Roberge et al present an important and welcome review with a practically useful conclusion that single-layer and locked first-layer closure during cesarean are associated with thinner myometrial thickness. Randomized controlled trials (RCTs) are of paramount importance in guiding/changing opinion, but could be rationally used to make wider practice recommendations rather than strictly limited narrow interpretations. Roberge et al have also highlighted many limitations of their metaanalysis and the studies included in it. Apart from being highly resource intensive (expensive), the RCTs of surgical procedures have particular limitations (compared to, say, pharmacological interventions) because of the wide spectrum of subset variation in surgical technique and skill involved; and are often less than conclusive. Another limitation of RCTs is the propensity and compulsion to study what is conveniently or objectively quantifiable–eg, single-/double-layer closure of uterus–creating a flawed impression that this must be the main/final arbitrator of the strength of uterine scar. In reality, these are only imperfect surrogates for the underlying surgical principles influencing the healing of uterine incision. A 2-layer closure would be ideal/preferable as it allows better approximation of thick myometrial edges. But this could be accomplished judiciously with adequate hemostasis without devascularization, or injudiciously with excessively tight locking sutures with strangulation of tissues. The common imitative practice in the United Kingdom of including wide bites of surrounding smooth uncut myometrium in the second layer with tight locking sutures could lead to ischemic necrosis of intervening myometrium leaving an area of poorly healed myometrium. Thus, the locking of second layer of sutures may be equally or more disadvantageous than locking the first layer, even if this has not been the subject of available studies. On the other hand, operative time saving of 6 minutes (with single-layer closure) is clinically irrelevant or unimportant and should not normally enter decision-making equation.

Thus, the thick myometrial edges are best sutured in 2 layers avoiding locking of both layers of sutures. Evidence-based surgical practice should be founded on knowledge from studies/RCTs but also supplemented by a more comprehensive process of observation, learning, and pragmatic expertise. Sir Austin Bradford Hill whose landmark work (RCTs) on streptomycin in tuberculosis ushered in the era of evidence-based medicine remarked, “Any belief that the controlled trial is the only way would mean not that the pendulum had swung too far, but that it had come right off its hook.” Good surgical principles (gentle tissue handling, minimizing tissue trauma, adequate hemostasis without devascularization, good anatomical reconstruction/approximation) are not easily amenable to evaluation by RCTs. But, their discussion (although unfashionable and somewhat unglamorous) should be included in all reviews/articles on cesarean delivery techniques avoiding the imbalance of sole emphasis on RCTs. This should promote more inclusive and pragmatic decision making and training in surgical techniques.