinical trials while acting as a possible treatment. In this study, we show that CREKA-targeted microbubbles preferentially bind fibrin over fibrinogen and are stable for long periods of time (∼48 h), that these bound microbubbles can be visualized by ultrasound, and that neither these lipid-based bubbles nor their diagnostic-ultrasound-induced vibrations damage mesothelial cells in vitro. Moreover, these bubbles show the potential to identify adhesionlike fibrin formations and may hold promise in blocking or breaking up fibrin formations in vivo.
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Affiliation(s)
- Catherine A. Gormley
- Department of Biomedical Engineering, Boston University, 44 Cummington Mall, Boston, Massachusetts 02215, United States
| | - Benjamin J. Keenan
- Department of Biomedical Engineering, Boston University, 44 Cummington Mall, Boston, Massachusetts 02215, United States
| | - Jo Ann Buczek-Thomas
- Department of Biomedical Engineering, Boston University, 44 Cummington Mall, Boston, Massachusetts 02215, United States
| | - Amanda C. S. N. Pessoa
- Laboratoire de Microfluidique, MEMS et Nanostructures, ESPCI Paris, PSL Research University, Institut Pierre Gilles de Gennes (IPGG), CNRS (CBI), 6 rue Jean Calvin, 75005 Paris, France
- School of Chemical Engineering, University of Campinas, UNICAMP, 500 Av Albert Einstein, 13083-852, Campinas, SP, Brazil
| | - Jiang Xu
- Laboratoire de Microfluidique, MEMS et Nanostructures, ESPCI Paris, PSL Research University, Institut Pierre Gilles de Gennes (IPGG), CNRS (CBI), 6 rue Jean Calvin, 75005 Paris, France
| | - Fabrice Monti
- Laboratoire de Microfluidique, MEMS et Nanostructures, ESPCI Paris, PSL Research University, Institut Pierre Gilles de Gennes (IPGG), CNRS (CBI), 6 rue Jean Calvin, 75005 Paris, France
| | - Patrick Tabeling
- Laboratoire de Microfluidique, MEMS et Nanostructures, ESPCI Paris, PSL Research University, Institut Pierre Gilles de Gennes (IPGG), CNRS (CBI), 6 rue Jean Calvin, 75005 Paris, France
| | - R. Glynn Holt
- Department of Mechanical Engineering, Boston University, 110 Cummington Mall, Boston, Massachusetts 02215, United States
| | - Jon O. Nagy
- NanoValent Pharmaceuticals Inc., 351-B Evergreen Drive, Bozeman, Montana 59715, United States
| | - Joyce Y. Wong
- Department of Biomedical Engineering, Boston University, 44 Cummington Mall, Boston, Massachusetts 02215, United States
- Division of Materials Science and Engineering, Boston University, 15 St. Mary’s Street, Boston, Massachusetts 02215, United States
- Corresponding Author:
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The occurrence and severity of intra-abdominal adhesions in cases of pregnancies complicated by placenta accreta: A case control study. Eur J Obstet Gynecol Reprod Biol 2018; 227:71-74. [PMID: 29902712 DOI: 10.1016/j.ejogrb.2018.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/30/2018] [Accepted: 06/04/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the occurrence of intra-abdominal adhesions (IAA) among women with placenta accreta (PA). STUDY DESIGN Case control study conducted at a single teaching hospital on data from January 2004 to December 2016. The cases included women who underwent a cesarean hysterectomy due to PA and had a pathological confirmation of accretion. The controls were matched for delivery date and number of cesarean deliveries (CDs) at a ratio of 1:4. IAA were categorized as "none", "filmy", or "dense". The outcome measures were rate of IAA. In order to detect a 25% difference in overall IAA between the groups, with alpha of 0.05 and 80% power, a sample size of 165 women was needed. RESULTS Overall, 165 women (33 and 132 in the case and control groups, respectively) were included. Except for maternal age, there were no statistically significant differences between the groups in demographic and obstetric variables. Overall IAA rate was 30.3% and 47.7% in the case and control groups, respectively (RR: 0.64; 95% CI: 0.37-1.10, p = 0.04). Rate of dense adhesions was 15.2% and 32.6% in the case and control groups, respectively (RR: 0.47, 95% CI: 0.20-1.08; p = 0.03). After adjustment for maternal age, there was a significantly lower rate of overall IAA (RR = 0.39; 95% CI: 0.17-0.93; p = 0.02) and dense adhesions (RR = 0.30; 95% CI: 0.11-0.87; p = 0.02) among the cases. CONCLUSION The incidence and severity of IAA following CDs are low, among women who develop PA.
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Çim N, Elçi E, Güneş Elçi G, Almalı N, Yıldızhan R. Are the skin scar characteristics and closure of the parietal peritoneum associated with pelvic adhesions? Turk J Obstet Gynecol 2018; 15:28-32. [PMID: 29662713 PMCID: PMC5894533 DOI: 10.4274/tjod.55491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 11/26/2017] [Indexed: 12/01/2022] Open
Abstract
Objective: To assess whether the abdominal scar characteristics and closure of the peritoneum were associated with pelvic adhesions. Materials and Methods: Patients who had undergone cesarean section between December 2015 and February 2016 were assessed prospectively in terms of age, gravida, body mass index, number of living children, number of cesarean sections, time passed since the last cesarean section, closure status of the peritoneum in the last cesarean section, presence of other diseases, smoking status, location of incision in the abdomen (medial, pfannenstiel) scar dimensions (length, width), scar status with respect to skin (hypertrophic, flat, depressive), scar color [color change/no color change (hyperpigmented/hypopigmented)], adhesion of bowel-omentum-uterus, omentum-anterior abdominal wall, uterus-anterior abdominal wall, uterus-bladder, bladder-anterior abdominal wall, fixed uterus, and uterus-omentum-anterior abdominal wall in abdominal exploration. Results: One hundred five pregnant women who had undergone previous ceserean section surgery by the same physician, were at least in their 30th gestational week, had surgery notes about their previous operation, and had no chronic diseases were included in the study. Age, gravida, body mass index, number of children, number of cesarean sections, time passed since the previous cesarean section, closure/non-closure of peritoneum in the previous cesarean section, and smoking status had no effect on pelvic adhesions. Intraabdominal adhesion was not found to be associated with scar length [odds ratio (OR): 1.54, 95% confidence interval (CI): 1.1-2.2; p=0.02], depressive scar (OR: 9.3, 95% CI: 3.2-27.2; p<0.001), or hypopigmented scar [OR: 0.01, 95% CI: 0.003-0.11; p<0.001]. Conclusion: Adhesions following surgical operations are of great importance due to complications for the patient, complications in relaparotomy, and high costs. Depressive and hypopigmented abdominal scars may be associated with pelvic adhesions. We believe that closure or non-closure of the parietal peritoneum is not associated with pelvic adhesions.
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Affiliation(s)
- Numan Çim
- Van Yüzüncü Yıl University Faculty of Medicine, Department of Gynecology and Obstetrics, Van, Turkey
| | - Erkan Elçi
- University of Health Sciences, Van Training and Research Hospital, Clinic of Gynecology and Obstetrics, Van, Turkey
| | - Gülhan Güneş Elçi
- University of Health Sciences, Van Training and Research Hospital, Clinic of Gynecology and Obstetrics, Van, Turkey
| | - Necat Almalı
- Van Yüzüncü Yıl University Faculty of Medicine, Department of General Surgery, Van, Turkey
| | - Recep Yıldızhan
- Van Yüzüncü Yıl University Faculty of Medicine, Department of Gynecology and Obstetrics, Van, Turkey
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Shenhav S, Grin L, Kapustian V, Anteby EY, Gdalevich M, Gemer O. Quantifying the effects of postcesarean adhesions on incision to delivery time. J Matern Fetal Neonatal Med 2018; 32:2500-2505. [DOI: 10.1080/14767058.2018.1439010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Simon Shenhav
- Department of Obstetrics and Gynecology, Barzilai University Medical Center, Ben Gurion University of the Negev, Ashkelon, Israel
| | - Leonti Grin
- Department of Obstetrics and Gynecology, Barzilai University Medical Center, Ben Gurion University of the Negev, Ashkelon, Israel
| | - Victoria Kapustian
- Department of Obstetrics and Gynecology, Barzilai University Medical Center, Ben Gurion University of the Negev, Ashkelon, Israel
| | - Eyal Y. Anteby
- Department of Obstetrics and Gynecology, Barzilai University Medical Center, Ben Gurion University of the Negev, Ashkelon, Israel
| | - Michael Gdalevich
- Department of Obstetrics and Gynecology, Barzilai University Medical Center, Ben Gurion University of the Negev, Ashkelon, Israel
| | - Ofer Gemer
- Department of Obstetrics and Gynecology, Barzilai University Medical Center, Ben Gurion University of the Negev, Ashkelon, Israel
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Seyam E, Ibrahim EM, Youseff AM, Khalifa EM, Hefzy E. Laparoscopic Management of Adhesions Developed after Peritoneal Nonclosure in Primary Cesarean Section Delivery. Obstet Gynecol Int 2018; 2018:6901764. [PMID: 29487625 PMCID: PMC5816863 DOI: 10.1155/2018/6901764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 11/29/2017] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Emaduldin Seyam
- Obstetrics and Gynecology Department, Minia University College of Medicine, Minya, Egypt
| | - Emad Moussa Ibrahim
- Obstetrics and Gynecology Department, Minia University College of Medicine, Minya, Egypt
| | - Ayman Moheb Youseff
- Obstetrics and Gynecology Department, Minia University College of Medicine, Minya, Egypt
| | - Eissa M. Khalifa
- Obstetrics and Gynecology Department, Minia University College of Medicine, Minya, Egypt
| | - Enas Hefzy
- Microbiology and Immunology Department, Fayoum University College of Medicine, Faiyum, Egypt
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Lyell DJ, Naqvi M, Wong A, Urban R, Carvalho B. Rectus Muscle Reapproximation at Cesarean Delivery and Postoperative Pain: A Randomized Controlled Trial. Surg J (N Y) 2017; 3:e128-e133. [PMID: 28840194 PMCID: PMC5565698 DOI: 10.1055/s-0037-1604074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 05/26/2017] [Indexed: 12/02/2022] Open
Abstract
Objective
Rectus muscle reapproximation at cesarean delivery (CD) is performed frequently by some obstetricians; however, the effect on postoperative pain is unclear. To this end, we investigated whether rectus muscle reapproximation increases postoperative pain.
Materials and Methods
This is a prospective, double-blind, randomized controlled trial of women undergoing primary CD with singleton or twin pregnancy at >35 weeks' gestation. Women were randomized to rectus muscle reapproximation with three interrupted sutures or no reapproximation. Exclusion criteria were prior cesarean, prior laparotomy, vertical skin incision, active labor, chronic analgesia use, allergy to opioid or nonsteroidal anti-inflammatory drugs, and body mass index ≥ 40. Intra- and postoperative pain management was standardized within the study protocol. The primary outcome was a combined movement pain and opioid use score averaged over the 72-hour study period, called the Silverman integrated assessment. Movement pain scores were assessed at 24, 48, and 72 postoperative hours.
Results
In total, 63 women were randomized, of whom 35 underwent rectus muscle reapproximation and 28 did not. Demographic and obstetric variables were similar between groups. Silverman integrated assessment scores during the 72-hour postoperative period were higher in the rectus muscle reapproximation group (15 ± 100% vs. –31 ± 78% difference from the mean;
p
= 0.04). Operative times were similar between groups (63 ± 15 vs. 65 ± 15 minutes;
p
= 0.61), and there were no surgical complications in either group. Maternal satisfaction with analgesia at 72 hours was high in both groups (85% [73–90] rectus muscle reapproximation vs. 90% [75–100];
p
= 0.16).
Conclusion
Rectus muscle reapproximation increased immediate postoperative pain without differences in operative time, surgical complications, or maternal satisfaction. Benefits of rectus muscle reapproximation should be weighed against increased postoperative pain, and analgesia should be planned accordingly.
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Affiliation(s)
- Deirdre J Lyell
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Mariam Naqvi
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Amy Wong
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Renata Urban
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Brendan Carvalho
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California
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Arlier S, Seyfettinoğlu S, Yilmaz E, Nazik H, Adıgüzel C, Eskimez E, Hürriyetoğlu Ş, Yücel O. Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section. Arch Gynecol Obstet 2016; 295:303-311. [PMID: 27770246 DOI: 10.1007/s00404-016-4221-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 10/14/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE OF INVESTIGATION We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity. MATERIALS AND METHODS We analyzed intra-abdominal adhesions of 672 patients. RESULTS Among the patients, 173, 206, 151, and 142 underwent CS for the first, second, third, and fourth time or more, respectively. There were adhesions in 393 (58.5 %) patients. Among first CSs, there were no adhesions, the rate of maternal morbidity [Morales et al. (Am J Obstet Gynecol 196(5):461, 2007)] was 26 %, and the rate of neonatal morbidity (NM) was 35 %. Among women who have history of two CSs, the adhesion rate was 66.3 %, the adhesion score was 2.05, MM was 14 %, and NM was 21 %. Among third CSs, these values were 82.1, 2.82, 23, and 14 %, respectively. Among women who have history of four or more CSs, these values were 92.2, 4.72, 31.7, and 18 %, respectively. Adhesion sites and dense fibrous adhesions increased parallel to the number of subsequent CSs. Increased adhesion score was associated with 1.175-fold higher odds of NM and 1.29-fold higher odds of MM. The rate of NM was eightfold higher in emergency-delivered newborns (emergency: 39.4, 40 %; elective: 4.9 %). MM was 20 and 26 % for elective and emergency CSs, respectively. CONCLUSIONS Emergency operations and adhesions increased complications.
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Affiliation(s)
- Sefa Arlier
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey.
| | - Sevtap Seyfettinoğlu
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - EsraSaygili Yilmaz
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Hakan Nazik
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Cevdet Adıgüzel
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Eda Eskimez
- Department of Obstetrics and Gynecology, Harran University, Sanliurfa, Turkey
| | - Şerif Hürriyetoğlu
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Oğuz Yücel
- Department of Obstetrics and Gynecology, Adana Numune Training and Research Hospital, Adana, Turkey
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Lyell DJ, Power M, Murtough K, Ness A, Anderson B, Erickson K, Schulkin J. Surgical Techniques at Cesarean Delivery: A U.S. Survey. Surg J (N Y) 2016; 2:e119-e125. [PMID: 28825004 PMCID: PMC5553495 DOI: 10.1055/s-0036-1594247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 10/13/2016] [Indexed: 02/02/2023] Open
Abstract
Objective To assess the frequency of surgical techniques at cesarean delivery (CD) among U.S. obstetricians. Methods Members of the American College of Obstetrician Gynecologists were randomly selected and e-mailed an online survey that assessed surgical closure techniques, demographics, and reasons. Data were analyzed using SPSS (IBM Corp., Armonk, New York, United States), descriptive statistics, and analysis of variance. Results Our response rate was 53%, and 247 surveys were analyzed. A similar number of respondents either "always or usually" versus "rarely or never" reapproximate the rectus muscles (38.4% versus 43.3%, p = 0.39), and close parietal peritoneum (42.5% versus 46.9%, p = 0.46). The most frequently used techniques were double-layer hysterotomy closure among women planning future children (73.3%) and suturing versus stapling skin (67.6%); the least frequent technique was closure of visceral peritoneum (12.2%). Surgeons who perform double-layer hysterotomy closure had fewer years in practice (15.0 versus 18.7 years, p = 0.021); surgeons who close visceral peritoneum were older (55.5 versus 46.4 years old, p < 0.001) and had more years in practice (23.8 versus 13.8 years practice; p < 0.001). Conclusion Similar numbers of obstetricians either reapproximate or leave open the rectus muscles and parietal peritoneum at CD, suggesting that wide variation in practice exists. Surgeon demographics and safety concerns play a role in some techniques.
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Affiliation(s)
- Deirdre J. Lyell
- Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Michael Power
- Research Department, American College of Obstetricians & Gynecologists, Washington, District of Columbia
| | - Katie Murtough
- Research Department, American College of Obstetricians & Gynecologists, Washington, District of Columbia
| | - Amen Ness
- Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Britta Anderson
- Research Department, American College of Obstetricians & Gynecologists, Washington, District of Columbia
| | - Kristine Erickson
- Research Department, American College of Obstetricians & Gynecologists, Washington, District of Columbia
| | - Jay Schulkin
- Research Department, American College of Obstetricians & Gynecologists, Washington, District of Columbia
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Plante B, Sukalich S, Elliott JO. Adhesion Assessment at First Repeat Caesarean Section With or Without Prior Adhesion Barrier Use. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:795-803. [DOI: 10.1016/j.jogc.2016.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/05/2016] [Indexed: 11/15/2022]
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Analysis of a Standardized Technique for Laparoscopic Cuff Closure following 1924 Total Laparoscopic Hysterectomies. Minim Invasive Surg 2016; 2016:1372685. [PMID: 27579179 PMCID: PMC4989084 DOI: 10.1155/2016/1372685] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 06/25/2016] [Indexed: 11/30/2022] Open
Abstract
Objective. To review the vaginal cuff complications from a large series of total laparoscopic hysterectomies in which the laparoscopic culdotomy closure was highly standardized. Methods. Retrospective cohort study (Canadian Task Force Classification II-3) of consecutive total and radical laparoscopic hysterectomy patients with all culdotomy closures performed laparoscopically was conducted using three guidelines: placement of all sutures 5 mm deep from the vaginal edge with a 5 mm interval, incorporation of the uterosacral ligaments with the pubocervical fascia at each angle, and, whenever possible, suturing the bladder peritoneum over the vaginal cuff edge utilizing two suture types of comparable tensile strength. Four outcomes are reviewed: dehiscence, bleeding, infection, and adhesions. Results. Of 1924 patients undergoing total laparoscopic hysterectomy, 44 patients (2.29%) experienced a vaginal cuff complication, with 19 (0.99%) requiring reoperation. Five patients (0.26%) had dehiscence after sexual penetration on days 30–83, with 3 requiring reoperation. Thirteen patients (0.68%) developed bleeding, with 9 (0.47%) requiring reoperation. Twenty-three (1.20%) patients developed infections, with 4 (0.21%) requiring reoperation. Three patients (0.16%) developed obstructive small bowel adhesions to the cuff requiring laparoscopic lysis. Conclusion. A running 5 mm deep × 5 mm apart culdotomy closure that incorporates the uterosacral ligaments with the pubocervical fascia, with reperitonealization when possible, appears to be associated with few postoperative vaginal cuff complications.
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Kiefer DG, Muscat JC, Santorelli J, Chavez MR, Ananth CV, Smulian JC, Vintzileos AM. Effectiveness and short-term safety of modified sodium hyaluronic acid-carboxymethylcellulose at cesarean delivery: a randomized trial. Am J Obstet Gynecol 2016; 214:373.e1-373.e12. [PMID: 26478104 PMCID: PMC4818004 DOI: 10.1016/j.ajog.2015.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/04/2015] [Accepted: 10/09/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND The rising cesarean birth rate has drawn attention to risks associated with repeat cesarean birth. Prevention of adhesions with adhesion barriers has been promoted as a way to decrease operative difficulty. However, robust data demonstrating effectiveness of such interventions are lacking. OBJECTIVE We report data from a multicenter trial designed to evaluate the short-term safety and effectiveness of a modified sodium hyaluronic acid (HA)-carboxymethylcellulose (CMC) absorbable adhesion barrier for reduction of adhesions following cesarean delivery. STUDY DESIGN Patients who underwent primary or repeat cesarean delivery were included in this multicenter, single-blinded (patient), randomized controlled trial. Patients were randomized into either HA-CMC (N = 380) or no treatment (N = 373). No other modifications to their treatment were part of the protocol. Short-term safety data were collected following randomization. The location and density of adhesions (primary outcome) were assessed at their subsequent delivery using a validated tool, which can also be used to derive an adhesion score that ranges from 0-12. RESULTS No differences in baseline characteristics, postoperative course, or incidence of complications between the groups following randomization were noted. Eighty patients from the HA-CMC group and 92 controls returned for subsequent deliveries. Adhesions in any location were reported in 75.6% of the HA-CMC group and 75.9% of the controls (P = .99). There was no significant difference in the median adhesion score; 2 (range 0-10) for the HA-CMC group vs 2 (range 0-8) for the control group (P = .65). One third of the HA-CMC patients met the definition for severe adhesions (adhesion score >4) compared to 15.5% in the control group (P = .052). There were no significant differences in the time from incision to delivery (P = .56). Uterine dehiscence in the next pregnancy was reported in 2 patients in HA-CMC group vs 1 in the control group (P = .60). CONCLUSION Although we did not identify any short-term safety concerns, HA-CMC adhesion barrier applied at cesarean delivery did not reduce adhesion formation at the subsequent cesarean delivery.
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Affiliation(s)
- Daniel G Kiefer
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA; Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY; Department of Obstetrics, Gynecology, and Reproductive Medicine, Stony Brook University, Stony Brook, NY.
| | - Jolene C Muscat
- Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY
| | - Jarrett Santorelli
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Stony Brook University, Stony Brook, NY; Department of Surgery, University of Buffalo, Buffalo, NY
| | - Martin R Chavez
- Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - John C Smulian
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA
| | - Anthony M Vintzileos
- Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY
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Hasdemir PS, Terzi H, Guvenal T. What are the best surgical techniques for caesarean sections? A contemporary review. J OBSTET GYNAECOL 2015; 36:141-5. [PMID: 26445144 DOI: 10.3109/01443615.2015.1041887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of this study was to evaluate the reported techniques used in caesarean sections in order to form a general perspective of the procedural options for this frequently performed operation. The PubMed database and Cochrane Reviews were searched separately with the key words 'caesarean', 'abdominal entry', 'abdominal incision', 'uterine repair', 'peritoneal repair', 'closure of abdominal incision', 'suture materials', 'extraction of the placenta' and 'review'. Reviews, meta-analyses and prospective randomised trials were included in this review. In conclusion, although caesarean delivery is a very common operation, standardised and globally accepted techniques for caesarean section have not been described. The best surgical techniques for this operation are still unknown. Although the long-term follow-up results from two large, prospective, randomised studies are pending, further research is needed to establish an evidence-based, standardised approach for caesarean sections.
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Affiliation(s)
- P S Hasdemir
- a Department of Obstetrics & Gynecology , Celal Bayar University School of Medicine , Manisa , Turkey
| | - H Terzi
- b Derince Education & Research Hospital, Obstetrics and Gynecology Clinic , Kocaeli , Turkey
| | - T Guvenal
- a Department of Obstetrics & Gynecology , Celal Bayar University School of Medicine , Manisa , Turkey
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Bolnick A, Bolnick J, Diamond MP. Postoperative Adhesions as a Consequence of Pelvic Surgery. J Minim Invasive Gynecol 2015; 22:549-63. [DOI: 10.1016/j.jmig.2014.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 01/12/2023]
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20
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Adhesions at repeat cesarean delivery: is there a personal impact? Arch Gynecol Obstet 2015; 292:813-8. [DOI: 10.1007/s00404-015-3718-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 04/07/2015] [Indexed: 11/27/2022]
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21
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Peritoneal closure over barbed suture to prevent adhesions: a randomized controlled trial in an animal model. J Minim Invasive Gynecol 2015; 22:619-25. [PMID: 25620215 DOI: 10.1016/j.jmig.2015.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/15/2015] [Accepted: 01/17/2015] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To compare adhesion formation and histological features of peritoneal closure and nonclosure over an intra-abdominally placed barbed suture. DESIGN Single-blind randomized controlled trial (Canadian Task Force Classification I). SETTING Certified animal research facility. SUBJECTS Eight nonpregnant rats. INTERVENTIONS Abdominal cavities were entered via midline incision. Left and right parietal peritoneal surfaces were incised 1.5 cm long separately and stitched with unidirectional barbed suture material (3/0 V-Loc). The parietal peritoneum was approximated over the barbed suture using polypropylene suture material (7/0 Prolene) to embed the barbed suture (peritonization) on one side, and left open on the other side. The side of the barbed suture to be peritonized was allocated at random. On the postoperative day 32, all rats were sacrificed, adhesion formations on each side were macroscopically scored, and histological features were evaluated microscopically. MEASUREMENT AND MAIN RESULTS The median adhesion score was 2.00 (range, 1-4) on operative fields. There was no statistically significant difference in median adhesion score between the peritonized and nonperitonized sides (1.5 vs 2, respectively; p = .13). Microscopically, there were no statistically significant differences in median acute and chronic inflammation scores between the peritonized and nonperitonized sides (p = .58 and p = .45, respectively), but a significantly higher median fibrosis score on the peritonized side (3 vs 1.5, respectively; p = .02). CONCLUSION Based on the results of the present study in a rat model, barbed suture material might be associated with adhesion formation when used intra-abdominally, and these adhesions could not be prevented by peritonization.
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Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis. Am J Obstet Gynecol 2014; 211:453-60. [PMID: 24912096 DOI: 10.1016/j.ajog.2014.06.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/28/2014] [Accepted: 06/05/2014] [Indexed: 02/07/2023]
Abstract
A systematic review and metaanalysis were performed through electronic database searches to estimate the effect of uterine closure at cesarean on the risk of adverse maternal outcome and on uterine scar evaluated by ultrasound. Randomized controlled trials, which compared single vs double layers and locking vs unlocking sutures for uterine closure of low transverse cesarean, were included. Outcomes were short-term complications (endometritis, wound infection, maternal infectious morbidity, blood transfusion, duration of surgical procedure, length of hospital stay, mean blood loss), uterine rupture or dehiscence at next pregnancy, and uterine scar evaluation by ultrasound. Twenty of 1278 citations were included in the analysis. We found that all types of closure were comparable for short-term maternal outcomes, except for single-layer closure, which had shorter operative time (-6.1 minutes; 95% confidence interval [CI], -8.7 to -3.4; P < .001) than double-layer closure. Single layer (-2.6 mm; 95% CI, -3.1 to -2.1; P < .001) and locked first layer (mean difference, -2.5 mm; 95% CI, -3.2 to -1.8; P < .001) were associated with lower residual myometrial thickness. Two studies reported no significant difference between single- vs double-layer closure for uterine dehiscence (relative risk, 1.86; 95% CI, 0.44-7.90; P = .40) or uterine rupture (no case). In conclusion, current evidence based on randomized trials does not support a specific type of uterine closure for optimal maternal outcomes and is insufficient to conclude about the risk of uterine rupture. Single-layer closure and locked first layer are possibly coupled with thinner residual myometrium thickness.
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Adhesion prevention after cesarean delivery: evidence, and lack of it. Am J Obstet Gynecol 2014; 211:446-52. [PMID: 24858198 DOI: 10.1016/j.ajog.2014.05.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/20/2014] [Indexed: 11/21/2022]
Abstract
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.
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Poole JH. Adhesions following cesarean delivery: a review of their occurrence, consequences and preventative management using adhesion barriers. ACTA ACUST UNITED AC 2014; 9:467-77. [PMID: 24007252 DOI: 10.2217/whe.13.45] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The objective of this article is to provide a comprehensive review of the occurrence and consequences of postoperative adhesions following cesarean delivery (CD), and an overview of the published clinical data on prevention in this setting using adhesion barriers. Adhesions occur frequently after CD and the incidence increases with each subsequent CD. Repeat CDs are complicated by adhesions, which increase operating time, time to delivery and risk of bladder injury. Clinical data on the efficacy of adhesion prevention strategies specific to the setting of CD are limited. Two small, nonrandomized studies found that the use of absorbable anti-adhesion barriers was associated with a significant reduction in adhesion formation and a shorter time to delivery at repeat CD, compared with no barrier use. Implications for practice and research are discussed. There is a significant need for well-controlled, randomized clinical studies investigating adhesion prevention in the labor and delivery setting.
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Affiliation(s)
- Judith H Poole
- Queens University of Charlotte, Blair College of Health, Presbyterian School of Nursing, 1900 Selwyn Avenue, Charlotte, NC 28274, USA.
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25
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Tarney CM. Bladder Injury During Cesarean Delivery. CURRENT WOMEN'S HEALTH REVIEWS 2013; 9:70-76. [PMID: 24876830 PMCID: PMC4033551 DOI: 10.2174/157340480902140102151729] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 06/07/2013] [Accepted: 06/17/2013] [Indexed: 11/22/2022]
Abstract
Cesarean section is the most common surgery performed in the United States with over 30% of deliveries occurring via this route. This number is likely to increase given decreasing rates of vaginal birth after cesarean section (VBAC) and primary cesarean delivery on maternal request, which carries the inherent risk for intraoperative complications. Urologic injury is the most common injury at the time of either obstetric or gynecologic surgery, with the bladder being the most frequent organ damaged. Risk factors for bladder injury during cesarean section include previous cesarean delivery, adhesions, emergent cesarean delivery, and cesarean section performed at the time of the second stage of labor. Fortunately, most bladder injuries are recognized at the time of surgery, which is important, as quick recognition and repair are associated with a significant reduction in patient mortality. Although cesarean delivery is a cornerstone of obstetrics, there is a paucity of data in the literature either supporting or refuting specific techniques that are performed today. There is evidence to support double-layer closure of the hysterotomy, the routine use of adhesive barriers, and performing a Pfannenstiel skin incision versus a vertical midline subumbilical incision to decrease the risk for bladder injury during cesarean section. There is also no evidence that supports the creation of a bladder flap, although routinely performed during cesarean section, as a method to reduce the risk of bladder injury. Finally, more research is needed to determine if indwelling catheterization, exteriorization of the uterus, and methods to extend hysterotomy incision lead to bladder injury.
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Affiliation(s)
- Christopher M. Tarney
- Womack Army Medical Center, Department of Obstetrics and Gynecology, 2817 Reilly Road, Fort Bragg, NC 28307, USA
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ten Broek R, Kok- Krant N, Bakkum E, Bleichrodt R, van Goor H. Different surgical techniques to reduce post-operative adhesion formation: a systematic review and meta-analysis. Hum Reprod Update 2012; 19:12-25. [DOI: 10.1093/humupd/dms032] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Ghahiry A, Rezaei F, Karimi Khouzani R, Ashrafinia M. Comparative analysis of long-term outcomes of Misgav Ladach technique cesarean section and traditional cesarean section. J Obstet Gynaecol Res 2012; 38:1235-9. [DOI: 10.1111/j.1447-0756.2011.01777.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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30
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Brochhausen C, Schmitt VH, Planck CNE, Rajab TK, Hollemann D, Tapprich C, Krämer B, Wallwiener C, Hierlemann H, Zehbe R, Planck H, Kirkpatrick CJ. Current strategies and future perspectives for intraperitoneal adhesion prevention. J Gastrointest Surg 2012; 16:1256-74. [PMID: 22297658 DOI: 10.1007/s11605-011-1819-9] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 12/28/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The formation of peritoneal adhesions still is a relevant clinical problem after abdominal surgery. Until today, the most important clinical strategies for adhesion prevention are accurate surgical technique and the physical separation of traumatized serosal areas. Despite a variety of barriers which are available in clinical use, the optimal material has not yet been found. DISCUSSION Mesothelial cells play a crucial physiological role in friction less gliding of the serosa and the maintenance of anantiadhesive surface. The formation of postoperative adhesions results from a cascade of events and is regulated by various cellular and humoral factors. Therefore, optimization or functionalization of barrier materials by developments interacting with this cascade on a structural or pharmacological level could give an innovative input for future strategies in peritoneal adhesion prevention. For this purpose, the proper understanding of the formal pathogenesis of adhesion formation is essential. Based on the physiology of the serosa and the pathophysiology of adhesion formation, the available barriers in current clinical practice as well as new innovations are discussed in the present review.
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Affiliation(s)
- Christoph Brochhausen
- REPAIR-lab, Institute of Pathology, University Medical Centre, Johannes Gutenberg-University, Langenbeckstraße 1,55101 Mainz, Germany.
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Rectus muscle and visceral peritoneum closure at cesarean delivery and intraabdominal adhesions. Am J Obstet Gynecol 2012; 206:515.e1-5. [PMID: 22463952 DOI: 10.1016/j.ajog.2012.02.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 01/04/2012] [Accepted: 02/29/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the effect of the rectus muscle and visceral peritoneum closure at cesarean delivery on adhesions. STUDY DESIGN We performed a secondary analysis of a prospective cohort study of women who underwent first repeat cesarean delivery. Surgeons scored the severity and location of adhesions. Records were abstracted to assess previous surgical techniques. RESULTS The original cohort included 173 patients. Rectus muscle closure was associated with fewer combined filmy and dense adhesions overall (27.5% vs 46%; P = .04) and fewer dense adhesions overall (17.5% vs 46%; P = .001; adjusted odds ratio, [aOR], 0.24; 95% confidence interval [CI], 0.09-0.65), particularly from fascia to omentum (aOR, 0.08; 95% CI, 0.007-0.82). Visceral peritoneum closure was associated with increased dense fascia-to-omentum adhesions (aOR, 15.78; 95% CI, 1.81-137.24). CONCLUSION Closure of the rectus muscles at cesarean delivery may reduce adhesions, and visceral peritoneum closure may increase them. Surgical techniques at cesarean delivery should be assessed independently, because they may have opposite effects on adhesion formation.
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Bonneau C, Nizard J. [Management of pregnancies with a previous cesarean]. ACTA ACUST UNITED AC 2012; 41:497-511. [PMID: 22609031 DOI: 10.1016/j.jgyn.2012.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Revised: 04/04/2012] [Accepted: 04/10/2012] [Indexed: 11/29/2022]
Abstract
The cesarean rate in France has reached 21% in 2010. With a maintained fertility rate, management of a pregnant woman with a previous caesarean scar is becoming a daily situation for most obstetrical teams. Considering the small rate of vaginal birth after cesarean (VBAC), we will try to establish an up-to-date review of the benefits and risks of encouraging trial of VBAC. This information can help professionals provide adequate counselling women or couples.
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Affiliation(s)
- C Bonneau
- Service de gynécologie obstétrique, UPMC Paris-6, hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 83, boulevard de l'Hôpital, 75013 Paris, France
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Kapustian V, Anteby EY, Gdalevich M, Shenhav S, Lavie O, Gemer O. Effect of closure versus nonclosure of peritoneum at cesarean section on adhesions: a prospective randomized study. Am J Obstet Gynecol 2012; 206:56.e1-4. [PMID: 21924397 DOI: 10.1016/j.ajog.2011.07.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 06/17/2011] [Accepted: 07/22/2011] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We sought to determine the effect of nonclosure of the visceral and parietal peritoneum during cesarean section on the formation of adhesions. STUDY DESIGN This was a prospective randomized trial of 533 women undergoing primary cesarean section; in 256 the peritoneum was left open and in 277 it was closed. Fifty women in the nonclosure group and 47 women in the closure group were subsequently evaluated intraoperatively at a repeat cesarean. The presence of adhesions and their severity were evaluated at several sites. RESULTS The nonclosure and closure groups were comparable with regard to the proportion of patients with adhesions at any site (60% vs 51%, respectively; P = .31). Time from incision to delivery was comparable in the nonclosure and closure groups (8.98 ± 4.7 vs 9.32 ± 5.2 minutes, respectively; P = .84). CONCLUSION Closure or nonclosure of the peritoneum at cesarean section did not lead to large differences in the adhesion rate.
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Affiliation(s)
- Victoria Kapustian
- Department of Obstetrics and Gynecology, Barzilai Medical Center Faculty of Health Sciences, Ben Gurion University of the Negev, Ashkelon, Israel
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Lyell DJ. Adhesions and perioperative complications of repeat cesarean delivery. Am J Obstet Gynecol 2011; 205:S11-8. [PMID: 22114993 DOI: 10.1016/j.ajog.2011.09.029] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 09/26/2011] [Accepted: 09/29/2011] [Indexed: 01/26/2023]
Abstract
The unprecedented high rate of cesarean delivery and the declining rate of vaginal birth after cesarean delivery make necessary awareness of the potential complications that are associated with repeat cesarean delivery. This article reviews the epidemiologic features of cesarean delivery and the perioperative risks that are associated with repeat cesarean delivery. These risks include increased adhesions, infections and wound complications, bleeding, bowel injury and obstruction, hysterectomy, operative time, hospital stay, and delays in delivery.
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Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol 2011; 205:S2-10. [PMID: 22114995 DOI: 10.1016/j.ajog.2011.09.028] [Citation(s) in RCA: 161] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 07/14/2011] [Accepted: 09/29/2011] [Indexed: 11/20/2022]
Abstract
Concern regarding the association between cesarean delivery and long-term maternal morbidity is growing as the rate of cesarean delivery continues to increase. Observational evidence suggests that the risk of morbidity increases with increasing number of cesarean deliveries. The dominant maternal risk in subsequent pregnancies is placenta accreta spectrum disorder and its associated complications. A history of multiple cesarean deliveries is the major risk factor for this condition. Pregnancies following cesarean delivery also have increased risk for other types of abnormal placentation, reduced fetal growth, preterm birth, and possibly stillbirth. Chronic maternal morbidities associated with cesarean delivery include pelvic pain and adhesions. Adverse reproductive effects may include decreased fertility and increased risk of spontaneous abortion and ectopic pregnancy. Clinicians and patients need to be aware of the long-term risks associated with cesarean delivery so that they can be considered when determining the method of delivery for first and subsequent births.
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Audebert A, Darai E, Bénifla JL, Yazbeck C, Déchaud H, Wattiez A, Crowe A, Pouly JL. [Postoperative abdominal adhesions and their prevention in gynaecological surgery: I. What should you know?]. ACTA ACUST UNITED AC 2011; 40:365-70. [PMID: 22129851 DOI: 10.1016/j.gyobfe.2011.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 09/02/2011] [Indexed: 11/25/2022]
Abstract
Adhesions are the most frequent complications of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with increased morbidity and mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, including laparoscopy, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in many patients. The extent of the problem of adhesions has been underestimated by surgeons and the health authorities. There is rising evidence however that surgeons can take important steps to reduce the impact of adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. This paper is the first of a two-part publication providing a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. In the second paper we review the various strategies to reduce the impact of adhesions and improve surgical outcomes to assist fellow surgeons in France to consider the adoption of adhesion reduction strategies in their own practice.
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Affiliation(s)
- A Audebert
- Service d'endoscopie gynécologique, polyclinique de Bordeaux, 145, rue du Tondu, 33000 Bordeaux, France.
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Greenberg MB, Daniels K, Blumenfeld YJ, Caughey AB, Lyell DJ. Do adhesions at repeat cesarean delay delivery of the newborn? Am J Obstet Gynecol 2011; 205:380.e1-5. [PMID: 21864825 DOI: 10.1016/j.ajog.2011.06.088] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 05/03/2011] [Accepted: 06/22/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to assess whether the presence and severity of adhesions at first repeat cesarean delivery are associated with delayed delivery of the newborn. STUDY DESIGN We conducted secondary analysis of a prospective cohort of women undergoing first repeat cesarean. Severity and location of adhesions were reported by surgeons immediately postoperatively. We compared adhesion density scores with delivery data. RESULTS Of 145 women analyzed, 92 (63.5%) had adhesions and 53 (36.5%) did not. Mean incision to delivery time in women with adhesion scores >3 was 19.8 minutes, compared to 15.6 minutes with scores ≤ 3 (P = .04). More women with adhesion scores >3 remained undelivered at 30 minutes after incision compared to scores ≤ 3 (17.9% vs 5.1%; odds ratio, 7.6; 95% confidence interval, 1.6-34.5), after controlling for potential confounders. CONCLUSION Among women undergoing first repeat cesarean, severity of adhesions may delay delivery of the newborn. Study of techniques to reduce adhesions may be warranted to prevent delayed delivery at repeat cesarean.
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Awonuga AO, Fletcher NM, Saed GM, Diamond MP. Postoperative adhesion development following cesarean and open intra-abdominal gynecological operations: a review. Reprod Sci 2011; 18:1166-85. [PMID: 21775773 DOI: 10.1177/1933719111414206] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In this review, we discuss the pathophysiology of adhesion development, the impact of physiological changes associated with pregnancy on markers of adhesion development, and the clinical implications of adhesion development following cesarean delivery (CD). Although peritoneal adhesions develop after the overwhelming majority of intra-abdominal and pelvic surgery, there is evidence in the literature that suggests that patients having CD may develop adhesions less frequently. However, adhesions continue to be a concern after CD, and are likely significant, albeit on average less than after gynecological operations, but with potential to cause significant delay in the delivery of the baby with serious, lifelong consequences. Appreciation of the pathophysiology of adhesion development described herein should allow a more informed approach to the rapidly evolving field of intra-abdominal adhesions and should serve as a reference for an evidence-based approach to consideration for the prevention and treatment of adhesions.
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Affiliation(s)
- Awoniyi O Awonuga
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA
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Shi Z, Ma L, Yang Y, Wang H, Schreiber A, Li X, Tai S, Zhao X, Teng J, Zhang L, Lu W, An Y, Alla NR, Cui T. Adhesion formation after previous caesarean section-a meta-analysis and systematic review. BJOG 2010; 118:410-22. [DOI: 10.1111/j.1471-0528.2010.02808.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chapa HO, Sbarra MA. The Paucity of Information on Adhesions After Cesarean Delivery. J Gynecol Surg 2010. [DOI: 10.1089/gyn.2009.0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hector O. Chapa
- Women's Specialty Center, Department of Obstetrics/Gynecology Methodist Medical Center, Dallas, TX
| | - Michael A. Sbarra
- Hackensack University Medical Center, Hackenack, NJ, and University of Medicine and Dentistry in New Jersey at New Jersey Medical School, Newark, NJ
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Pérez-Medina T, Álvarez J, Degollada M, de Santiago J, Lara A, Pascual A, Pérez Milán F, Crowe AM. Documento de consenso del Grupo de Trabajo sobre las Adherencias de la sección de endoscopia de la SEGO. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.pog.2010.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Andolf E, Thorsell M, Källén K. Cesarean delivery and risk for postoperative adhesions and intestinal obstruction: a nested case-control study of the Swedish Medical Birth Registry. Am J Obstet Gynecol 2010; 203:406.e1-6. [PMID: 20875502 DOI: 10.1016/j.ajog.2010.07.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 06/28/2010] [Accepted: 07/14/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of the study was to estimate the risk for postoperative adhesions and intestinal obstruction after cesarean delivery and to estimate whether the rate remains stable over time. STUDY DESIGN Women who had the aforementioned diagnoses in the Swedish Hospital Discharge Registry were linked to the Swedish Medical Birth Registry. Women with diagnoses increasing the risk for adhesions were excluded. More than 900,000 women were investigated. Risks were calculated and were adjusted for age, parity, body mass index, and smoking. RESULTS Women delivered by cesarean delivery had an increased risk of adhesions: adjusted odds ratio, 2.1 (95% confidence interval, 1.8-2.4) and intestinal obstruction: adjusted odds ratio, 2.0 (95% confidence interval, 1.7-2.4). The number needed to harm was 360. Multiple caesarean deliveries increased the risk of adhesions. The risk did not increase over time. CONCLUSION The absolute risk of postoperative adhesions and intestinal obstruction after cesarean section are low but should be included when counseling women requesting cesarean delivery.
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Abstract
Most studies of cesarean morbidity focus on short term, rather than long term complications. However, women undergoing cesarean delivery are at increased risk for a chronic problems as well. These include pain and surgical adhesions, as well as a possible increased risk for infertility or sub-fertility and perinatal complications in subsequent pregnancies. The most serious risk for women undergoing multiple repeat cesarean deliveries is a dramatically increased risk for life threatening hemorrhage and morbidity in the setting of placenta accreta. This chapter outlines these long term risks of cesarean delivery so that they may be factored into the risk:benefit ratio for women considering vaginal birth after cesarean delivery (VBAC).
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Affiliation(s)
- Robert M Silver
- University of Utah School of Medicine, Department of Obstetrics and Gynecology, Salt Lake City, UT 84132, USA.
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Fucoidan film safely inhibits surgical adhesions in a rat model. J Surg Res 2010; 171:495-503. [PMID: 20638689 DOI: 10.1016/j.jss.2010.04.043] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Revised: 03/20/2010] [Accepted: 04/21/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the in vivo efficacy of 13 compounds and to further characterize the load limiting and potential toxicity of the most efficacious compound. The cascade of biochemical and molecular events that results in the formation of postsurgical adhesions provides numerous theoretical opportunities for prophylactic intervention. METHODS Candidate agents were loaded into sodium hyaluronate (HA) films and administered to male Sprague-Dawley rats using a cecal-sidewall model of surgical adhesions. An adhesion score was obtained for each rat based on the strength and extent of the adhesions. The most efficacious agent, fucoidan, was further evaluated in a load-limiting study with a concentration range of 0.0033 to 33% w/w per film. The potential toxicity of fucoidan was evaluated in a separate study by comparison of hematology findings, blood chemistry, urinalysis, and incision thickness from rats administered control films or 33% w/w fucoidan films 1 to 4 d prior to sacrifice. RESULTS Fucoidan loaded films reduced adhesion scores by approximately 90% compared with control films (P<0.05). A total of 50% to 100% of animals were adhesion free at fucoidan film loadings of 0.33% to 33% w/w compared with all control film animals having adhesions. No adverse effects were observed from 33% w/w fucoidan films equivalent to approximately 30 mg fucoidan/kg body weight. CONCLUSIONS Local administration of fucoidan film during rat cecal-sidewall surgery safely reduced adhesion scores by approximately 90% and resulted in 50% to 100% of animals being adhesion free.
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Brotherton J, McCarus S, Redan J, Jones KY, Kim JC. Hand-assist laparoscopic surgery for the gynecologic surgeon. JSLS 2010; 13:484-8. [PMID: 20202388 PMCID: PMC3030780 DOI: 10.4293/108680809x12589998404001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hand-assisted laparoscopic surgery (HALS) has not been extensively used in gynecologic surgery. This approach may offer a safe, viable alternative for gynecological cases that might otherwise require a large laparotomy incision. Background: Hand assist laparoscopy (HALS) is a minimally invasive technique which allows for the placement of the surgeon's non-dominant hand through a hand-port device while maintaining pneumoperitoneum. There is no standardization of this procedure and it is rarely used in gynecology. Methods: The multidisciplinary team of authors, with experience in minimally invasive pelvic surgery, has developed a practical approach performing HALS over several years. Here we present our technique. Conclusions: There are several roles for HALS in the world of gynecology and pelvic surgery. Further experience will help improve upon a standard technique.
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Affiliation(s)
- Joy Brotherton
- Celebration Women's Center for Pelvic Health, Celebration, Florida, USA.
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Imai A, Takagi H, Matsunami K, Suzuki N. Non-barrier agents for postoperative adhesion prevention: clinical and preclinical aspects. Arch Gynecol Obstet 2010; 282:269-75. [DOI: 10.1007/s00404-010-1423-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Accepted: 03/01/2010] [Indexed: 11/24/2022]
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Blumenfeld YJ, Caughey AB, El-Sayed YY, Daniels K, Lyell DJ. Single- versus double-layer hysterotomy closure at primary caesarean delivery and bladder adhesions. BJOG 2010; 117:690-4. [PMID: 20236104 DOI: 10.1111/j.1471-0528.2010.02529.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the association between single-layer (one running suture) and double-layer (second layer or imbricating suture) hysterotomy closure at primary caesarean delivery and subsequent adhesion formation. DESIGN A secondary analysis from a prospective cohort study of women undergoing first repeat caesarean section. SETTING Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA. POPULATION One hundred and twenty-seven pregnant women undergoing first repeat caesarean section. METHODS Patient records were reviewed to identify whether primary caesarean hysterotomies were closed with a single or double layer. Data were analysed by Fisher's exact tests and multivariable logistic regression. MAIN OUTCOME MEASURE Prevalence rate of pelvic and abdominal adhesions. RESULTS Of the 127 women, primary hysterotomy closure was single layer in 56 and double layer in 71. Single-layer hysterotomy closure was associated with bladder adhesions at the time of repeat caesarean (24% versus 7%, P = 0.01). Single-layer closure was associated in this study with a seven-fold increase in the odds of developing bladder adhesions (odds ratio, 6.96; 95% confidence interval, 1.72-28.1), regardless of other surgical techniques, previous labour, infection and age over 35 years. There was no association between single-layer closure and other pelvic or abdominal adhesions. CONCLUSIONS Primary single-layer hysterotomy closure may be associated with more frequent bladder adhesions during repeat caesarean deliveries. The severity and clinical implications of these adhesions should be assessed in large prospective trials.
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Affiliation(s)
- Y J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA 94305, USA.
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