From the Editor

Hysterotomy incision and repair: Many options, many personal preferences

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

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.

2,141 women, that evaluated blunt versus sharp expansion of a low transverse uterine incision.¹ There was no difference in maternal febrile morbidity or major morbidity between the two techniques. However, blunt expansion of the uterine incision was associated with slightly less maternal blood loss and a lower risk of maternal blood transfusion than sharp incision (0.7% vs 3.1%).¹ In another meta-analysis blunt expansion of the uterine incision with the surgeon’s fingers resulted in a smaller decrease in hematocrit and hemoglobin levels and fewer unintended extensions, but no difference in the rate of blood transfusion.¹² Based on these findings some authorities recommend using blunt expansion of the uterine incision when a lower uterine segment incision is performed.³

One study, involving 811 women, compared cephalad-caudad blunt expansion versus transverse blunt expansion of the uterine incision.¹³ Cephalad-caudad blunt expansion compared with transverse blunt expansion resulted in a trend to less blood loss (398 mL versus 440 mL; P = .09), a significantly lower rate of unintended extension of the uterine incision (3.7% vs 7.4%, P = .03) and fewer cases with blood loss greater than 1,500 mL (0.2% vs 2.0%, P = .04). However, there was no difference in the rate of transfusion (0.7% vs 0.7%, P = 1.0) between cephalad-caudad versus transverse blunt expansion. Based on the results from this one trial, some authorities recommend that cephalad-caudad blunt extension be utilized rather than transverse blunt extension.³

Closing the uterine incision—One or two layers?
In the recent Cochrane meta-analysis, researchers compared outcomes of single-layer and two-layer closure of the uterine incision in 14 studies involving 13,890 women.¹ There was no difference in rates of febrile morbidity (5.0% vs 5.1%), wound infection (9.4% vs 9.5%), or blood transfusion (2.1% vs 2.4%) between the two techniques. Authors of another systematic review of 20 trials of single- versus double-layer closure of the uterine incision concluded that, based on the available evidence from randomized trials, single- and double-layer closure appeared to produce similar outcomes.¹⁴ These authors cautioned, however, that based on nonrandomized studies, single layer closure might be associated with an increased risk of uterine rupture in a subsequent pregnancy.^15,16

A uterine incision that was closed with a locked single-layer closure may be at an especially high risk of rupture during a subsequent trial of labor. In one analysis of relevant reports with heterogeneous study designs, the risk of uterine rupture during a trial of labor after a prior cesarean was 1.8% with a double-layer closure, 3.5% with an unlocked single-layer closure, and 6.2% with a locked single-layer closure.¹⁷ My perspective is that a double-layer closure generally is preferred because in a future pregnancy with a planned vaginal delivery, the double-layer closure may be associated with a lower rate of uterine rupture.

Some authorities recommend single-layer uterine closure if the patient is sure that she has no future plans to conceive. For example, a woman who is undergoing a tubal ligation at the time of cesarean delivery may be an optimal candidate for single-layer closure.³

Individualization and innovation in surgical care
Surgeons advance their skills by continually using the best evidence and advice from colleagues to guide changes in their practice. Many clinical situations present unique combinations of medical and anatomic problems, and surgeons need to use both creativity and expert judgment to solve these unique problems. Surgical choices that are guided by both the best evidence and hard-won clinical experience will result in optimal patient outcomes.

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