From the Editor

Hysterotomy incision and repair: Many options, many personal preferences

OBG Manag. 2015 March;27(3):6,8,10

Is there evidence of a best approach to managing the hysterotomy incision?

References

1. Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for uterine incision and uterine closure at the time of cesarean section. Cochrane Database Sys Rev. 2014;7(3):CD004732.

2. Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery. Am J Obstet Gynecol. 2005;193(5):1607–1617.

3. Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol. 2013;209(4):294–306.

4. Hohlagschwandtner M, Ruecklinger E, Husslein P, Joura EA. Is the formation of a bladder flap at cesarean necessary? A randomized trial. Obstet Gynecol. 2001;98(6):1089–1092.

5. Malvasi A, Tinelli A, Guido M, et al. Effect of avoiding bladder flap formation in caesarean section on repeat caesarean delivery Eur J Obstet Gynecol. 2011;159(2):300–304.

6. Tuuli MG, Obido AO, Fogertey P, Roehl K, Stamilio D, Macones GA. Utility of the bladder flap at cesarean delivery. A randomized controlled trial. Obstet Gynecol. 2012;119(4):815–821.

7. Cahill AG, Stout MJ, Stamillo DM, Odibo AO, Peipert JF, Macones GA. Risk factors for bladder injury in patients with a prior hysterotomy. Obstet Gynecol. 2008;112(1):116–120.

8. Holmgren G, Sjoholm L, Stark M. The Misgav-Ladach method for cesarean section: method description. Acta Obstet Gynecol Scand. 1999;78(7):615–621.

9. Wallin G, Fall O. Modified Joel-Cohen technique for cesarean delivery. Br J Obstet Gynaecol. 1999;106(3):221–226.

10. Gilstrap LC, Cunningham FG, Van Dorsten JP, eds. Operative Obstetrics, 2nd ed. New York, NY: McGraw Hill; 2002.

11. C SAFE. http://www.csafe.us/. Trumbull, CT: CooperSurgical, Inc.

12. Saad AF, Rahman M, Costantine MM, Saade GR. Blunt versus sharp uterine incision expansion during low transverse cesarean delivery: a metaanalysis. Am J Obstet Gynecol. 2014;211(6):684.e1–e11.

13. Cromi A, Ghezzi F, Di Naro E, Siesto G, Loverro G, Bolis P. Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques. Am J Obstet Gynecol. 2008;199(3):292.e1–e6.

14. Roberge S, Demers S, Berghella V, Chaillet N, Moore L, Bujold E. Impact of single- and double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis. Am J Obstet Gynecol. 2014; 211(5):453–460.

15. Yasmin S, Sadaf J, Fatima N. Impact of methods for uterine incision closure on repeat cesarean section scar of lower uterine segment. J Coll Physicians Surg Pak. 2011;21(9): 522–526.

16. Bujold E, Mehta SH, Bujold C, Gauthier RJ. Interdelivery interval and uterine rupture. Am J Obstet Gynecol. 2002;187(5): 1199–1202.

17. Roberge S, Chaillet N, Boutin A, et al. Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. Int J Gynaecol Obstet. 2011;115(1): 5–10.

CASE: Your colleague’s hysterotomy practices vary from yours
You are in the hospital on a weekend inducing labor in your patient with hypertension. A colleague asks you to assist at a primary cesarean delivery for failure to progress in the second stage. You are glad to help. During the cesarean delivery, your colleague does not create a bladder flap, makes a superficial incision in the uterus and enters the uterine cavity bluntly with her index finger, uses blunt cephalad-caudad expansion of the uterine incision, and closes the uterine incision in a single-layer of continuous suture.

In your practice your general preference is to routinely dissect a bladder flap, enter the uterus using Allis clamps and sharp dissection; use blunt transverse expansion of the uterine incision; and close the uterine incision in two layers, locking the first layer. You wonder, is there any evidence that there is one best approach to managing the hysterotomy incision?

For many obstetrician-gynecologists, cesarean delivery is the major operation we perform most frequently. In planning and performing a cesarean delivery there are many technical surgical decision points, each with many options. A recent Cochrane review concluded that for most surgical options for uterine incision and closure, short-term maternal outcomes were similar among the options and that surgeons should use the techniques that they prefer and are comfortable performing.¹ However, other authorities believe that the available evidence indicates that certain surgical techniques are associated with better maternal outcomes.^2,3

In this editorial I focus on the varying surgical options available when performing a low transverse hysterotomy during cesarean delivery and the impact of these choices on maternal outcomes.

The bladder flap—surgeon’s choice
Theoretically, dissecting a bladder flap moves the dome of the bladder away from the anterior surface of the lower uterine segment, thereby protecting it from injury during the hysterotomy incision and repair. Three randomized trials have evaluated maternal outcomes following a hysterotomy with or without a bladder flap. All three trials reported that maternal outcomes were similar whether or not a bladder flap was created.^4–6 In one trial, the creation of a bladder flap during a primary cesarean delivery was associated with increased adhesions between the parietal and visceral peritoneum and between the bladder and uterus at a repeat cesarean delivery.⁵

Some authorities have concluded that in most cesarean deliveries it is not necessary to create a bladder flap because the evidence does not indicate that it improves surgical outcomes.³ However, there may be clinical situations where a bladder flap is warranted. For example, during a repeat cesarean delivery, if the bladder is observed to be advanced high on the anterior uterine wall because of previous uterine surgery, a bladder flap may be helpful to ensure that the hysterotomy incision is performed in the lower uterine segment and not in the thickest, most muscular part of the uterine wall.

A second example is a case of arrested labor in the second stage with a deep transverse arrest of a macrosomic fetus. Lower segment lacerations may occur in this scenario, and some clinicians elect to dissect a bladder flap in anticipation of the risk of multiple extensions and a difficult hysterotomy repair. Since bladder injury occurs in less than 1% of cesarean deliveries, it would be difficult to perform a study with sufficient statistical power to determine whether creating a bladder flap influences the rate of bladder injury.⁷

Entering the uterine cavity—Try blunt entry
There are few clinical trial data to guide the technique for entering the uterine cavity. A major goal is to minimize the risk of a fetal laceration. One technique to reduce this risk is to superficially incise the uterus with a scalpel and then enter the uterus bluntly with a finger. Both the Misgav Ladach and modified Joel-Cohen techniques for cesarean delivery advocate the use of a superficial incision of the lower uterine segment with blunt entry into the uterine cavity.^8,9 Other surgical options for entering the uterine cavity with minimal risk to the fetus include:

Superficially incise the uterus with a scalpel and then apply Allis clamps to the upper and lower incision. Pull the tissue away from the underlying fetus before incising the final layer of uterine tissue and entering the cavity.¹⁰
Apply the tip of the suction tubing with suction on and gently elevate the tissue trapped in the suction tip, incising the tissue to enter the uterus.
Use a surgical device designed to reduce fetal lacerations (such as C-SAFE, CooperSurgical) to enter the uterus and extend the hysterotomy incision.¹¹

Expanding the uterine incision—Use blunt expansion
Authors of a recent Cochrane meta-analysis analyzed five randomized controlled trials, involving