Peritoneal closure reduces adhesions after cesarean section
Last Updated: 2011-01-12 10:00:12 -0400 (Reuters Health)
By Will Boggs, MD
NEW YORK (Reuters Health) - Closing both peritoneal layers after cesarean section reduces the formation of adhesions, according to a meta-analysis published online December 23rd in BJOG.
"Reasonable theories" exist for closing the peritoneum, and for not closing it, say the authors of the study. Those who would not close it say it heals on its own within three to five days, and closure would lead to foreign body reactions to sutures, ischemia, inflammation, and necrosis. Arguing for peritoneal closure, others say it takes six weeks for the uterus to return to normal size and position, so if the peritoneum heals in less than a week, the enlarged uterus will be in the way. Furthermore, women are mobilized early after the surgery, and the "left-open" peritoneum can't separate the uterus from the omentum, the intestines, or the fascia and rectus abdominis.
In their meta-analysis and systematic review, Dr. Zhongjie Shi from Temple University, Philadelphia, Pennsylvania, and colleagues compared adhesion formation after three cesarean techniques: Stark's cesarean section, modified Stark's cesarean section, and classic lower-segment cesarean section.
The modified Stark's cesarean section differs from the original Stark's cesarean section only in that both peritoneal layers are closed with a continuous suture in the modified procedure and neither layer is closed in the original approach. The classic lower-segment cesarean section also closes both peritoneal layers but involves more maneuvers to achieve greater exposure of the uterine lower segment.
The 33 observational studies selected by Dr. Shi and colleagues involved 4423 women undergoing repeat cesarean deliveries - which allowed the research teams to quantify the adhesions from the first procedure.
"Our results show a clear trend that closure of both layers of peritoneum during modified Stark's caesarean section significantly reduces the risk of adhesion formation," Dr. Shi told Reuters Health by email.
In the 12 studies that directly compared the two Stark approaches, the risk of adhesion formation was 4.69-fold higher with the original vs the modified Stark's cesarean section. The modified approach significantly reduced the number of grade 1, grade 2, and grade 3 adhesions compared with the original Stark's approach.
In the 21 studies that compared Stark's cesarean section with the classic lower-segment cesarean section, there were fewer grade 1 adhesions after Stark's but fewer grade 2 and grade 3 adhesions after lower-segment cesarean section. Total adhesion formation was similar for the two approaches.
The modified Stark's cesarean section was associated with fewer adhesions than was the lower-segment cesarean section. There were significantly fewer grade 1 adhesions with modified Stark's, but there was no significant difference between the two approaches in the occurrence of grade 2 and grade 3 adhesions.
Dr. Shi suggests discussing the issue of adhesion formation with patients in advance. "If the patients definitely want to have more children after the present pregnancy, the modified c-section will maximize the chance of a subsequent pregnancy and reduce the difficulties of the following c-section," Dr. Shi said. "The original Stark's c-section is good for the (upcoming) operation, and the modified one is good for the next pregnancy and operation."
At some point Dr. Shi's group might test the roles of antiseptic fluids, antibiotics, or other substances in preventing adhesions after cesarean section. It's also possible that amniotic fluid and blood have a role in the adhesion process, and the research team would like to investigate those effects as well, Dr. Shi said.
SOURCE:http://bit.ly/hWZqTM
BJOG 2010.
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