We agree with Dr Sholapurkar about the fact that: (1) good surgical principles should remain at the basis of the recommendations regarding uterus closure; and (2) randomized controlled trials are usually designed to answer very specific questions that do not include important variables such as, in our case, the locking of the sutures and the inclusion of the endometrium into the scar. Observational studies suggest that both surgical procedures are important factors that could lead to impaired healing of uterine scar, uterine rupture, and impaired placentation (placenta accreta) in the next pregnancies.

While there is no evidence that locking the second layer is related to impaired healing of the uterine scar, it is, to our knowledge, an unusual procedure that has not been reported in literature. With all our respect, we are skeptical that this could be a common practice, as we do not understand why a surgeon would do this.

To our opinion, beside good surgical principles, there are 3 modifiable factors that have been interrelated and that can be implicated in long-term impaired healing of the uterine scar: a single-layer; the inclusion of endometrium (decidual layer of the uterine wall); and the locking of the first layer. The actual literature suggests that a combination of the 3 (a locked single-closure of the uterus including the full thickness of the myometrium with the endometrium into the scar) is detrimental for future pregnancies’ outcomes when compared to the unlocked double-layer closure aiming at good approximation of the individual layers (endometrium-endometrium; myometrium-myometrium) of the uterine wall. Future randomized controlled trials with adequate power should be designed to evaluate this specific hypothesis using short-term surrogate outcomes, such as scar defect and remaining myometrium evaluated by ultrasound at 6-9 months postcesarean.