NEW YORK (Reuters Health) – Closure of both peritoneal layers after cesarean section reduces the formation of adhesions, according to a report in the December 23rd online issue of BJOG.

“Although Stark’s c-section has been shown by previous studies to have better short-term postoperative outcomes, such as operation time, blood loss, analgesia requirement, febrile morbidity, return of bowel function, length of hospital stay, and infection,” Dr. Zhongjie Shi from Temple University, Philadelphia, Pennsylvania told Reuters Health by email, “our results show a clear trend that closure of both layers of peritoneum during modified Stark’s caesarean section significantly reduces the risk of adhesion formation, which might be beneficial to women undergoing repeated abdominal operations and encourage normal subsequent pregnancy.”

Dr. Shi and colleagues compared adhesion formation detected in repeat cesarean section procedures according to the different techniques used in the previous surgeries, including Stark’s cesarean section, modified Stark’s cesarean section, and classic lower-segment cesarean section in a meta-analysis based on 33 retrospective observational studies including 4423 women.

The modified Stark’s cesarean section differs from the original Stark’s cesarean section only in that both peritoneal layers are closed with a continuous suture in the modified procedure and neither peritoneal layer is closed in the original approach. The classic lower-segment cesarean section also closes both peritoneal layers but requires more maneuvers be performed to achieve greater exposure of the uterine lower segment.

In the 12 studies that directly compared the 2 Stark approaches, the risk of adhesion formation was 4.69-fold higher with the original cesarean section than with the modified Stark’s cesarean section. The modified approach significantly reduced the number of grade 1, grade 2, and grade 3 adhesions compared with the original Stark’s approach.

In the 21 studies that compared Stark’s cesarean section with the classic lower-segment cesarean section, there were fewer grade 1 adhesions after Stark’s but fewer grade 2 and grade 3 adhesions after lower-segment cesarean section. Total adhesion formation was similar for the 2 approaches.

The modified Stark’s cesarean section was associated with fewer adhesions than was the lower-segment cesarean section. There were significantly fewer grade 1 adhesions with modified Stark’s, but there was no significant difference between the 2 approaches in the occurrence of grade 2 and grade 3 adhesions.

The differences in adhesion formation likely contributed to the increased bleeding and longer operation duration during repeat cesarean section seen after lower-segment cesarean section.

“Our suggestion for Obstetrical coworkers is, before c-section, it would be helpful to discuss the issue of adhesion formation with their patients,” Dr. Shi said. “If the patients definitely want to have more children after the present pregnancy, physicians are encouraged to apply the modified c-section in order to maximize the chance of next pregnancy and reduce the difficulties of the following c-section. The original Stark’s c-section is good for the present operation, and the modified one is good for the next pregnancy and operation.”

“For future studies about minimizing adhesion formation after c-section,” Dr. Shi said, “we would like to test antiseptic fluid, antibiotics, or adhesion prevention materials during c-section. We might also touch base on the role of amniotic fluid and blood in the formation of adhesion.”

BJOG 23 December 2010.