Closure versus non-closure of the peritoneum at caesarean section

 

Abstract

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.]

 

Plain language summary

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.

 

摘要

背景

比較剖腹產縫合或未縫合腹膜之差異

剖腹產是世界普遍的手術方式，剖腹產縫合腹膜層是否有益處仍不清楚，因此有需要進一步評估是否此步驟應忽略。

目標

本回顧的目標為評估剖腹產手術縫合與不縫合腹膜層的影響立即以及長期預後以及長期效果。

搜尋策略

我們搜尋Cochrane Pregnancy and Childbirth Group's Trials Register (2006年10月)

選擇標準

採用對照試驗，比較接受緊急或選擇性剖腹產中未縫合內臟及腹壁之腹膜層，和有縫合腹膜層之婦女。

資料收集與分析

兩位回顧作者評估試驗的品質和摘錄資料。

主要結論

總共有14個試驗，包含2908個婦女. 整個試驗的方法品質差異相當大。未縫合腹膜層可以降低手術時間，如果雙層腹膜未縫合，可節省6.05分鐘(95% CI: −6.74至−5.37)。手術後止痛藥劑量在未縫合組當中是減少的(weighted mean difference −0.20， 95% CI −0.33 to −0.08)。此外便沒有其它統計上顯著的差異。在傷口感染方面，較傾向不縫合，但若有子宮內膜炎，則其預後狀況則較不一定。一個長期追蹤的試驗呈現兩者間並無顯著差異， 而呈現差異的研究其檢力較低。

作者結論

如果腹膜未縫合的話，短期內有較佳的結果，此論點給予不縫合腹膜的醫生強力的支持。長期追蹤剖腹產結果的研究有限，因此除非能夠獲得長期追蹤的資料，否則目前沒有全面的證據顯示未縫合的結果是否有差異。

翻譯人

本摘要由周產期醫學會(Taiwan Society of Perinatology)周靜玉翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

不縫合腹膜可以減少手術時間，降低發燒機率，但其可能的缺點仍然不明。剖腹產有相當多的作法，其作法根據許多不同的原因，例如不同的臨床狀況及醫師不同的喜好。腹膜是一層薄細胞膜，剖腹產時為了要讓嬰兒出生必須切開這層膜。傳統上，剖腹產後會將腹膜縫合，也就是子宮上、膀胱上及腸子上的腹膜縫合，但有人提出因為縫線的關係，這麼做反而會讓沾黏更嚴重。這篇研究回顧過去的研究，總共有十四篇包括2698位女士，整個試驗的方法品質差異相當大。雖然未縫合的婦女可能比較沒有術後發燒，手術時間較短，但其他重要結果並沒有很好的評估，特別是術後沾黏及長期後果，尤其是下一胎的時候或是其他手術的時候。進一步的研究則目前仍在進行中。