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ORIGINAL ARTICLE
Year : 2021  |  Volume : 48  |  Issue : 3  |  Page : 152-155

Peritoneal closure versus nonclosure in cesarean delivery


1 Department of Obstetrics and Gynaecology, SKIMS, Srinagar, Jammu and Kashmir, India
2 Department of Surgery, GMC, Srinagar, Jammu and Kashmir, India
3 Department of Anaesthesia, SKIMS, Srinagar, Jammu and Kashmir, India
4 Department of Medicine, GMC, Srinagar, Jammu and Kashmir, India

Date of Submission24-May-2021
Date of Acceptance25-Aug-2021
Date of Web Publication28-Dec-2021

Correspondence Address:
Azhar Un Nisa Quraishi
Department of OBGY, SKIMS, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.jss_61_21

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  Abstract 


Background: Routine closure of parietal peritoneum during cesarean section has been a custom. However, current evidence argues against peritoneal closure. Methods: A total of 100 pregnant women who had to undergo cesarean delivery were taken for the study. They were divided into two groups: Group C (50 patients) and Group NC (50 patients). Group C included the patients in whom parietal peritoneum was sutured during cesarean delivery, whereas, Group NC included the patients in whom parietal peritoneum was left unsutured during cesarean delivery. The two groups were then compared in terms of postoperative morbidity and outcome. Results: The mean operating time was significantly less in Group NC than in Group C (P < 0.001). The mean analgesia requirement in Group C was 210.4 ± 31.45 mg, whereas it was 178.5 ± 28.63 mg in Group NC (P < 0.001). Mean time for ambulation after cesarean delivery in Group C was 12.9 ± 3.42 h, whereas it was 10.1 ± 3.19 h in Group NC (P < 0.001). There was a longer duration of hospital stay in the C group (mean = 4.3 ± 1.07 days) than NC group (mean = 2.9 ± 0.95 days). Conclusion: Nonclosure of parietal peritoneum at cesarean delivery is associated with reduced operation time, lesser postoperative analgesia requirement, and lesser duration of hospital stay with no increased morbidity.

Keywords: Analgesia, hospital stay, nonclosure, operating time, peritoneum


How to cite this article:
Quraishi AU, Farooq R, Andrabi SA, Quraishi AU, Quraishi KA. Peritoneal closure versus nonclosure in cesarean delivery. J Sci Soc 2021;48:152-5

How to cite this URL:
Quraishi AU, Farooq R, Andrabi SA, Quraishi AU, Quraishi KA. Peritoneal closure versus nonclosure in cesarean delivery. J Sci Soc [serial online] 2021 [cited 2022 May 25];48:152-5. Available from: https://www.jscisociety.com/text.asp?2021/48/3/152/333849




  Introduction Top


Cesarean delivery defines the birth of a fetus via laparotomy and then hysterotomy. Cesarean delivery has had a tumultuous and controversial history. The procedure was seldom used before the end of the nineteenth century because of its prohibitive maternal mortality. However, a dramatic rise in abdominal delivery has occurred over the past few decades. From 1970 to 2010, the cesarean delivery rate in the United States rose from 4.5% of all deliveries to 32.8%. It appears to have plateaued, and in 2013, the rate was slightly lower at 32.7%.[1] Each year in the United States, approximately one-third of more than 4 million neonates are born by cesarean delivery. Indeed, the operation is the most commonly performed major surgery in this country in women aged 18–44 years.[2]

Routine closure of parietal peritoneum during cesarean section has been a custom which has been handed over through generations of obstetricians. The traditional arguments for peritoneal closure have included restoring the anatomy and approximation of tissues for healing.[3] However, current evidence argues against peritoneal closure. Peritoneal healing, unlike epidermal repair which gradually heals from wound edges, heals by regeneration.[4],[5],[6] Histological studies in animals have revealed that the peritoneum regenerates de novo and the entire surface gets mesothelialized simultaneously throughout the surgical site.[7],[8] Regenerated serosa usually arises from metaplasia of underlying connective tissue[5] but could also arise from implantation of detached mesothelial cells from adjacent structures.[6]


  Methods Top


This was a prospective observational study conducted in the department of Obstetrics and Gynaecology, SKIMS, Soura, Srinagar, J&K from October 2018 to April 2020. A total of 100 pregnant women who had to undergo cesarean delivery were taken for the study. They were divided into two groups: Group C (50 patients) and Group NC (50 patients). Group C included the patients in whom parietal peritoneum was sutured during cesarean delivery, whereas, Group NC included the patients in whom parietal peritoneum was left unsutured during cesarean delivery. The two groups were compared in terms of:

  1. Operating time,
  2. Postoperative analgesia requirement,
  3. Time for ambulation,
  4. Postoperative complications such as fever, blood transfusion, hematoma formation, and wound dehiscence
  5. Postoperative hospital stay.


Both groups were operated by the same surgeon. Cesarean delivery was done under spinal anesthesia. The patients included in the study did not have any previous scar on the abdomen or uterus. They were either primigravida or multigravida who had previously delivered vaginally. The indications of the cesarean deliveries were: fetal distress, nonprogression of labor, cephalopelvic disproportion, and maternal request. During the postoperative period, once the effect of spinal anesthesia was over, intravenous infusion of paracetamol was used for analgesia. The staff involved in the postoperative care was same in the both groups of patients. The score used for pain assessment in the postoperative period was (visual analog score).

Statistical methods

Determination of sample size

Using GPOWER software (Version 3.0.10 by Heinrich Heine University Düsseldorf, Germany), it was estimated that the least number of patients required in each group with 80% power and 5% significance level is 50. Since we had to compare two groups in our study, therefore a total of 100 patients were included in our study.

The patients were randomly divided into two groups using computer-generated sequences. The recorded data were compiled and entered in a spreadsheet (Microsoft Excel) and then exported to the data editor of SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as mean ± standard deviation and categorical variables were summarized as frequencies and percentages. Student's independent t-test or Mann–Whitney U-test, whichever feasible, was employed for comparing continuous variables. Chi-square test or Fisher's exact test, whichever appropriate, was applied for comparing categorical variables. A P < 0.05 was considered statistically significant. All P values were two-tailed.


  Results Top


[Table 1] shows the demographic characteristics of the study patients in two groups. The mean age of the patients in Group C and Group NC was 23.8 ± 3.71 years and 24.3 ± 4.64 years, respectively. There was a statistically insignificant difference in age between the two groups (P = 0.553). Similarly, the two groups were comparable in terms of parity and gestational age.
Table 1: Demographic characteristics of study patients in two groups

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[Table 2] shows the comparison based on mean operating time in the two groups. Mean operating time in Group C and Group NC was 43.9 ± 4.17 min and 36.4 ± 3.89 min, respectively. It was significantly higher in Group C than the NC Group with P < 0.001.
Table 2: Comparison based on operative time (min) in two groups

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[Table 3] shows the time required for the closure of the abdomen during cesarean delivery. Mean time required for closure of the abdomen in Group C was 13.1 ± 3.07 min, while that required for Group NC was 10.7 ± 2.65 min. The time required for closure of the abdomen was significantly higher in Group C than in Group NC (P < 0.001).
Table 3: Time required for abdominal closure (min) in two groups

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[Table 4] shows the comparison based on postoperative analgesia requirement (mg) in two groups. The mean analgesia requirement in Group C was 210.4 ± 31.45 mg, whereas it was 178.5 ± 28.63 mg in Group NC. The analgesia requirement was significantly more in Group C than in Group NC (P < 0.001).
Table 4: Comparison based on postoperative analgesia (mg) in two groups

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[Table 5] shows the time for ambulation (hours) in two groups. Mean time for ambulation after cesarean delivery in Group C was 12.9 ± 3.42 h, whereas it was 10.1 ± 3.19 h in Group NC, the difference between the two being statistically significant (P < 0.001).
Table 5: Time for ambulation (h) in two groups

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[Table 6] shows the comparison based on postoperative complications in two groups. The difference in complication rate between the two groups was statistically insignificant. In the C group, six patients required blood transfusion, whereas in the NC group, five patients required the same. The difference between the two was insignificant with P = 0.749. Similarly, the incidence of fever, hematoma formation, and wound dehiscence was similar in the two groups.
Table 6: Comparison based on postoperative complications in two groups

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[Table 7] shows the comparison based on postoperative hospital stay (Days) in two groups. There was a longer duration of hospital stay in the C group (mean = 4.3 ± 1.07 days) than NC group (mean = 2.9 ± 0.95 days), the difference between the two being statistically significant (P < 0.001).
Table 7: Comparison based on postoperative hospital stay (days) in two groups

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  Discussion Top


In our study, the mean age of the patients in Group C and Group NC was 23.8 ± 3.71 years and 24.3 ± 4.64 years, respectively [Table 1]. There was a statistically insignificant difference in age between the two groups (P = 0.553). both the groups had similar parity distribution. In Group C, among 50 patients, 42 were primigravida and multigravida were 8 in number. However, the multigravida included in the study had previously delivered vaginally and did not have any scar on the abdomen or uterus. Similarly, out of 50 NC patients, 39 were primigravida and multigravida were 11 in number. In both the groups, most of the patients had gestational age of more than 37 weeks and preterm cesarean deliveries were very less in number.

Our study showed that the mean operating time was significantly less in Group NC than in Group C (P < 0.001) [Table 2]. Mean operating time in group C and Group NC was 43.9 ± 4.17 min and 36.4 ± 3.89 min, respectively. Our results were consistent with a study conducted by Irion et al.[9] In their study, it was found that the operating time was lesser in nonclosure group than in the closure group. Similarly, operating time was lesser in nonclosure than that of the closure group in a study conducted by Ohel et al.[10] Many other studies recommend nonclosure of the parietal peritoneum.[11],[12] They found that nonclosure of parietal peritoneum in cesarean section reduces the surgical time by 5–6 min. In our study, the mean time for closure of abdomen in Group NC was significantly lower than Group C (P < 0.001) [Table 3].

In our study, the mean analgesia requirement in Group C was 210.4 ± 31.45 mg, while it was 178.5 ± 28.63 mg in Group NC [Table 4]. The analgesia requirement was significantly more in Group C than in Group NC (P < 0.001). Our results were consistent with a study conducted by Ohel et al.,[10] who found that postoperative analgesic requirement was significantly lesser in nonclosure than closure group. Similar results were seen in a study conducted by Hull and Verner.[13]
Figure 1: Determination of Sample Size

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In our study, mean time for ambulation after cesarean delivery in Group C was 12.9 ± 3.42 h while it was 10.1 ± 3.19 h in Group NC, the difference between the two being statistically significant (P < 0.001) [Table 5]. Our study showed that the difference in complication rate between the two groups was statistically insignificant [Table 6]. In the C group, six patients required blood transfusion while in the NC group, five patients required the same. The difference between the two was insignificant with P = 0.749. Similarly, the incidence of fever, hematoma formation, and wound dehiscence was similar in the two groups with statistically insignificant differences. Our results were consistent with a study conducted by Mahdi et al.[14] In their study, there was no significant difference in the incidence of hematoma formation, blood transfusion, and postoperative wound dehiscence between closure and nonclosure groups. Pyrexia was higher in closure than nonclosure group, but the difference was statistically nonsignificant.

There was significantly shorter duration of hospital stay in NC group (mean = 2.9 ± 0.95 days), than C group (mean = 4.3 ± 1.07 days), P < 0.001 [Table 7].


  Conclusion Top


Nonclosure of parietal peritoneum at cesarean delivery is associated with reduced operation time, lesser postoperative analgesia requirement, and lesser duration of hospital stay with no increased morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Matthews TJ. Births: Final data for 2013. Natl Vital Stat Rep 2015;64:1-65.  Back to cited text no. 1
    
2.
Boyle A, Reddy UM. Epidemiology of cesarean delivery: The scope of the problem. Semin Perinatol 2012;36:308-14.  Back to cited text no. 2
    
3.
Duffy DM, diZerega GS. Is peritoneal closure necessary? Obstet Gynecol Surv 1994;49:817-22.  Back to cited text no. 3
    
4.
Robbins GF, Brunschwig A, Foote FW. Deperitonealization: Clinical and experimental observations. Ann Surg 1949;130:466-75.  Back to cited text no. 4
    
5.
Williams DC. The peritoneum; a plea for a change in attitude towards the membrane. Br J Surg 1955;42:401-5.  Back to cited text no. 5
    
6.
Ellis H, Harrison W, Hugh TB. The healing of peritneum under normal and pathological conditions. Br J Surg 1965;52:471-6.  Back to cited text no. 6
    
7.
Hubbard TB Jr., Khan MZ, Carag VR Jr., Albites VE, Hricko GM. The pathology of peritoneal repair: Its relation to the formation of adhesions. Ann Surg 1967;165:908-16.  Back to cited text no. 7
    
8.
Elkins TE, Stovall TG, Warren J, Ling FW, Meyer NL. A histologic evaluation of peritoneal injury and repair: Implications for adhesion formation. Obstet Gynecol 1987;70:225-8.  Back to cited text no. 8
    
9.
Irion O, Luzuy F, Béguín F. Nonclosure of the visceral and parietal peritoneum at caesarean section: A randomised controlled trial. Br J Obstet Gynaecol 1996;103:690-4.  Back to cited text no. 9
    
10.
Ohel G, Younis JS, Lang N, Levit A. Double-layer closure of uterine incision with visceral and parietal peritoneal closure: Are they obligatory steps of routine cesarean sections? J Matern Fetal Med 1996;5:366-9.  Back to cited text no. 10
    
11.
diZerega GS, Campeau JD. Peritoneal repair and post-surgical adhesion formation. Hum Reprod Update 2001;7:547-55.  Back to cited text no. 11
    
12.
Practice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeons. Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery. Fertil Steril 2008;90:S144-9.  Back to cited text no. 12
    
13.
Hull DB, Verner MW. A randomized study of closure of the peritoneum at caesarean delivery. Obstet Gynecol 1991;77:818-21.  Back to cited text no. 13
    
14.
Mahdi MH, Hamzah I, Khalid H. Peritoneal closure versus non-closure at caesarean section. Int J Contemp Med Res 2019;6:C22-4.  Back to cited text no. 14
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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