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Closure versus non‐closure of the peritoneum at caesarean section

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Abstract

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Background

Caesarean section is a very common surgical procedure worldwide. Suturing the peritoneal layers at caesarean section may or may not confer benefit, hence the need to evaluate whether this step should be omitted or not.

Objectives

The objective of this review was to assess the effects of non‐closure as an alternative to closure of the peritoneum at caesarean section on intraoperative, immediate and long‐term postoperative and long‐term outcomes.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2006). We updated this on 30 April 2010 and added the results to the awaiting classification section.

Selection criteria

Controlled trials comparing leaving the visceral or parietal peritoneum, or both, unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section.

Data collection and analysis

Two review authors assessed trial quality and extracted the data.

Main results

Fourteen trials, involving 2908 women, were included and analysed. The methodological quality of the trials was variable. Non‐closure of the peritoneum reduced operating time whether both or either layer was not sutured. For both layers, the operating time was reduced by 6.05 minutes, 95% confidence interval (CI) ‐6.74 to ‐5.37. There was significantly less postoperative fever and reduced postoperative stay in hospital for visceral peritoneum and for both layer non‐closure. The number of postoperative analgesic doses was reduced in the peritoneal non‐closure group (weighted mean difference ‐0.20, 95% CI ‐0.33 to ‐0.08). There were no other statistically significant differences. The trend for wound infection tended to favour non‐closure, while endometritis results were variable. Long‐term follow up in one trial showed no significant differences. The power of the study to show differences was low.

Authors' conclusions

There was improved short‐term postoperative outcome if the peritoneum was not closed. This in itself can support those who opt not to close the peritoneum. Long‐term studies following caesarean section are limited; there is therefore no overall evidence for non‐closure until long‐term data become available.

[Note: The 18 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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Closure versus non‐closure of the peritoneum at caesarean section

Not stitching the peritoneum after caesarean section shows less fever for mothers and takes less time, but possible disadvantages are unclear.

There are many ways of performing a caesarean section, and the techniques used depend on a number factors, including the clinical situation and the preference of the operator. The peritoneum is a thin membrane of cells supported by a thin layer of connective tissue, and during caesarean section these peritoneal surfaces have to be cut through in order for the baby to be born. Following a caesarean section, it has been standard practice to stitch the peritoneum closed, that is to stitch the two layers of tissue lining the abdomen and covering internal organs such as the uterus, bladder and bowel. It has been suggested that peritoneal adhesions may be more likely, rather than less likely, when the peritoneum is closed, possibly as a result of reaction to the suture material. The review of trials assessed whether closing these layers of peritoneal tissue or leaving them unstitched was preferable. Fourteen trials were identified, involving 2698 women, and the methodological quality was variable. Although women suffered less postoperative fever and it saved several minutes when the peritoneum was not stitched, other important outcomes were not adequately assessed, particularly adhesions and longer term outcomes, for example, in subsequent pregnancies and births, but also at other surgeries and in later life. Further studies are at present underway assessing these outcomes further.