European Journal of Obstetrics & Gynecology and Reproductive Biology 128 (2006) 267–269 www.elsevier.com/locate/ejogrb

Non-closure versus closure of peritoneum during cesarean section: A randomized study Zahra Zareian a,*, Parvin Zareian b a

Department of Obstetrics and Gynecology, Jahrom School of Medical Sciences, Jahrom, Iran b Department of Physiology, Jahrom School of Medical Sciences, Jahrom, Iran

Received 28 May 2005; received in revised form 8 February 2006; accepted 8 February 2006

Abstract Background: Adhesion bands are reported to be among the most common complications of gynecological surgery procedures. The aim of this study was to compare the frequency of post-surgical adhesion among patients with closed or open peritoneal repair in the subsequent cesarean sections. Methods: A prospective randomized trial was performed on 45 patients who underwent cesarean section during a 5-year period. Among these patients, 24 patients were operated on by closure of the peritoneum and 21 patients were operated on by the non-closure method. Overall, 31 patients had a second pregnancy and cesarean section within the time of the study. These patients were evaluated to determine if they had any adhesion between the omentum and abdominal wall or uterus or between the uterus and abdominal wall or rectus muscle. Results: The two groups were similar to each other with regard to the causes of cesarean section. Seven cases of adhesions were diagnosed during subsequent cesarean sections among 13 patients (54%) with peritoneal non-closure, compared with 3 in 18 women (15%) with peritoneal closure (relative risk: 3.2; 95% confidence interval: 1.0–10.2). Conclusion: Closure of the peritoneum increases the operating time, but may decrease the risk of adhesions. The results of this study suggest that, during cesarean section, suture of the peritoneum may be a better option than leaving it unsutured. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Cesarean section; Closure group; Visceral and parietal peritoneum

1. Introduction Cesarean section is the most common surgical procedure performed by a gynecologist. In recent years, widespread attempts have been made to reduce the frequency of this procedure. In conventional methods of cesarean section, the visceral and parietal peritoneum is repaired separately. It is believed that peritoneal repair permits the normal anatomy of the tissues to be restored, which results in faster recovery, reduction of risk of infection, hernia through the incision, dehiscence and post-surgical adhesion [1–3]. Adhesion bands are among the most common complications of surgical procedures of the abdominal and pelvic regions; especially appendectomy and gynecological surgi* Corresponding author. Tel.: +98 791 3333988; fax: +98 791 3331520. E-mail address: [email protected] (Z. Zareian).

cal procedures [4]. The causes of adhesion bands in these procedures include ischemia, necrosis and inflammation of operated tissues, and foreign body reaction to the suture materials [5,6]. Ischemia in the operated tissues is among the most common causes of chronic pelvic pain and referral to gynecologists, and its treatment imposes a great cost on health care providers [7,8]. The United Kingdom Royal College of Obstetricians suggested that non-closure of the peritoneum is associated with fewer post-surgical complications and can be used in many gynecological procedures [4]. However, many gynecologists prefer to use the conventional method of peritoneal repair, which may increase the above-mentioned complications. There have been a few randomized, controlled trials comparing non-closure of the parietal [3,4], visceral [5,6] or both parietal and visceral peritoneum [7,8] during cesarean section compared with suture

0301-2115/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2006.02.021

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Z. Zareian, P. Zareian / European Journal of Obstetrics & Gynecology and Reproductive Biology 128 (2006) 267–269

Table 1 Indication for cesarean section

Non-closure (21) Closure (24)

Previous C/S

BX presentation

Fetal distress

Dysfunction of labor

Others

0 0

3 5

4 6

5 7

9 6

peritonization. Most of these trials have addressed early postoperative morbidity. There has been one trial in which a long-term follow-up was pursued [9]. The technique of peritoneal repair during cesarean section may influence the risk of developing adhesions. There is presently no evidence that one technique is superior to another. A second-look laparoscopy would be the best technique to assess the presence of adhesions, but it is not possible to perform this. Therefore, we planned to check adhesion during the next cesarean.

2. Materials and methods This study was performed in the Obstetrics and Gynecology Department of Jahrom Medical College Hospital. Forty-five women undergoing elective or emergency cesarean section from March 1999 to November 2004 were randomized to one of the two categories. The random number was drawn with the help of a random number table. A system of sealed envelopes, which were opened in the operation theatre at the beginning of operation, was used. Among these patients, 24 patients were operated on by closure of the parietal and visceral peritoneum by 2.0 chromic sutures and 21 patients were operated on by nonclosure of the peritoneum. All of the patients were operated on via Pfannenstiel incisions and all uterine incisions were repaired in two layers by chromic 1.0 sutures, the peritoneum was repaired with a continuous 2.0 chromic, and the fascia with a continuous 1.0 chromic. The skin margins were approximated by 2.0 or 3.0 nylon sutures subcuticularly. All of the patients received antibiotics preoperatively and continued to do so for 24 h after the procedure. Febrile morbidity was defined as a sublingual temperature higher than 38 8C. If the patients did not experience any fever, they were discharged from the hospital on the second postoperative day. Among these patients, 31 patients had had a second pregnancy and cesarean section at the time of the study. These patients were evaluated to determine if they had any adhesion between the omentum and abdominal wall or uterus, or between the uterus and the abdominal wall or rectus muscle. The grading of adhesion was as follows. The adhesion was considered to be mild if easily removable adhesion bands were found between the site of uterine incision and the omentum or the rectus muscle. It was considered to be severe if the not easily removable adhesion bands extended to the lower uterine segment and the wall of bladder. In this case, the arrival into the abdomen was difficult.

The data obtained were analyzed using statistical software SPSS WIN 10.0. Fisher’s exact test was used to statistically analyze the results. A p value less or equal to 0.05 was considered statistically significant.

3. Results This study was performed on 45 pregnant women who underwent cesarean section. The mean maternal age was 24.5 years in the non-closure and 24.2 years in the closure groups. They were also similar to each other with regard to the indications for cesarean section (Table 1). The duration of the operation was shorter in patients whose peritoneums were not closed (about 5.2 min) and this difference was statistically significant ( p = 0.001). There was no statistically significant difference between the two groups with regard to the febrile complications of the operation ( p = 1.000). Seven cases of adhesions were diagnosed during subsequent cesarean section among 13 patients (54%) with peritoneal non-closure, of which two cases had a severe degree of adhesion. In comparison, 3 out of 18 women with peritoneal closure (relative risk: 3.2; 95% confidence interval: 1.0–10.2) had developed adhesions (15%), which were of a mild degree (Table 2). There was a statistically significant difference between the two groups ( p = 0.05).

4. Discussion Peritoneum is replaced de novo from its underlying connective layer rather than by creeping from the cut mesothelial margins. After 48–72 h the entire surface is remesothelialized simultaneously. Regeneration of peritoneal defects is completed in 5–6 days. Adhesion formation after peritoneal closure is primarily the result of foreign body reactions to the suture material, ischemia, tissue necrosis and inflammation [5]. Adhesion is one of the most important postoperative complications. Occurrence of adhesion after cesarean section could increase both the duration of the next operations and Table 2 Operative findings during subsequent cesarean

Adhesion No-adhesion

Non-closure

Closure

p

7 6

3 15

0.05 0.05

Z. Zareian, P. Zareian / European Journal of Obstetrics & Gynecology and Reproductive Biology 128 (2006) 267–269

other intraoperative complications of the surgical procedures such as injury to the intestines, bladder, ureter and also bleeding. Pelvic adhesions and the resulting complications cost a quarter of a million dollars annually in Sweden alone [5]. Lower et al. showed that in a 10-year period, 5.7% of patients who underwent cesarean section were admitted again for treatment of adhesion complications [10]. Considering the results of this study, it was shown that closure of the parietal and visceral peritoneum during the operation could increase the operation time. This was similar to the results reported by other investigators [7,9– 15]. The frequency of febrile complications in both techniques of operation was also similar to other studies [11–13]. The frequency of postoperative adhesions, however, was different from previous trials. The results of other studies were controversial about the frequency of postoperative adhesion following peritoneal closure and peritoneal non-closure techniques. In some studies, no difference was observed between these two techniques [14,15]. Kumar and Weerawetwat reported an increase in adhesions after peritoneal closure compared with the peritoneal non-closure technique [12– 16]; on the contrary, Duffy and diZerega [1] as well as Lyell [17] reported that the frequency of adhesion was lower in peritoneal closure (five-fold overall reduction with an odds ratio of 0.19) compared with the peritoneal non-closure technique, which is in accordance with the findings of our study. The differences may be due to differences in the surgical techniques or the low sample size [7]. Finally, the limitation of this study was the small sample size. However, the results of the study are favorable toward closure of the peritoneum. Further studies are suggested to confirm these results.

Acknowledgements The authors would like to thank the Office of the ViceChancellor for Research of Jahrom School of Medical Sciences for financial support, Dr. Davood Mehrabani, Dr. S.A. Alavi and the Center for Development of Clinical

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Research of Nemazee Hospital for editorial and statistical assistance.

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