The Peritoneum—To Close or Not to Close During a Cesarean Section?

Abstract & Commentary

By John C. Hobbins, MD, Professor and Chief of Obstetrics, University of Colorado Health Sciences Center, Denver, is Associate Editor for OB/GYN Clinical Alert.

Dr. Hobbins reports no financial relationship to this field of study.

Synopsis: The practice of non-closure of the peritoneum should be performed at cesarean.

Source: Komoto Y, et al. Prospective study of non-closure or closure of the peritoneum at cesarean delivery in 124 women: Impact of prior peritoneal closure at primary cesarean on the interval time between first cesarean section and the next pregnancy and significant adhesion at second cesarean. J Obstet Gynaecol Res. 2006;32:396-402.

There continues to be controversy regarding the merits and risks of one- or two-layer closure of the uterus during cesarean section. Also, although opinions abound concerning whether or not to close the peritoneum during a cesarean section, until now there has been sparse evidence in the literature to back either side.1,2 A recent report from Japan suggests that you "non closers" are on the right track.

One hundred and twenty-four patients having cesareans were randomized to either having both parietal and visceral peritoneum closed (70) or not having this done during the exit portion of the operation (54). Every other part of the procedure was identical between groups, and the uteri were closed in 2 layers. Not surprisingly, the closure (C) group had significantly longer operative times than the non closure (NC) group (46.7 minutes vs 39.7 minutes), but also the need for analgesia was greater (2.4 doses vs 2.0 doses). The most interesting findings came from the 50 patients returning for a repeat cesarean section (27 C's and 23 NC's). Adhesions were encountered in 11/27 of the C group and only 2/23 in the NC group (P < 0.05). The need to lyze adhesion prior to uterine incision was 6/27 in the C group vs 0/23 in the NC patients. In the C group the total operative time was longer (46.7 minutes vs 39.7 minutes) for the repeat cesarean as well as the time taken from skin incision to uterine incision (11.1 minutes vs 7.6 minutes). Last, and this is fascinating, the time in months between pregnancies was statistically significantly longer in the C group (45.7 vs 33.6).

Commentary

Here is a simple study in a relatively obscure journal which was well constructed and patiently carried out that provides evidence-based insight as to how to best perform a cesarean section. Leaving the peritoneum alone on the way out shortened the operation itself, indirectly diminished the need for pain alleviation, decreased adhesion formation, and decreased operative time for a subsequent cesarean section.

The fact that it took, on average, 12 months longer for C group patients to become pregnant again got my attention. Was it because of a relative infertility perhaps secondary to adhesions, motility, or other reasons that only our fertility brethren can explain? Was it because they needed a little more time to sort through their memories of their last birth experience? Or was this just a statistical fluke based on an underpowered study with only 50 patients returning for a repeat cesarean section?

Those of my colleagues who still close the peritoneum steadfastly claim that this will enhance healing and decrease adhesion formation. They may not wish to read this study.

References

  1. Chanrachakul B, et al. A randomized comparison of postcesarean pain between closure and nonclosure of peritoneum. Eur J Obstet Gynecol Reprod Biol. 2002;101:31-35.
  2. Roset E, et al. Nonclosure of the peritoneum during caesarean section: Long-term follow-up of a randomized controlled trail. Eur J Obstet Gynecol Reprod Biol. 2003;108:40-44.