[Use of a stapler instrument for hysterotomy in cesarean section]. Introduction of the Misgav Ladach caesarean section at an African tertiary centre: a randomised controlled trial. Comparative study of single layer and conventional closure of uterine incision in cesarean section. Can Joel-Cohen incision and single layer reconstruction reduce cesarean section morbidity? Transverse uterine incision closure: one versus two layers. The modified Misgav-Ladach versus the Pfannenstiel-Kerr technique for cesarean section: a randomized trial. Blunt versus sharp expansion of the uterine incision in low-segment transverse cesarean section. Surgical staples in cesarean section: a randomized controlled trial. The Misgav Ladach method for cesarean section compared to the Pfannenstiel method. [Comparison of two cesarean techniques: classic versus Misgav Ladach cesarean]. Modified Joel-Cohen technique for caesarean delivery. Ultrasound evaluation of the uterine scar after cesarean delivery: a randomized controlled trial of one- and two-layer closure. Short-term outcome of newborn infants born by a modified procedure of cesarean section. A prospective randomized study.
In a prospective, randomized study covering 100 patients with cesarean delivery the potential benefit of using a stapler for hysterotomy was investigated. Expectations were high, in particular in regard to loss of blood. However, no significant differences were found as regards this criterion, nor in the postoperative complication rate, duration of hospitalization or surgery, or febrile morbidity. The stapler is unwieldy and not always completely safe. If the higher cost of using the stapler is also taken into account one is bound to conclude that there is no reason to abandon the technique used hitherto. To determine whether the Misgav Ladach caesarean section technique can offer benefits compared with conventional caesarean section technique in the prevailing conditions of a busy African tertiary centre.
                A randomised controlled trial.
                A tertiary African obstetric unit with 18,000 deliveries annually.
                Three hundred and thirty-nine women undergoing caesarean section.
                Eight residents and registrars were instructed in the Misgav Ladach technique for caesarean section during one week, after which the study commenced. The course participants instructed their colleagues; in total, 16 doctors participated. Women requiring caesarean section were randomised to Misgav Ladach or to the conventional lower midline incision procedure, excluding those with a previous scar.
                During 11 weeks 339 randomised procedures (328 of which were emergency procedures) were carried out. Mean operating time was 25 x 3 minutes for Misgav Ladach and 32 x 6 minutes for the lower midline incision procedure (95% CI -8 x 3; -6 x 3). Mean blood loss was 354 mL and 447 mL (-133; -53), and the number of sutures 3 x 1 and 6 x 1 (-3 x 1; -2 x 9), respectively. No significant difference was found in Apgar scores. Mobilisation was earlier with the Misgav Ladach procedure. No difference was found in overall post-operative infection rates i.e. wound infection or febrile illness, but the combination of wound infection and fever was more common in the Misgav Ladach group.
                The Misgav Ladach caesarean section confers benefits such as reduced blood loss, conservation of time and suture material, and rapid mobilisation, but more studies are needed to explore modifications aimed at reducing post-operative infections in settings with limited resources. Single layer interrupted suture closure of uterine wound incisions represent a viable choice over conventional closure since the operation not only has benefits in case of performance but also possesses a rational basis for the avoidance of ischemia of the wound, infection and hematoma formation. There is a distinct advantage of single interrupted suture closure over conventional closure because there is a substantially higher number of normal hysterograms in this group showing good integrity of the scar in the uterus. To compare an innovative cesarean section based on Joel-Cohen incision with the traditional Pfannenstiel technique in terms of operative data and post-operative recovery.
                Out of 158 randomized patients, 83 patients underwent the innovative cesarean section (Joel-Cohen incision, one-layer locked uterine suture, no peritoneization) and 75 the traditional operative approach (Pfannenstiel incision, double layer closure of the uterus, visceral and parietal peritoneization). Operative data and post-operative morbidity were compared; sample size was calculated to detect a 13% difference in the occurrence of post-operative fever with a statistical power of 80%.
                Post-operative fever was not different in the two groups. Total operating time was shorter with the innovative technique: 31.6 +/-1.38 min vs. 44.4+/-1.44 (P=0.0001) and fewer sutures were used: 3.6+/-0.13 vs. 6+/-0.13 (P=0.001). Patients operated by the new technique began moving sooner and intestinal function restarted earlier.
                The proposed technique made for shorter operating times and faster recovery but no decrease in puerperal morbidity. Closure of a low transverse cesarean incision with one layer of suture results in less operating time, better hemostasis, and less infectious morbidity than a two-layer closure.
                At our institution 906 women were randomized to closure of a low transverse cesarean incision with either one continuous layer of a locking No. 1 chromic suture and a CTX needle (n = 457) or two continuous layers of No. 1 chromic suture with the first layer locked (n = 449). The Student t test, chi 2 test of proportion, and Wilcoxon rank sum test were used to compare groups of patients.
                A one-layer closure required less operative time, 43.8 versus 47.5 minutes (p = 0.0003). Fewer additional uterine hemostatic sutures were required in 369 women in whom either the one- (n = 179) or the two-layer (n = 190) closure did not achieve hemostasis (p = 0.046). Endometritis was similar in both groups, 83 (22%) in the one-layer group versus 65 (18%) in the two-layer group (p = 0.17). In no outcome assessment was the two-layer closure superior to the one-layer closure.
                We recommend a one-layer closure when its use is anatomically feasible. Modifications to the classic cesarean section technique described by Pfannenstiel and Kerr have been proposed in the last few years. The objective of this trial was to compare intraoperative and short-term postoperative outcomes between the Pfannenstiel-Kerr and the modified Misgav-Ladach (MML) techniques for cesarean section.
                This prospective randomized trial involved 162 patients undergoing transverse lower uterine segment cesarean section. Patients were allocated to one of the two arms: 88 to the MML technique and 74 to the Pfannenstiel-Kerr technique. Main outcome measures were defined as the duration of surgery, analgesic requirements, and bowel restitution by the second postoperative day. Additional outcomes evaluated were febrile morbidity, postoperative antibiotic use, postpartum endometritis, and wound complications. Student's t, Mann-Whitney, and Chi-square tests were used for statistical analysis of the results, and a p < 0.05 was considered as the probability level reflecting significant differences.
                No differences between groups were noted in the incidence of analgesic requirements, bowel restitution by the second postoperative day, febrile morbidity, antibiotic requirements, endometritis, or wound complications. The MML technique took on average 12 min less to complete (p = 0.001).
                The MML technique is faster to perform and similar in terms of febrile morbidity, time to bowel restitution, or need for postoperative medications. It is likely to be more cost-effective. Both blunt and sharp expansion of the initial incision at transverse cervical cesarean birth have advocates, on the basis of theoretic concerns. We sought to study the incidence of complications, including unintended extension, associated with each of these methods by comparison by means of a prospective, randomized study.
                Women scheduled to undergo nonemergency cesarean birth were assigned to blunt and sharp expansion groups. Other than expansion of the incision, standard technique was used throughout surgery. Data, including length and number of unintended extensions, vessel laceration, and length of surgery, were recorded immediately.
                The blunt (n = 139) and sharp (n = 147) expansion groups were similar with regard to indication and duration of labor. No difference in the incidence of unintended extension, postoperative endometritis, duration of surgery, or estimated blood loss was noted. The frequency of unintended extension (1.4%, 15.5%, and 35.0% for no labor and first and second stages, respectively) correlated with the stage of labor.
                Blunt and sharp expansions of the uterine incision are equivalent in ease and safety. This randomized controlled trial compares the use of the Auto Suture Poly CS 57 disposable surgical stapler (n = 98) with standard hysterectomy (n = 102) in low transverse cesarean sections. Subjective assessment of blood loss by the surgeon resulted in lower mean (+/- SEM) total blood loss estimates in the stapled group (492 +/- 24 ml) than in the nonstapled group (579 +/- 38 ml) (p = 0.05). However, surgeon's estimation of blood loss as a result of the hysterotomy and blood loss estimated by the hemoglobin deficit measured on the second postoperative day did not significantly differ between the two groups. The use of the stapling device tended to lengthen the total operating time, which averaged 42.5 minutes in the group with the staples and 39.2 minutes in the group with the standard hysterotomy (p = 0.05). The risk of febrile morbidity, the frequency of endometritis, and the length of hospitalization were similar in the two groups. Our results do not support the routine use of the Auto Suture Poly CS 57 disposable surgical stapler in low transverse cesarean sections. The aim of the study was to evaluate the outcome of two different methods of cesarean section (CS).
                The study was designed as a prospective, randomized, controlled trial.
                All CS were performed at the University Hospital in Uppsala, Sweden.
                Fifty women admitted to hospital for a first elective CS were consecutively included in the study. They were randomly allocated to two groups.
                One group was operated on by the Misgav Ladach method for CS and the other group by the Pfannenstiel method. All operations were performed by the same surgeon.
                Duration of operation, amount of bleeding, analgesics required, scar appearance and length of hospitalization.
                Operating time was significantly different between the two methods, with an average of 12.5 minutes with the Misgav Ladach method and 26 minutes with the Pfannenstiel method (p<0.001). The amount of blood loss differed significantly, with 448 ml and 608 ml respectively (p=0.017). Significantly less analgesic injections and tablets (p=0.004) were needed after the Misgav Ladach method.
                The Misgav Ladach method of CS has advantages over the Pfannenstiel method by being significantly quicker to perform, with a reduced amount of bleeding and diminished postoperative pain. The women were satisfied with the appearance of their scars. In this study no negative effects of the new operation technique were discovered. The aim of the study was to compare two cesarean section techniques Methodology. A prospective study was conducted UB 400 cesareans performed at the Gynecological and Obstetric Clinic of the Dakar Teaching Hospital between March 2000 and August 2000. Two hundred patients underwent the classical procedure (CL group) and the other 200 the Misgav Ladach procedure (ML group). Per- and post-operative data were compared between the two groups with Student's test and the Chi(2) test. A p-value less than 0.05 was considered statistically significant.
                The two groups were similar for socio-demographic and clinical data. The delay between the skin incision and infant delivery was significantly shorter in the ML group (5 minutes 26 seconds versus 6 minutes 20 seconds). The same trend was found for the length of operation (36 minutes 36 seconds versus 54 minutes 38 seconds). Fewer sutures were used in the ML group (2.92 versus 4.14). There is no significant difference for dose of analgesia, post-operative complications and hospital discharge. Cost analysis demonstrated that the Misgav Ladach procedure was 10000 FCFA (15 euros) less costly.
                Misgav Ladach method is simple, rapid, cost-effective cesarean procedure which appears to be an attractive alternative to traditional cesarean section. To investigate whether a series of changes in the current caesarean section operative routine, based on new knowledge, would be beneficial.
                A prospective controlled trial.
                Labour ward with approximately 3000 deliveries annually in a suburban area of Gothenburg, Sweden.
                Seventy-two pregnant women scheduled for delivery by caesarean section were randomised to either modified Joel-Cohen technique (n = 36) or Pfannenstiel technique (n = 36).
                Blood loss during surgery and operating time.
                The median estimated intra-operative blood loss was 250 mL in the modified Joel-Cohen group and 400 mL in the Pfannenstiel group (P = 0.026). The proportion of women with > or = 300 mL was 16/36 in the modified Joel-Cohen group vs 28/36 in the Pfannenstiel group (OR 0.229, 95% CI 0.082-0.637). Median operating time was 20 min in the modified Joel-Cohen group compared with 28 min in the Pfannenstiel group (P < 0.001). The proportion of women with > or = 25 min was 1/36 in the modified Joel-Cohen group vs 33/36 in the Pfannenstiel group (OR 0.003, 95% CI 0.000-0.026).
                We conclude that the modified Joel-Cohen technique of caesarean delivery reduced intraoperative blood loss and operating time compared with the Pfannenstiel technique. To survey the uterine scar thickness by ultrasonography in women randomly assigned to one- or two-layer hysterotomy closure after primary cesarean delivery.
                This was a randomized, blinded trial of uterine scar closure with ultrasonographic follow-up. Thirty consecutive patients undergoing primary cesarean delivery were enrolled and randomly assigned to one- or two-layer closure of the hysterotomy. Ultrasound surveillance of the uterine scar thickness was performed at baseline (before surgery) and 48 hours, 2 weeks, and 6 weeks post partum.
                Patient compliance with the postpartum surveillance protocol was 90%, and the uterine scar was visualized in 99% of attempted ultrasonographic examinations. There were no differences between groups at baseline or at any of the follow-up evaluations. An initial 5- to 6-fold increase in uterine scar thickness was observed, followed by a gradual decrease with the 6-week measurements still thicker than baseline. Repeated measures analysis of variance showed significant variation across time points starting either at baseline (P<.001) or at 48 hour postoperatively (P<.001), but this variation did not depend on closure type (P=.79 for all visits and P=.81 beginning with 48-hour postoperative time point).
                The process of uterine scar remodeling can be successfully monitored by ultrasonography. Uterine scar thickness diminishes progressively after both one- or two-layer closure but does not vary with mode of hysterotomy closure. The uterine scar thickness remains increased even at 6 weeks post partum, suggesting that the process of uterine scar remodeling extends beyond the traditional postpartum period. CLINCAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00224250 nan
While caesarean section is a common procedure performed on women worldwide, there is little information available to inform the most appropriate surgical technique to adopt.
[Note: The 34 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]