The review by Walfisch et al alongside many other reviews draws out the debate on the peritoneal closure/nonclosure during cesarean delivery. Any discussion on pathophysiologic adhesion-formation most importantly should include that the denuded and surgically traumatized areas on the uterus and abdominal wall undergo invariable inflammatory reaction commencing the process of adhesion-formation and that the restoration of peritoneal continuity seems a natural barrier against this. Historically, both visceral and parietal peritoneum were closed because of rational reasoning and careful observation that exposed raw areas in the peritoneal cavity lead to adhesion-formation. Subsequently, guideline groups recommended nonclosure of peritoneum for clinically irrelevant short-term outcomes such as saving a few minutes (in an operation that takes only 30 minutes) or reduced analgesic requirement in 24-48 hours, which is an unimportant surrogate outcome completely unrelated to the purpose of peritoneal closure; findings also contradicted by an equal number of randomized controlled trials (RCTs). Such misapplication of evidence-based medicine has been a subject of current debate. Hence, it could be argued that peritoneal closure should not have been abandoned in the first place without robust evidence that it does not reduce or increases the incidence of adhesion formation. The argument that peritoneal closure (taking the most basic care) could cause tissue damage, necrosis, and foreign body reaction–causing adhesions (especially with modern sutures) is not supported by trials or even by wider surgical experience/observation.

Walfisch et al quite rightly quote other metaanalyses of RCTs and observational studies that provide robust evidence of reduction of all grades of adhesions with peritoneal closure. Omental adhesions to parietal peritoneum may not be of much consequence; however, cases of extensive dense adherence of the lower part of the uterus to anterior abdominal wall have been observed by the author and others that leads to pain, dyspareunia, possible subfertility, and significant operative difficulty during further surgery. These are most likely attributed to nonclosure of peritoneum. The RCTs that deal with surgical techniques have particular limitations and difficulties, particularly an attrition rate as seen in the trial in which only 97 of 533 women had a repeat cesarean delivery ; hence, pragmatic observational studies can be equally informative. Thus, the suturing of peritoneum during cesarean deliveries should now be recommended based on the existing evidence, without waiting for long-term results of any more RCTs. If peritoneal layers are sutured, there seems no need for synthetic adhesion barriers for which there is no reasonable evidence, as rightly concluded in the review.