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Low transverse incision: Lower-Segment Transverse Cesarean Section – PMC

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TRANSVERSE LOW ABDOMINAL INCISION WITH DETACHMENT OF THE RECTI FROM THE PUBIS: FOLLOW-UP STUDY OF EIGHT HUNDRED CASES | JAMA

TRANSVERSE LOW ABDOMINAL INCISION WITH DETACHMENT OF THE RECTI FROM THE PUBIS: FOLLOW-UP STUDY OF EIGHT HUNDRED CASES | JAMA | JAMA Network










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Article

January 1, 1955


L. S. Cherney, M.D.

Author Affiliations

San Francisco

From the Department of Surgery, University of California School of Medicine.


JAMA. 1955;157(1):23-26. doi:10.1001/jama.1955.02950180025006

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Abstract

An abdominal incision is evaluated on the basis of (1) exposure, (2) technical simplicity, (3) a cosmetically pleasing scar, (4) strength of the resulting wound, and (5) relative postoperative comfort. When the transverse low abdominal incision with detachment of the rectus abdominis muscles from the pubis was first described in 1941,1 it was obvious that it satisfied the first three of the above-mentioned criteria, and hope was expressed that it would also satisfy the last two. Enough time has now elapsed to permit a reassessment of the advantages that this incision offers.

An incision is only a means to an end. It is, therefore, obvious that in most cases involving the same surgical procedure the surgeon has a choice of several anatomic approaches. The pioneer surgeons preferred vertical abdominal incisions. The first transverse abdominal incision was made in the lower part of the abdomen and was transverse only through

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Module | ACOG

Transverse Incisions

  • Pfannenstiel
  • Cherney
  • Maylard
  • Küstner

Courtesy of Meeks GR. Clinical anatomy of incisions. In: Mann WJ Jr, Stovall TG, editors. Gynecologic surgery. New York (NY): Churchill Livingstone; 1996: p 136.

Pfannenstiel Incision

The Pfannenstiel incision is a transverse skin incision, two finger-breadths above the symphysis pubis, which is extended in the direction of the anterior superior iliac spine (ASIS) and ends 2–3 cm medial to ASIS on both sides.

Advantages

  • More cosmetic
    • Scar is almost imperceptible
    • Hidden in the pubic hairline
    • Obscured by a skin crease
  • Less painful
  • Less pulmonary depression
  • Excellent postoperative strength

Disadvantages

  • No upper abdominal exposure
  • Possible increased hematoma rate

Separate Fascia

The fascia is separated from rectus muscle superiorly and inferiorly.

Courtesy of Meeks GR. Clinical anatomy of incisions. In: Mann WJ Jr, Stovall TG, editors. Gynecologic surgery. New York (NY): Churchill Livingstone; 1996: p 137.

Entering Peritoneum 

The rectus muscle is separated in the midline and the peritoneum is incised longitudinally.

Courtesy of Meeks GR. Clinical anatomy of incisions. In: Mann WJ Jr, Stovall TG, editors. Gynecologic surgery. New York (NY): Churchill Livingstone; 1996: p 137.

Rectus Muscle Reapproximation

Sutures may be placed in the rectus muscle to close a rectus diastasis. Muscle reapproximation is not routine. 

Courtesy of Meeks GR. Clinical anatomy of incisions. In: Mann WJ Jr, Stovall TG, editors. Gynecologic surgery. New York (NY): Churchill Livingstone; 1996: p 138.

The sheath is closed with continuous suture, and the skin is approximated with a subcuticular suture.

Fascia is closed with continuous delayed-absorbable suture. 

Subcutanous tissue closure if > 2 cm depth.

Skin is approximated with subcuticular, absorbable monofilament suture.

Courtesy of Meeks GR. Clinical anatomy of incisions. In: Mann WJ Jr, Stovall TG, editors. Gynecologic surgery. New York (NY): Churchill Livingstone; 1996: p 138.

Cherney Incision

The Cherney incision is similar to the Pfannenstiel incision, except it involves incising the rectus tendons and is placed slightly lower on the abdomen. 

Advantages

  • Excellent pelvic exposure
  • Dehiscence or hernia is rare
  • Incision of choice to “extend” Pfannenstiel

Disadvantages

  • Limited upper abdominal exposure

Cherney Incision: Opening

Transverse incision of rectus sheath.

  • The lower sheath is separated from rectus muscles
  • The tendons are exposed and incised 1.5 cm above periosteum of symphysis

Cherney Incision: Closing

The tendons are sutured to lower rectus sheath above symphysis

Maylard Incision

Advantages

  • Excellent exposure, including upper abdomen • Dehiscence or hernia is rare

Disadvantages

  • Risk of femoral nerve injury from retractor
  • Risk of subfascial hematoma
  • Poor choice for patients with extensive vascular disease

Maylard Incision: Opening

  • The incision of rectus sheath is extended laterally to iliac spine to expose rectus muscle
  • The rectus muscles are cut transversely
  • Cut edges of muscles are sutured to the rectus sheath
  • Ligated epigastric vessels and exposed transversalis fascia
  • Transversalis fascia and peritoneum are incised transversely
  • Urachus is ligated

Küstner Incision

The Küstner incision is not commonly used.  

Advantages

  • More cosmetic
  • Increased exposure versus Pfannenstiel

Disadvantages

  • Visible erythema in area of fat dissection postoperatively
  • Unable to extend around the umbilicus
  • More painful than transverse fascial incision

Küstner Incision: Opening

  • Transverse incisions to sheath
  • Subcutaneous tissue separated from linea alba

Vertical Incisions

  • Midline
  • Paramedian

Vertical Midline Incision

Advantages

  • Versatile, rapid, low blood loss
  • Excellent exposure

Disadvantages

  • More painful
  • Increased pulmonary depression
  • Less cosmetic

    • The line alba is incised and muscles are separated in the midline
    • The peritoneum is opened at cephalic pole of incision
    • The peritoneal incision is expanded longitudinally, slightly off midline to avoid urachus

    Vertical Paramedian Incision

    Advantages

    • Theoretical decreased risk of herniation
    • Improved lateral exposure

    Disadvantages

    • More likely to encounter the inferior epigastric vessels compared with midline incision
    • Less cosmetic
    • The anterior rectus sheath is opened for the full length of the incision 2-3 cm from the midline
    • The rectus muscle is retracted laterally and the posterior sheath is incised longitudinally under the muscle bed
    • The lateral paramedian incision is placed near the lateral border of the rectus muscle
    • When the muscle is retracted laterally, the inferior deep epigastric artery is seen
    • Finally, the posterior sheath is closed

    incision, sutures, processing, care after surgery

    Caesarean section is always performed in the interests of the mother and fetus when a woman cannot give birth through the natural birth canal.

    Every year there is an increase in the number of operative delivery in obstetric practice. For example, in the 90s, the number of caesarean sections was 10.2%, and by 2005 – 17.9% 1 .

    Currently, the number of primiparous women over 35 has increased, as well as the number of in vitro fertilization (IVF). The widespread use of modern methods of fetal diagnostics: ultrasound, cardiac monitoring (registration of fetal cardiac activity and contractile activity of the uterus), X-ray pelvimetry (to determine the degree of narrowness of the bones of the female pelvis) – make it possible to better detect pregnancy anomalies and establish indications for caesarean section.

    If indications for a caesarean section are determined during pregnancy, then surgery is planned. With a planned caesarean section, the frequency of postoperative complications is 2-3 times less than with an emergency operative caesarean section.

    Vaginal disinfection with a solution of chlorhexidine or povidone-iodine is performed before caesarean section for ruptured membranes and in women in childbirth to reduce the risk of postoperative endometritis (inflammation of the inner layer of the uterus) 2 .

    Povidone iodine

    Characteristics and properties of povidone iodine. What is povidone-iodine used for? Instructions for use of the solution, ointment, suppositories Betadine ® with povidone-iodine.

    More

    Types of incisions for caesarean section

    By localization incisions on the uterus for caesarean section are: in the lower segment partly in the body of the uterus

  • transverse incision in the lower segment with bladder detachment
  • transverse incision in the lower segment without bladder detachment

Cesarean section is classified as a complex surgical intervention 1 . Most often, manipulation is performed in the lower segment of the uterus with a transverse incision due to better healing of the postoperative wound 2 in this area.

There are 3 types e steps through the anterior abdominal wall :

  • Pfannenstiel incision (transverse incision of the skin and subcutaneous tissue along the suprapubic fold)
  • Joel-Cohen incision (transverse incision of the skin and subcutaneous tissue 2. 5-3 cm below the line connecting the anterior superior iliac spines bones)
  • Inferior median incision (incision along the line between the umbilicus and the pubic bone)

Suturing

After the birth of the child and afterbirth, the uterus, peritoneum, abdominal muscles, and skin are sutured.

Tissue suturing is carried out with absorbable synthetic threads from catgut, vicryl, monocryl and others. Catgut threads dissolve in about 100 days, monocrylic threads in 90-120 days, Vicryl threads will dissolve by 42 days.

Immediately after a caesarean section, cold is applied to the lower abdomen for two hours to reduce bleeding. According to the indications, a woman is prescribed drugs that improve blood flow, painkillers, anticoagulants (prevent the formation of blood clots), oxytocin (improves the contractile function of the uterus), antibiotics. Some time after a caesarean section, unpleasant pain in the lower abdomen will persist. On the 5th day, ultrasound is prescribed to determine the condition of the wound. Staples or sutures from the anterior abdominal wall are removed on the 6-7th day, and on the 8th day the woman is discharged under the supervision of a antenatal clinic doctor at the place of residence.

How to treat healing wounds, see a short video with surgeon Fedor Yanovich Kraskovsky

Algorithm for treating sutures after caesarean section

6 hours after delivery by caesarean section, in order to minimize the risk of wound infection, the dressing is removed 3 .

Stitches after caesarean section are treated daily 1 .
Processing may include the following steps:

Washing

If washing of the suture area is required, disinfecting solutions can be used: povidone-iodine, potassium permanganate solution, chlorhexidine solution.

Disinfection

At this stage, disinfectants and drying agents are applied: based on iodine, alcohol-containing solutions of brilliant green, fucorcin and others.

Let’s consider the most popular means for decontamination of postoperative sutures.

Applying a dressing

After each treatment of the suture, it is recommended to apply a sterile dressing, which will protect the injured area from external influences.

Povidone-iodine solution (Betadine®)

Povidone-iodine solution ( Betadine ® ) is a modern broad-spectrum antiseptic. It is used in various areas of modern medicine due to its activity against many microorganisms and a favorable benefit/risk ratio.

Solution Betadine ® is active against bacteria, viruses, fungal pathogens and protozoa 4 . In this disinfectant, the iodine molecule is attached to the carrier – povidone, which made it possible to exclude alcohol from the composition and thereby ensure comfortable use of the drug, without burning sensations, even when applied to fresh wounds and sutures. When treating wounds, the components of the solution Betadine ® are practically not absorbed into the body 8 , which ensures a high safety profile.

Wash with solution Betadine ® diluted 1:10, and used undiluted for joint lubrication. It is important to note separately that the solution Betadine ® allows for comfortable use without burning. Yellow-brown staining is easily washed off the skin with plain water.

Instruction

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Based on povidone-iodine, Betadine® ointment is produced, which has a dual effect:

  • povidone-iodine disinfects
  • macrogol, which is part of the ointment, helps to “pull out” pus when it appears as a result of wound complications

Ointment Betadine ® can be used under dressings in a thin layer without rubbing into the incision twice a day.

In the treatment of infected wounds under wipes soaked in solution or Betadine Ointment ® , during the first 5-7 days the area of ​​edema noticeably decreased and the amount of purulent discharge decreased, there was also a decrease in pain 5 .

Instruction

Where to buy Betadine® ointment?

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Solutions of hydrogen peroxide 3% and potassium permanganate

Solution of hydrogen peroxide 3% and solution of potassium permanganate (manganese) belong to the group of oxidizers. Upon contact with an unhealed suture, the active substance decomposes with the release of active oxygen, which causes a disinfecting effect. They are especially effective for suppressing anaerobic infections (clostridia, streptococci, shigella, yersinia, fusobacteria and others), for these microorganisms oxygen is detrimental, since an oxygen-free environment is needed for the normal functioning of these organisms. However, treating a wound with hydrogen peroxide does not guarantee against contracting a wound infection 6 , must not be used under occlusive (airtight) dressings 4 .

Use of hydrogen peroxide may cause allergic reactions 7 .

To prepare a solution of potassium permanganate, several crystals of potassium permanganate are placed in a container with warm water, only freshly prepared agent 8 is used. Potassium permanganate is subject to special control and accounting in the Russian Federation, therefore, the sale of this product is limited. Moreover, an undissolved crystal of potassium permanganate can cause skin burns.

Chlorhexidine solution

Chlorhexidine solution 9 belongs to the group of antiseptic and disinfectants, active against viruses, bacteria, fungal infections. Use 2-3 times a day with a mandatory exposure of 1-3 minutes. Simultaneous use with iodine is not recommended. It is used with caution during breastfeeding.

In addition, today there is a decrease in the effectiveness of a number of antiseptic preparations having a chlorine-containing molecule 11 .

Care of a maturing scar

After the sutures have dissolved, the wound has healed, scar tissue begins to form. At this stage, to prevent the development of rough scars, it is recommended to use creams and gels based on silicone, hyaluronidase, natural plant components (for example, combined preparations based on onion extract, sodium heparin and allantoin).

Possible complications from incorrect or no handling

On the first day after caesarean section, the temperature may rise to 38°C and the number of leukocytes in the blood may increase 3 .

In the modern medical community, the strategy of “Accelerated recovery after surgery” is actively practiced – the woman in labor is prescribed pain relief, prevention of postoperative blood clots, and early physical activity is recommended.

4-6 hours after the operation, they are allowed to sit up in bed, put their feet on the floor, then walk. This reduces the risk of thrombosis, congestion in the lungs, the formation of adhesions in the abdominal cavity 3 .

However, a woman may experience the following problems with suture healing: Therefore, after the operation, it is not recommended to lift weights.

Formation of a hypertrophic or keloid scar

  • If the scar tissue begins to protrude above the skin surface, then most likely a hypertrophic or keloid scar has formed 10 .
  • Keloid scars form not earlier than 3 months after suture, may extend beyond the suture, often accompanied by pain 10 . Grow indefinitely.
  • Hypertrophic scars begin to form in the first month after skin injury, do not extend beyond the suture and grow over the next 6 months. Hypertrophic scars can spontaneously decrease in size.

Infection/suppuration of the wound

Signs of infection are: increasing pain in the suture area, swelling, redness of the skin, the suture may become hot to the touch, pus may be released when pressed. Infection of the wound slows down the healing process and the inflammatory process can spread to the abdominal muscles and abdominal cavity, which can be life threatening.

Therefore, it is important to keep the area of ​​the healing suture clean, treat it with antiseptics in a timely manner, do not touch it with unwashed hands, and wear clean underwear.

As the postoperative wound heals, itching may appear in the area of ​​scar formation. This is the norm when healing any wounds, the main thing is not to accidentally injure the suture and not to remove the suture material on your own.

Frequently Asked Questions

When can I bathe after a caesarean section?

The bandage from the suture after caesarean section is removed after 6 hours, after which it is possible to take a shower daily 3 .

How do you know if a caesarean section is healing properly?

Over time, swelling and soreness should decrease, as well as the amount of sanious discharge in the suture area. There should be no purulent discharge. The skin around the suture becomes normal in color, although the scar itself may remain red for several months.

How can ugly scars after caesarean section be treated?

For the treatment of keloid and hypertrophic scars, doctors prescribe 10 :

  • course intralesional administration of anti-inflammatory hormonal drugs
  • exposure to liquid nitrogen once every 3-4 weeks, at least 3 procedures per course
  • laser exposure (pulsing laser on dyes or based on carbon dioxide)
  • surgical excision

To prevent the formation of scars after the healing of the suture, preparations based on hyaluronidase, plant extracts, and silicone are prescribed.

How long can you not lift weights?

To reduce the load on the abdominal muscles and improve their healing, physical activity is limited to 1.5 months.

Moshkova Elena Mikhailovna

Dermatovenereologist, Head of the CDO for the provision of paid services, St. Petersburg State Budgetary Institution of Healthcare “City Dermatovenerological Dispensary”, St. Petersburg

Read on the topic

Ointment based on iodine 900 20

Iodine-based ointment : mechanism of action, scope. Ointment Betadine® based on povidone-iodine for the treatment of various skin diseases.

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Povidone iodine

Characteristics and properties of povidone iodine. What is povidone-iodine used for? Instructions for use of the solution, ointment, suppositories Betadine ® with povidone-iodine.

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Infected wounds

Not all abrasions and cuts heal quickly and without complications. How to treat infected wounds?

Read more

References

  1. “National guide to obstetrics”. Edited by E.K. Ailamazyan, V.I. Kulakova, V.E. Radzinsky, G.M. Savelyeva, 2015.
  2. Clinical guidelines. Singleton birth, delivery by caesarean section, 2021.
  3. Clinical guidelines. Singleton birth, delivery by caesarean section, 2020.
  4. Instructions for medical use Betadine ® (solution, ointment), P N015282/03, P N015282/02.
  5. breast cancer No. 29 dated 12/23/2010 “The use of the drug Betadine ® in the treatment of infected wounds.” Authors: V.V. Mikhalsky, A.E. Bogdanov, S.V. Zhilina, A.I. Prvidentsev, A.I. Anikin, A.A. Ulyanina.
  6. Hydrogen peroxide, 3% solution, radar.
  7. Rational pharmacotherapy of skin diseases and sexually transmitted infections. Edited by A.A. Kubanova, 2007.
  8. Potassium permanganate, powder. radar.
  9. Chlorhexidine solution, radar.
  10. “Federal Clinical Guidelines for the Management of Patients with Keloid and Hypertrophic Scars”, 2015
  11. “Prevalence of microbial resistance to chlorhexidine from a systematic review and analysis of regional resistance monitoring.” Authors: Kvashnina D.V., Kovalishena O.V. Fundamental and clinical medicine. 2018;3(1):63-71.

Modern technique of caesarean section in evidence-based medicine Obstetrics and Gynecology academician V.I. Kulakov of the Ministry of Health of Russia, Moscow, Russia

This lecture presents the currently available data of evidence-based medicine for each of the stages of the caesarean section. It has been shown that Joel-Kohen laparotomy, a transverse incision in the lower segment of the uterus with an increase in the incision with the surgeon’s fingers, placenta extraction by traction behind the umbilical cord, suturing the uterine wall in one or two layers with a continuous suture, leaving the parietal and visceral peritoneum unsutured , routine suturing of subcutaneous tissue with a thickness of 2 cm or more without routine drainage of the subcutaneous and subaponeurotic space.

cesarean section

laparotomy

uterine incision and fetal extraction

restoration of the integrity of the uterus and anterior abdominal wall

surgical technique

Caesarean section (CS) is one of the most ancient operations with a long history of development . In the modern world, CS is the most frequent abdominal operation and the trend of its frequency growth continues. For 2007–2008 in developed countries, the highest frequency of CS in Mexico (43.9%), Italy (39.8%), South Korea (35.3%) [1]. In the United States during this period, abdominal delivery was performed in 31.8% of cases. Currently, every fifth pregnant woman is delivered by CS in Russia.

With such a high frequency of CS, this operation should be accompanied by a proven, practically routine technique. At the same time, the data of modern literature indicate a significant variety of approaches to the implementation of individual stages of this operation, not only in different countries, but even in neighboring institutions and, moreover, often within the walls of one maternity hospital.

This diversity indicates the incompleteness of ideas about the advantages and disadvantages of certain methods. To date, there have been certain approaches to the choice of CS technique, but how correct they are can only be assessed from the standpoint of evidence.

The main technical stages of delivery by CS are laparotomy, uterine incision and fetal extraction, restoration of the integrity of the uterus and anterior abdominal wall.

Laparotomy

The following types of laparotomies can be used during CS surgery: lower median, transverse suprapubic according to Pfannenstiel, Joel-Kohen, as well as transmuscular according to Czerny or Maylard. Each laparotomy has its own advantages and disadvantages. When choosing the type of laparotomy, one should rely on the following characteristics: the adequacy of access to the area of ​​surgical intervention, the absence of obstacles to the free cure of the fetus, the possibility of revision of adjacent organs.

Inferomedian incision is a classic laparotomy method that quickly provides good access to the organs of the lower half of the abdominal cavity and small pelvis, as well as the possibility of revision of the organs of the upper half of the abdomen. Compared to the suprapubic Pfannenstiel ventricular surgery, the lower midline laparotomy is a faster method of ventricular surgery. According to S. Timonen et al. (1970) [2], with laparotomy according to Pfannenstiel in 72%, it takes more than 4 minutes to extract the fetus, while with the lower median incision in 56%, it is born earlier. Difficult extraction of the fetus, the duration of which exceeds 8 minutes, occurs in 17% with a suprapubic incision, while with a longitudinal laparotomy it is twice as rare (8%). Therefore, in emergency situations, when an urgent extraction of the fetus is necessary, a lower median incision is usually recommended. At the same time, N. Youssef et al. (1989) [3] on a large number of observations (7216 CS performed over 5 years in 102 perinatal centers, public and private institutions in France) showed that, despite the longer time from the start of the operation to the extraction of the fetus with a Pfannenstiel incision, the condition of the newborn regardless of the type of laparotomy.

Thus, the advantages of the inferomedian laparotomy are the short time from skin incision to the incision on the uterus, wide access and ease of retrieval of the fetus. However, in the postoperative period, there is severe pain, a higher risk of postoperative hernia formation, worse cosmetic than with transverse suprapubic laparotomy. The Pfannenstiel incision prolongs the operation time, is often accompanied by the formation of hematomas, which makes it difficult to remove the fetus.

Currently, in developed countries, a transverse suprapubic incision is more often used, including in obese women (the risk of complications is 12 times lower). The proportion of lower median laparotomy is about 1%. In addition, with the introduction of Joel-Kohen transverse laparotomy into obstetric practice, such a criterion as the speed of entry into the abdominal cavity has lost its relevance [4]. During laparotomy according to Joel-Kohen, a superficial transverse rectilinear incision of the skin of the abdomen is made 2.5–3 cm below the line connecting the anterior superior iliac spines. Along the midline with a scalpel, the incision is deepened until the aponeurosis is exposed, which is incised on the sides of the white line. Then the aponeurosis is dissected to the sides under the subcutaneous fat with slightly open ends of straight scissors. The rectus abdominis muscles are released in a blunt way, opening access to the parietal peritoneum. Muscles and subcutaneous fat are simultaneously bred by bilateral traction. The peritoneum is opened in a blunt way, stretching the fingers in the transverse direction.

This type of laparotomy reduces the time to delivery of the fetus by an average of 3-4 minutes. In addition, the overall duration of the operation, the volume of blood loss, the severity of pain syndrome and the frequency of fever in the postoperative period are reduced [5, 6].

Incision on the uterus

The classic (corporal) incision does not require the formation of a vesicouterine fold flap, provides a wide operating window, is performed quickly and allows for easy removal of the fetus. However, at present, a longitudinal incision of the uterus is rarely used due to the intersection of the pronounced muscular layer of the uterine body and a large number of large vessels, which is accompanied by significant bleeding, and in repeated pregnancies, there is a high frequency of uterine rupture along the scar [4, 7]. The peritoneum covering the body of the uterus is rather tightly attached to the myometrium, so peritonization of the wound is difficult.

The wall of the uterus in the lower segment is thinner, contains fewer muscle fibers and blood vessels, which causes less trauma and reduces blood loss, promotes better wound healing. As a result, the risk of uterine rupture in subsequent pregnancies is reduced. The mobility of the peritoneal cover in the area of ​​the vesicouterine fold creates favorable conditions for subsequent peritonization of the uterine wound.

Regardless of the direction of the incision, the initial stage of the CS operation in the lower segment is its release from the peritoneal cover with the formation of a flap of the vesicouterine fold, which is subsequently used to peritonize the uterine wound. The peritoneum of the vesicouterine fold is grasped with tweezers 2-3 cm above the point of attachment to the bladder and cut with scissors in the transverse direction, almost close to the round ligaments of the uterus. The corners of the incision are directed slightly upward, so that the incision has a crescent shape, with a convexity downwards.

The advantage of a vertical incision in the lower uterine segment is the possibility of extending it upwards towards the body if the original dimensions are not adequate for free delivery of the fetus. At the same time, for a vertical incision in the lower uterine segment, it is necessary to expose the lower segment from the peritoneal cover and bladder down over a large extent. If delivery is difficult, the incision may extend into the vaginal wall and/or bladder. Involvement in a vertical incision of a contracting part of the myometrium of the body of the uterus in a subsequent pregnancy creates a higher risk of rupture than after a transverse incision in the lower segment.

It is possible to use an oblique incision in the lower uterine segment, which provides sufficient space for easy removal of the fetus with a “narrow”, unformed lower segment, as occurs in preterm pregnancy. At the same time, the probability and depth of the spread of the incision into the myometrium of the uterine body is less than with a vertical incision. At the same time, this incision option also has a higher risk of bladder injury, due to the need to mobilize it, and in subsequent pregnancy, careful monitoring is necessary due to an increased risk of uterine rupture.

The transverse section in the lower uterine segment is devoid of most of the above disadvantages. At the same time, it should be borne in mind that the continuation of the transverse incision into the gap (with difficult extraction of the fetus, its large size, etc.) can lead to damage to the vascular bundles of the uterus passing along its lateral surface, which is accompanied by massive blood loss. In addition, there may be difficulties for the birth of the fetus with a high location of the presenting head. Therefore, when determining the level of the transverse incision in the lower segment of the uterus with the head presentation of the fetus, one should first of all strive to ensure that the incision, if possible, falls on the projection area of ​​the largest diameter of the head.

In general, low trauma, less blood loss, favorable conditions for peritonization, low incidence of complications in the postoperative period and scar rupture in subsequent pregnancies determine the current situation, in which a transverse incision in the lower uterine segment is used in most women who are indicated for abdominal delivery. Other variants of cuts (along the back wall, in the bottom) are used extremely rarely or have only historical significance.

For a transverse incision of the uterus, the incision is initially made in the middle of the lower segment by 2-3 cm. From this point on, one of two options for continuing the incision is possible. In the first variant (according to Derfler), the incision is enlarged to 10–12 cm in lateral directions with scissors under the control of the surgeon’s index and middle fingers inserted into the wound [8]. The incision at the corners should be slightly raised upward (semilunar), which corresponds to the course of muscle fibers and allows you to increase access to the uterus for easy delivery of the fetal head without damaging the vascular bundles.

L.A. Gusakov (1939) CS is performed with an incision at the level of the vesicouterine fold without separation and displacement of the bladder. After a transverse incision of the lower segment of the uterus by 2-3 cm, the expansion of her wound is achieved by blunt dilution with the help of index fingers. The technique of blunt tissue dilution is combined with a decrease in blood loss by an average of 43 ml [9].

To reduce the risk of trauma to the fetus and reduce blood loss, it is recommended to make a careful incision in the lower uterine segment in layers without damaging the membranes, which are opened after its complete completion [10]. When using a layered technique, the pressure of the fetal bladder on the lower segment and the edges of the incision helps to reduce blood loss.

Birth of the fetus and afterbirth

In cephalic presentation, the surgeon passes four fingers between the anterior wall of the uterus and the fetal head, placing them below its level. Then the head is somewhat taken up and, bending the fingers, contribute to its eruption into the wound. At this moment, the assistant helps the birth of the head with dosed pressure on the fundus of the uterus through the anterior abdominal wall. After the birth of the head, it is carefully grasped with both hands, placing the palms biparietally, and with the help of gentle traction, the anterior and posterior shoulders of the fetus are alternately released. After removing the shoulder girdle, index fingers are inserted into the armpits and, carefully clasping the body at the level of the chest, contribute to the birth of the fetus. In case of difficult birth of the fetus, one should avoid swinging movements, do not use excessive efforts, but calmly assess the situation, determine the cause of the difficulty, after the elimination of which the birth will take place without difficulty (insufficient degree of incision of the aponeurosis, passage of the shoulders of the fetus perpendicular to the length of the incision, etc. ).

After the fetus is delivered and the umbilical cord is cut, the fetus is handed over to the midwife or pediatrician, and the operation continues with the birth of the placenta. To prevent bleeding, an infusion of oxytocin 10 U is started intravenously in saline solution (500 ml). It is preferable to extract the placenta by traction by the umbilical cord, which is accompanied by less blood loss, a decrease in the fall in hematocrit in the postoperative period, the incidence of endometritis and bed-days compared with those after separation and extraction by hand (Table 1) [11].

Table 1. Comparison of scores after removal of placenta by umbilical cord traction or separation and removal by hand .

Restoration of the integrity of the uterine wall

Before considering the methods and restoration of the integrity of the walls and uterus, it is advisable to discuss the issue of its removal from the abdominal cavity (exteriorization). The available data were analyzed in a systematic review in 2004 [12].

Supporters of uterine suture in the abdominal cavity point to a higher incidence of nausea and vomiting during surgery, pain during hysterectomy, while proponents of removal point to a decrease in the amount of blood loss and the duration of the operation. But the greatest controversy was the risk of an increased likelihood of infectious complications. The Cochrane study found no difference in complication rates, except for a reduction in postoperative fever with uterine exteriorization (Table 2).

Table 2. Restoration of the integrity of the uterus during its exteriorization or in the abdominal cavity.

Thus, at present there is no evidence that the removal or, on the contrary, leaving the uterus in the abdominal cavity during its suturing is more advantageous. The experience of Russian obstetric institutions over the past 15 years shows that the removal of the uterus for suturing it is a safe manipulation that creates favorable conditions for restoring the integrity of the wall.

Scientific development of the suture on the uterus began about 130 years ago (since 1882), when the German doctor Max Senger recommended that the peritoneum be separated from the myometrium first, then, making an incision in the uterus, excise its part in the form of a wedge up to 2 cm wide, the top of which is directed towards the uterine cavity. This type of incision was developed for the subsequent layer-by-layer two-story peritonizing suturing of the uterine wound, thus achieving the most favorable cooptation of its edges.

The principles proposed more than 100 years ago are used in more modern designs of the uterine suture. At present, the evolution of the technique for restoring the integrity of the uterine wall has gone through a number of stages. Separate, continuous, one-, two-, three-layer sutures were used, with and without endometrial puncture. Special complex variants were also proposed, some of which are shown in Fig. 1 and 2. The advantages of separate sutures are better comparison with torn, non-matching wound edges, while with a continuous suture, the technique is simpler, the duration of the operation is reduced, and the amount of suture material is reduced.

Comparison of single-layer and double-layer techniques for suturing the uterine wound shows that the first one is combined with less blood loss, the duration of the operation, and the severity of pain in the postoperative period also decreases (Table 3) [9].

Table 3. Comparison of single-layer and double-layer techniques for suturing a uterine wound.

In this regard, since the late 1990s and early 2000s. The continuous single-layer uterine suture technique has been recommended for closure of the uterine wound in CS in most studies and has been widely adopted throughout the world. An important condition for good healing of the uterine wall and maintaining the necessary strength of the scar is the mandatory restoration of the integrity of the uterine fascia, which is located immediately under the serous membrane.

However, some experts believe that the effectiveness and safety of a single-layer suture remains insufficiently elucidated. Thus, the British Royal College of Obstetricians and Gynecologists recommends using a two-layer technique for restoring the integrity of the uterine wall.

Caution with single layer uterine suture technique based on E. Bujold et al. (2002) [15]. In this study, on a large number of observations (about 2000), it was shown that with a single-layer technique for restoring the integrity of the uterine wall, the probability of uterine rupture during a subsequent pregnancy is 3.95 times higher than double layer.

One of the most discussed issues in modern obstetrics for a long time was the need to suture the peritoneal integument during CS. In 2003, the results of a systematic Cochrane review were obtained, which showed that leaving an unsutured visceral and/or parietal peritoneum does not lead to the development of complications, but is accompanied by a decrease in the duration of surgery, the need for analgesics, morbidity in the postoperative period, postoperative bed-day (Table . 4) [16].

Table 4. Comparison of outcomes for unsutured and sutured parietal and visceral peritoneum during caesarean section.

Thus, the immediate results of non-suturing of the peritoneal integument showed the feasibility of using this approach, although there is still insufficient data on long-term outcomes. Meanwhile, most modern guidelines, including those of the British Royal College of Obstetricians and Gynecologists, have already excluded the suturing of the peritoneal integument during CS from the mandatory stages of this operation.

Restoration of the integrity of the abdominal wall

Suturing of the aponeurosis and rectus abdominis muscles has not been studied in separate studies. Meanwhile, the opinion of experts indicates that the muscles restore anatomical localization in a natural way and their stitching can lead to pain and adhesions. The aponeurosis is recommended to be sutured with a continuous suture without blockage with a slowly absorbable suture material.

To suture or not to suture the subcutaneous tissue? To answer this question, one should refer to the results of a systematic review in 2004 [17]. The results of this review are presented in Table. 5.

Table 5. Comparison of sutured and non-sutured subcutaneous fat during caesarean section.

Thus, suturing the subcutaneous tissue helps to reduce the overall incidence of complications from the wound of the abdominal wall, especially the number of hematomas and seromas. It does not matter which needles were used (RR=2.73, 0.54–13.76). The criterion that determines the need for suturing the subcutaneous tissue is its thickness of 2 cm or more. At the same time, the restoration of the integrity of the abdominal wall is combined with a significant decrease in wound dehiscence (RR=0.66, 95% CI 0.48–0.91) and seroma formation (RR=0.42, 95% CI 0.24–0.75).

Routine drainage of subcutaneous tissue in obese women (body mass index over 30 kg/m2) deserves discussion. As the results presented in Table. 6, routine drainage increases the duration of the operation and presents additional inconvenience to patients, but has no advantages [18].

Table 6. Comparison of outcomes with subcutaneous tissue suturing without and with routine drainage in obese patients.

Currently, there are few works devoted to comparing different options for skin suturing during CS surgery, and the results of studies are often contradictory, much also depends on the woman’s body [19].

When restoring the integrity of the skin, separate sutures are used, a continuous subcutaneous removable or removable suture, staples are applied, and cyanoacrylate glue is also used. At one time, many hopes were associated with the use of staples, but they are inferior to absorbable suture material (Table 7). Brackets reduce the time spent on the seam, but they have a worse cosmetic effect. The effect is also worse when using a non-absorbable suture material (if it is not removed). In general, a cosmetic suture is more convenient for women, although it takes more time to close the skin wound.

Table 7. Comparison of staple and subcutaneous suture for skin resurfacing.

Thus, the Joel-Cohen laparotomy, transverse incision in the lower uterine segment with an increase in the incision with the surgeon’s fingers, removal of the placenta by traction behind the umbilical cord, suturing the uterine wall in one or two layers with a continuous suture, leaving an unsutured parietal and visceral peritoneum, routine suturing of subcutaneous tissue with a thickness of 2 cm or more without routine drainage of the subcutaneous and subaponeurotic space.

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