Archive for May 29, 2010

A look at the data on hysterotomy closure – how many layers?

Given that cesarean delivery is the second most common surgery performed in this country, it is somewhat surprising that as a profession we can’t seem to settle on what the best way to do it is.  We argue about how we should open, what we should close on the way out, and how we should close these layers.  Some have even argued that we shouldn’t even enter the peritoneal cavity in doing the surgery, which leads to a radically different approach.

Of all the variations on this surgery, one element that has been up to a great deal of discussion is how many layers we should close the uterus in.   Like many things in surgical and clinical technique, the answer to this question seems to have changed over time, and has even gone back and forth.   When I was training in the late 90’s, we were closing the uterus with a single layer of chromic gut suture.  Towards the end of my training, we slid towards a double layer of gut, and now we are seeing some movement back towards a single layer, but now with polygalactin 910 (Vicryl or Polysorb.)

There have been two separate areas of concern with how many layers we should close with.  One of these concerns have been the immediate effects of how we close the uterus on patient factors such as immediate postop pain, infection rates, blood loss, and surgical time.  The second concern has been the effect of closure technique on uterine rupture rate in subsequent VBAC attempts.

Like all areas of controversy, there are surgeons that are passionate on either side.  There are also groups of non-physicians that have taken strong stands on this issue, which to surgeons can seem a little out of place given the heterogeneity of the data and the variable interpretations of that data.
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Categories: Obstetrics
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