Blumenfeld Y, Caughey A, El-Sayed Y, Daniels K, Lyell D.

Single-
versus double-layer hysterotomy closure at primary caesarean
delivery and bladder adhesions. BJOG 2010;117:690694.
SINGLE VERSUS DOUBLE-LAYER HYSTEROTOMY CLOSURE
AT PRIMARY CAESAREAN DELIVERY AND BLADDER
ADHESIONS
Introduction
The frequency of primary and repeat caesarean
deliveries in USA and worldwide associated
with an increased risk of placenta accreta,
hysterectomy, cystotomy, bowel injury, ureteral
injury, ileus, intensive care unit admission and
blood transfusion
In addition increase the risk of postoperative
pelvic and abdominal adhesions can increase
the time required to deliver the newborn, operative
blood loss and the occurrence of bladder injury
Introduction
To reduce maternal and neonatal morbidity studies
have addressed including manual placental removal,
uterine exteriorisation, subcutaneous tissue
reapproximation and single- versus double-layer
uterine incision closure to minimize infectious
morbidity and uterine rupture.
In this study, is analysed retrospectively data from
previous study to determine whether single- versus
double-layer hysterotomy closure at primary caesarean
delivery is associated with subsequent adhesion
formation
Methods
This study analysed a data set from a previously
reported prospective cohort study to examine the
association between caesarean hysterotomy closure
and pelvic adhesions.
The original study enrolled prospectively at Stanford
University Medical Center from 1996 to 2003.
The data set was generated when all surgeons, were
asked to complete an adhesion score sheet detailing
the location and severity of adhesions
The surgeons were unaware of the purpose of the
adhesion score sheet.
Methods
Women were excluded from the original study if:
on record review, they were found to have had adhesions,
the use of a permanent suture
additional operations at first caesarean delivery
postoperative wound infection or breakdown occurred following first surgery
the first operative note was unavailable
intervening abdominal surgery occurred
women with insulin dependent diabetes mellitus or steroid-dependent disease
The original data set included detailed information from the first and second
caesarean deliveries, labour and postoperative courses.
All surgeries were performed by a resident who was supervised directly by an
attending physician.
The method of surgical closure and suture material used were dependent on the
preference of the attending physician.
Methods
For the study, patient records from the primary
caesarean delivery were reviewed again to identify
whether single- or double-layer hysterotomy closure
had been performed.
All participants were included in, if the hysterotomy
closure could be determined from the primary
caesarean operative note.
Only women who underwent a low transverse uterine
incision were included in this study.
The primary outcome measure was the prevalence rate
of pelvic and abdominal adhesions as reported on the
adhesion score sheet at the time of repeat caesarean
delivery.
Methods
All data were entered into a Stata 7.0 (StataCorp,
College Station, TX, USA) database.
Univariable statistical tests using Fishers exact tests
were considered to be significant with P < 0.05.
Multivariable logistic regression analysis was used to
control for potential confounders, including surgical
technique (closure of the parietal peritoneum, visceral
peritoneum and rectus muscles), previous labour,
prior peripartum infection, labour and age over 35
years.
The study was approved by the Committee on Human
Research at Stanford University Medical Center.
Women were excluded from the original study if:
on record review, they were found to have had adhesions,
the use of a permanent suture
additional operations at first caesarean delivery
postoperative wound infection or breakdown occurred following first surgery
the first operative note was unavailable
intervening abdominal surgery occurred
women with insulin dependent diabetes mellitus or steroid-dependent disease
FLOW CHART
Previous reported prospective cohort study in order to examine the association between
caesarean hysterotomy closure (single versus double layer) and pelvic adhesions
Surgeon fills an adhesion score sheet detailing the location and severity of adhesions
All data were entered into a Stata 7.0 (StataCorp, College Station, TX, USA) database.
Univariable statistical tests using Fishers exact tests were considered to be significant with
P < 0.05.
Multivariable logistic regression analysis was used to control for potential confounders
127 women were included
Single-layer hysterotomy closure 56 women (44%) Double-layer hysterotomy closure 71 (56%)
Results
127 women were included in the study (Table 1).
Single-layer hysterotomy closure at the time of
primary caesarean section was performed in 56
women (44%)
Double-layer closure was performed in 71 (56%).
There were no demographic or obstetric
differences between the two groups
The mean maternal age was 29 years.
Results
The primary caesarean hysterotomy was closed
with chromic suture in 78% of women, and
synthetic delayed absorbable suture (including
dexon and vicryl) in 22%.
Primary single-layer hysterotomy closure was not
associated with fascial to uterine adhesions (29%
versus 20%, P = 0.29), omental to uterine
adhesions (20% versus 14%, P = 0.47) or bowel
adhesions (2% versus 0%, P = 0.44).
Results
Single-layer hysterotomy closure was associated
significantly with bladder adhesions (24% versus 7%, P
= 0.01; Table 2).
The presence of bladder adhesions was determined
when obstetricians specified bladder in the other
category of the adhesion score sheet.
A multivariable logistic regression analysis of bladder
adhesions was then performed (Table 3).
The odds of bladder adhesions were seven times
greater with single-layer hysterotomy closure [odds
ratio (OR), 6.96; 95% confidence interval (CI), 1.72
28.1] after adjusting for potential confounding factors
Results
Results
Results
Discussion
Single-layer hysterotomy closure at the time of
primary caesarean delivery was associated with more
frequent bladder adhesions at the time of repeat
caesarean when compared with double-layer closure;
no differences were documented in adhesions at the
other surgical sites examined.
When controlling for other surgical techniques,
bladder adhesions were reported 7 times more
frequently when single-layer hysterotomy closure was
performed.
Double-layer hysterotomy closure generally reduces
exposed raw surgical surfaces
Discussion
Adhesions are the consequence of tissue trauma
resulting from sharp, mechanical or thermal
injury, infection, ischaemia or foreign bodies.
Such trauma triggers a cascade of events that
begins with the disruption of stromal cells which
release vasoactive substances that increase
vascular permeability.
Fibrin deposits then form, containing exudates of
cells, leucocytes and macrophages. Healing occurs
by a combination of fibrosis and mesothelial
regeneration.
Discussion
Adhesions have been associated with increased
operative difficulty and patient injury.
Among bladder injury cases, adhesions were
present in 60%, compared with only 10% in
controls.
Double-layer uterine closure has the potential to
reduce bladder injury at the time of repeat
caesarean delivery.
Discussion
Single- versus double-layer hysterotomy closure has
been studied in the obstetrics literature primarily in
relation to the uterine rupture.
Durnwald and Mercer, in 2003, performed a
retrospective study of uterine rupture In their
cohort, there were no differences (37% versus 32.7%, P
= 0.39) in subsequent adhesions between the two
groups
It is possible that their findings were caused by
confounding variables, such as whether the parietal or
visceral peritoneum was closed.
Discussion
This study was retrospective and had several
limitations the datasheet did not contain a
specific category for bladder adhesions.
This study analysed bladder as a category after
finding that it was mentioned frequently in the
other category this may lead to reporting bias,
and we would encourage future studies of
adhesion that use an adhesion score sheet to
include the category bladder.
Discussion
Details of the number of sutures placed in
hysterotomy may have been omitted in operative
dictations.
The sample was small: 46 of 127 women had
bladder adhesions; the confidence interval for the
prevalence rate of bladder adhesions was quite
large.
Discussion
This study included many surgeons at various levels of
training.
All residents were supervised by an attending
physician, but there may have been significant
variability in operative technique.
Moreover, the physicians completing the adhesion
score sheet were not blind to the hysterotomy closure.
Although we controlled for differences in operative
technique in our multivariable logistic regression
analysis, there may be residual confounding because
of this heterogeneity that could not be captured.
Discussion
Finally, the best way to conduct such a study would be
a randomised controlled trial.
However, when searched PubMed from 1950 to 2009
using the keywords adhesions and hysterotomy,
there is found no other studies that methodically
addressed this question.
This study intention is to use the information from the
current study to inform the study design of such a
prospective, multicentre, randomised controlled trial
of this and other caesarean surgical technique
questions.
Discussion
Despite limitations, this study was strengthened by the fact
that this did not rely solely on surgical dictations to assess
adhesions.
The standardised adhesion score sheet allowed to query the
effect of hysterotomy closure type by both the presence and
location of adhesions.
This study included only women undergoing a first repeat
caesarean delivery and all surgeries were performed at a
single tertiary care centre.
This study found that only bladder adhesions seemed to be
affected by single- versus double-layer closure this
association should be considered when closing the
hysterotomy during a primary caesarean delivery, and
requires further examination in large prospective trials.
CRITICAL APRAISAL
What is the research question and/hypothesis ?
Research question:
What is the association between single-layer and
double-layer hysterotomy closure at primary
caesarean delivery and subsequent adhesion
formation
What is the study type?
Retrospective Cross-sectional
What is the reference population?
Previous study enrolled prospectively, women
undergoing first repeat caesarean delivery at
Stanford University Medical Center from 1996 to
2003
CRITICAL APRAISAL
What are the sampling frame and sampling methode?
Sampling Frame
Data from previous study who had primary caesarean
delivery.
Sampling Methode
Consecutive sampling technique
What are the study factor and how are they measured?
Study factor is bladder adhesion in association between
single-layer and double-layer hysterotomy closure at
primary caesarean delivery
Measured by a adhesion score sheet
CRITICAL APRAISAL
What are the outcome factors and how are they measured?
The outcome is prevalence rate of pelvic and abdominal
adhesions.
They measured by statistical analysis
Are these sources of bias relevant to the study?
Selection bias: Yes consecutive sampling
Recall bias: Yes if the first operative note was unavailable
Confounding bias: Yes heterogeneity of the surgeon and
the physicians completing the adhesion score sheet were not
blind to the hysterotomy closure
CRITICAL APRAISAL
Are sample size issues considered ? Is the power of
the study indicate?
No, the size sample is not considered
No, the power of the study is not indicated

Are statistical methods described?
Yes, the statistical methods are describe
CRITICAL APRAISAL
What conclusion did the author reach about the
research question ?
Primary single-layer hysterotomy closure may be
associated with more frequent bladder adhesions
during repeat caesarean deliveries. The severity and
clinical implications of these adhesions should be
assessed in large prospective trials

Did they generate new hypothesis ?
No, they did not

Do you agree with the conclusions ?
Yes, I do
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