Objective
The purpose of this study was to evaluate the effect of the rectus muscle and visceral peritoneum closure at cesarean delivery on adhesions.
Study Design
We performed a secondary analysis of a prospective cohort study of women who underwent first repeat cesarean delivery. Surgeons scored the severity and location of adhesions. Records were abstracted to assess previous surgical techniques.
Results
The original cohort included 173 patients. Rectus muscle closure was associated with fewer combined filmy and dense adhesions overall (27.5% vs 46%; P = .04) and fewer dense adhesions overall (17.5% vs 46%; P = .001; adjusted odds ratio, [aOR], 0.24; 95% confidence interval [CI], 0.09–0.65), particularly from fascia to omentum (aOR, 0.08; 95% CI, 0.007–0.82). Visceral peritoneum closure was associated with increased dense fascia-to-omentum adhesions (aOR, 15.78; 95% CI, 1.81–137.24).
Conclusion
Closure of the rectus muscles at cesarean delivery may reduce adhesions, and visceral peritoneum closure may increase them. Surgical techniques at cesarean delivery should be assessed independently, because they may have opposite effects on adhesion formation.
In 2009, which represented the 13th year of consecutive increase, nearly 32.9% of all deliveries in the United States occurred by cesarean delivery. Despite this dramatic increase in cesarean delivery over the last several decades, data are limited on the association between commonly used surgical techniques and such long-term morbidities as surgical adhesions. Closure of the rectus muscles and closure of the visceral peritoneum (commonly called “the bladder flap”) at cesarean delivery are 2 examples of commonly used surgical techniques for which outcome data are limited.
Visceral peritoneum closure has been studied most frequently in conjunction with parietal peritoneum closure, with outcomes assessed as a single entity. When studied among women who underwent parietal peritoneum closure, visceral peritoneum closure was associated with increased adhesions and histologic inflammation. In a study from Poland of 577 cesarean deliveries, visceral peritoneum closure was associated with more postoperative adhesions and upward positioning of the bladder at repeat cesarean delivery. Nagele et al examined short-term associations with visceral peritoneum closure that included operative times, febrile morbidity, cystitis, and antibiotic usage, all of which were increased.
We previously reported that, unlike what has been found among nonpregnant patients, parietal peritoneum closure at cesarean delivery appears to decrease adhesion formation when assessed independently of other surgical techniques, which includes visceral peritoneum closure. Given its anatomic location away from the involuting portion of the postpartum uterus, visceral peritoneum closure may have a different effect on adhesion formation than that seen with parietal peritoneum closure.
In a PubMed search of the literature with the terms rectus , cesarean , and adhesion from 1960-2011, we did not identify any studies on the effects of closure of the rectus muscles at cesarean delivery. In the current investigation, we sought to identify the effects of rectus muscle closure and visceral peritoneum closure on adhesions, independent of other surgical interventions. We hypothesized that rectus muscle closure would have no effect on adhesions and that visceral peritoneum closure would increase adhesions.
Materials and Methods
We previously published a prospective cohort study of women who underwent first repeat cesarean delivery at Stanford Medical Center from 1996-2003 to assess the effect of surgical technique on intraabdominal adhesions. This secondary analysis is a cohort study that used the same data.
As previously described, surgeons were asked to complete a validated adhesion score sheet immediately after performing a first repeat cesarean delivery. On the score sheet surgeons were asked to fill in check boxes describing adhesions as “none,” “filmy,” or “dense” at 5 locations (bowel, fascia to omentum, fascia to uterus, omentum to uterus, and other pelvic structures; Figure ) . Validation studies were conducted previously during 5 cesarean deliveries; different attending-resident pairs were instructed not to discuss adhesions during surgery and to fill out an adhesion score sheet independently after surgery. Each of 15 potential data points was then compared between members of the pair. If both physicians from a pair checked the same box on the data sheet, the response was judged to be similar; any discrepant responses were judged to be different. The interrater reliability of the adhesion score sheet was 0.84. For data analysis, a checked box was assigned a “yes” value for that adhesion category (none, dense, or filmy). A box that was not checked was assigned a “no” value.
Medical records were then reviewed, and data were abstracted from the patients’ first and second cesarean deliveries, labor, and postoperative courses. Abstracted data included patient gravity, parity, age, payor status, ethnicity, wound and postoperative infections, chorioamnionitis, bowel function, previous closure of the rectus muscles, closure of the parietal and visceral peritoneum, suture types, use of irrigation and antibiotics, anesthetic type, operative complications, operative times, and estimated blood loss.
After review of medical records, patients were excluded if they were found at first cesarean delivery to have adhesions, to have undergone other surgeries (such as myomectomy or cystectomy), to have experienced the use of permanent suture, to have had postoperative wound infection or breakdown after first cesarean delivery, to have no available first operative note and course, to have had intervening laparotomy or laparoscopy, to have had steroid dependent disease, and to have insulin-dependent diabetes mellitus.
The primary outcomes that we examined were closure of the rectus muscle and visceral peritoneum and formation of any adhesions (dense and filmy combined) and dense adhesions. Rectus muscle closure was defined by placement of ≥1 sutures into the rectus muscles. The visceral peritoneum was considered closed if it was described as such during the primary cesarean delivery. Whether the rectus muscles and visceral peritoneum were closed was left to the discretion of the surgeons at the time of the primary cesarean delivery. The power analysis was determined in a post-hoc fashion based on our existing sample size. For rectus muscle closure, our study had 92% power to find a 50% difference in adhesions overall, with a 2-tailed alpha. For visceral peritoneum closure, our study had 81% power to detect a 50% difference in any adhesions overall, with a 2-tailed alpha. Secondary outcomes were operative times of the first and second surgery and length of time to bowel function.
All data were entered into STATA software (version 7; StataCorp, College Station, TX) database. Statistical tests that used the χ 2 test of proportions, Fisher exact tests, and the Student t tests of differences of means were considered significant with a probability value of < .05. Multivariable logistic regression analysis was used to control for potential confounding variables. We received approval for this study from the Committee on Human Research at Stanford University Medical Center.
Results
One hundred seventy-three patients were included in the study. There were no differences in operative techniques on the basis of demographic characteristics, except that the rectus muscles were more frequently left open among women who received public assistance ( P = .02; Table 1 ) .
| Variable | Rectus closed (n = 40) | Rectus open (n = 125) a | P value | Visceral peritoneum closed (n = 25) | Visceral peritoneum open (n = 146) b | P value |
|---|---|---|---|---|---|---|
| Age ≥35 y | 10 (31%) | 22 (69%) | .36 | 4 (13%) | 27 (87%) | 1.00 |
| Public assistance | 3 (9%) | 30 (91%) | .02 | 6 (18%) | 28 (82%) | .42 |
| A1 gestational diabetes mellitus | 3 (23%) | 10 (77%) | 1.00 | 1 (8%) | 12 (92%) | .70 |
| Previous infection | 4 (17%) | 20 (83%) | .44 | 5 (22%) | 18 (78%) | .34 |
| Previous labor | 26 (22%) | 94 (78%) | .26 | 19 (16%) | 103 (84%) | .60 |
| Race | .67 | .57 | ||||
| White | 26 (28%) | 68 (72%) | 17 (18%) | 79 (82%) | ||
| Black | 5 (71%) | 2 (29%) | 0 | 8 (100%) | ||
| Hispanic | 17 (85%) | 3 (15%) | 2 (9%) | 20 (91%) | ||
| Asian | 26 (79%) | 7 (21%) | 4 (12%) | 29 (88%) |
a Data regarding rectus muscle closure were unavailable for 8 patients;
b Data regarding visceral peritoneum closure were unavailable for 2 patients.
The rectus muscles were closed in 40 patients. Rectus muscle closure was not associated significantly with the occurrence of increased adhesions overall or at the individual locations that were queried ( Table 2 ). However, rectus muscle closure was associated with significantly fewer adhesions when a composite of the 4 sites was considered (27.5% vs 46%; P = .04) and with more bladder adhesions (28% vs 9%; P = .002). When dense-only adhesions were assessed, rectus muscle closure was associated with fewer adhesions overall (17.5% vs 46%; P = .001) and, by location, fewer dense omentum-to-fascia adhesions (2.5% vs 16%; P = .03).
| Variable | Rectus closed (n = 40) | Rectus open (n = 125) a | P value | Visceral peritoneum closed (n = 25) | Visceral peritoneum open (n = 146) b | P value |
|---|---|---|---|---|---|---|
| Any dense and filmy adhesions | 23 (57.5%) | 85 (66%) | .34 | 17 (65%) | 96 (65%) | 1.0 |
| Fascia to uterus | 5 (12.5%) | 30 (24%) | .13 | 5 (19%) | 31 (21%) | 1.0 |
| Fascia to omentum | 5 (12.5%) | 32 (26%) | .13 | 5 (20%) | 34 (23%) | .80 |
| Omentum to uterus | 4 (10%) | 26 (21%) | .16 | 3 (12%) | 27 (18%) | .58 |
| Bowel | 1 (2.5%) | 1 (1%) | .43 | 0 | 2 (1%) | 1.0 |
| Composite of 4 sites | 11 (27.5%) | 59 (46%) | .04 | 12 (46%) | 60 (41%) | .70 |
| Other | 18 (50%) | 40 (39%) | .25 | 11 (48%) | 51 (42%) | .65 |
| Bladder to fascia | 3 (7.5%) | 0 | .002 | 0 | 3 (2%) | .47 |
| Bladder to uterus | 8 (20%) | 11 (9%) | .05 | 4 (16%) | 15 (10%) | .40 |
| Bladder adhesions | 11 (27.5%) | 11 (9%) | .005 | 4 (16%) | 18 (12%) | .75 |
| Any dense adhesions | 7 (17.5%) | 58 (46%) | .001 | 8 (31%) | 60 (41%) | .39 |
| Dense fascia to uterus | 4 (10%) | 21 (17%) | .45 | 3 (12%) | 23 (16%) | .77 |
| Dense fascia to omentum | 1 (2.5%) | 20 (16%) | .03 | 4 (15%) | 18 (12%) | .75 |
| Dense omentum to uterus | 1 (2.5%) | 13 (10%) | .19 | 1 (4%) | 14 (10%) | .47 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
