Common Caesarian-Section Method Leads To Unnecessary Scars
- Common Caesarian-Section Method Leads To Unnecessary Scars
STANFORD, CA -- August 1, 2005 -- A controversial surgical procedure
that has lost favor among medical professionals may benefit women who
have had caesarean sections. So say researchers at the Stanford
University School of Medicine, who have found that closing the
parietal peritoneum, a multi-layered membrane that lines the abdomino-
pelvic walls, substantially decreases the likelihood of scarring that
can make future C-sections more difficult.
The finding on this link between peritoneum closure and fewer
adhesions (scars that form abnormal connections between two parts of
the body) runs contrary to current literature on the drawbacks of the
procedure in non-pregnant women and contrary to current thinking
among many surgeons.
"This was a surprise finding," said Deirdre Lyell, MD, assistant
professor of obstetrics and gynecology and lead author of a paper
appearing in the August issue of Obstetrics and Gynecology. "We were
fully expecting to find that closing the peritoneum at caesarean
delivery would increase adhesions."
More than 1 million caesareans - just over 27 percent of all births
in the United States-are performed each year. However, Lyell said
there is a lack of literature on the long-term impact of various
parts of the procedure, including the closure of a woman's peritoneum
following delivery. When c-sections are performed, surgeons must cut
through the parietal peritoneum layer. The question plaguing Lyell
was whether it is better to close it at the end of the caesarean or
allow the membrane to heal on its own.
"There is surprisingly little data on the best way to perform c-
sections," said Lyell, who is also part of the Johnson Center for
Pregnancy and Newborn Services at Lucile Packard Children's Hospital.
Although the tradition had been to close the peritoneum following
delivery, recent short-term studies have linked such closures with
increased operation time and postoperative pain. There has also been
concern that closure of the peritoneum at caesarean may lead to
adhesions-which can cause problems such as bowel obstruction, chronic
pelvic pain and infertility, and can make future surgeries longer and
more difficult-though such a connection lacks sufficient supporting
Because it is increasingly common for women to have repeat
caesareans, Lyell said adhesions are of particular concern to this
group of patients. She said the majority of surgeons don't close the
parietal peritoneum; in Lyell's study, 60 percent of surgeons left
the peritoneum open.
Eager to gather more information, Lyell and her colleagues launched a
study involving 173 women at Stanford who were undergoing a repeat
caesarean. During the study, surgeons were asked after surgery to
score the severity and location of any adhesions. The researchers
then examined patient records to determine whether a participant's
first caesarean included peritoneal closure; it had for about 39
percent of the women.
The researchers found that patients whose peritoneum was surgically
closed following their first delivery were significantly less likely
to have developed abdominal adhesions: 52 percent of patients with
prior closure had adhesions versus 73 percent of non-closure
patients. When controlling for potential confounding variables, the
researchers determined that closing the peritoneum offered five times
as much protection against the formation of adhesions as leaving it
open. It also offered three times as much protection against dense
adhesions, which are considered the most difficult to treat.
Based on the results, the authors noted that "the practice of non-
closure of the parietal peritoneum at caesarean delivery should be
Lyell said the results, which differ from findings in studies on non-
caesarean surgeries, also show that surgeons cannot rely on data from
non-pregnant patients. "We shouldn't simply extrapolate what we know
about others to pregnant women," said Lyell. "The patients are
different; they have different physiology, and labor creates a unique
While recommending closure of the peritoneum following caesarean
delivery, Lyell cautioned that this study shouldn't be taken as the
definitive answer on the procedure. More data is needed, she said,
and a randomized clinical trial is warranted.
Lyell's co-authors on the study include Stanford's Kay Daniels, MD;
and Aaron Caughey, MD, and Emily Hu, MD, both at the University of
SOURCE: Stanford University