Dr Sholapurkar raises the important question of whether suturing of the peritoneum during cesarean deliveries now should be recommended invariably based on the existing evidence. We thank him for this comment because we are also debating this issue in our local protocols now that short-term safety is proved by well-designed randomized controlled trials and because restoration of peritoneal continuity appears to have lower adhesion rates. There is also no doubt with regards to the challenges and morbidity associated with dense adhesions of the uterus to the anterior abdominal wall. We are not sure, however, that we can agree with Dr Sholapurkar’s statement that “…peritoneal closure should not have been abandoned in the first place…” This practice was abandoned because of concerns raised by different authors; reassuring data are emerging only presently. Studies that investigate the morbidity that is associated with uterine adhesions usually are unable to ascertain whether the causative factor, in fact, is related to a particular surgical technique. Randomized controlled trials and metaanalyses that are designed specifically to address the question of peritoneal closure efficacy in reducing uterine adhesions are simply conflicting, and no clear conclusion can be drawn at this point.

Although evidence-based medicine has its shortcomings, it is the only tool we have. No clinical practice should be changed without solid and well-designed scientific grounds that prove both safety and efficacy.