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Cesarean closure techniques impact adhesions

NEW YORK (Reuters Health) – Whether the rectus abdominis muscle and visceral peritoneum are closed in a cesarean section has a clear impact on the extent of adhesions afterward, a new study shows.

Closure of rectus muscles may reduce adhesions, while closing the visceral peritoneum may increase them, researchers report.

However, the best approach is still unclear, they said in paper published online March 9th in the American Journal of Obstetrics and Gynecology.

As lead author Dr. Deirdre J. Lyell told Reuters Health by email, “Adhesions caused by cesarean matter, and their prevention is important. Studies of peritoneal closure at cesarean have yielded conflicting results, as many combine the two types of peritoneum closure (parietal and visceral) which appear to having opposing effects (decreased adhesions with parietal closure, increased with visceral closure).”

Before undertaking the current study, Dr. Lyell of Stanford University Medical Center, California and colleagues expected that rectus muscle closure would have no effect on adhesions, and that visceral peritoneum closure would increase them.

Their data came from a prospective cohort study of 173 women undergoing a first repeat cesarean. Surgeons were asked to complete a validated adhesion score sheet immediately following this procedure.

Whether or not the rectus muscles and visceral peritoneum had been closed was left to the discretion of the surgeons at the time of the primary cesarean. The rectus muscles were closed in 40 patients and the visceral peritoneum in 25.

Rectus muscle closure was indeed not significantly associated with occurrence of increased adhesions overall, or at individual sites (i.e., “bowel,” “fascia to omentum,” “fascia to uterus,” “omentum to uterus,” or “other pelvic structures”).

In fact, compared to visceral peritoneum closure, rectal muscle closure was associated with fewer combined filmy and dense adhesions overall (27.5% vs 46.0%) and fewer dense adhesions overall (17.5% vs 46.0%).

“While we hypothesized that rectus muscle closure would have no effect on adhesions, we found a 76% reduction in the occurrence of dense abdominal adhesions independent of other surgical practices such as closure of the parietal peritoneum,” the authors wrote.

But, they pointed out, the study was not powered “to assess adequately whether closure of both the rectus muscles and the parietal peritoneum results in fewer adhesions than simply closure of one of these tissues.”

“Studies which examine closure of both layers likely net out the true effect,” Dr. Lyell said. “Future studies should examine these layers separately to understand the impact of closure, in order to learn how we can best reduce a woman’s chance of developing adhesions.”

With the high cesarean delivery rate, she concluded, “post-cesarean adhesions are, and will continue to be, a public health problem.”


Am J Obstet Gyncol 2012.