Many gynaecologists do not currently close the peritoneum after caesarean section (CS). Recently, several studies examining adhesion formation after repeat CS appear to favour closure of the peritoneum after caesarean section. We performed a systematic review of the current available evidence with regard to the long-term outcome, mainly in terms of adhesion formation after closure versus non-closure of peritoneum during CS. We undertook a literature search between January 1995 and February 2008 using MEDLINE, Pubmed, EMBASE, Cochrane central controlled trials register and Cochrane pregnancy and childbirth group trials register. We also had searched all the references cited in the relevant studies. Both English and non-English language papers were included. Prospective studies which compared peritoneal closure versus non-closure during CS in terms of adhesion formation were included. Studies were included if they had a primary objective to examine adhesion formation in a repeat caesarean section, had a clear study design, had an adhesion scoring system, excluded patients who had adhesions in the primary caesarean section or interim surgeries after the primary caesarean section, and had no usage of anti-adhesion agents in the primary caesarean section. Retrospective studies which were performed by case-notes review alone, were excluded. Eleven studies were identified via our search strategy. Five were retrospective and six were prospective. Out of the eleven studies, three satisfied the inclusion criteria and were included (n = 249); two studies were follow-ups of RCTs and one was not randomised. Out of 249 women included in the analysis, 110 had peritoneal closure during CS whereas the other 139 did not have peritoneal closure. Meta-analysis was performed using the two randomised studies plus (i) the unadjusted estimate from the non-randomised study and (ii) the reported adjusted estimate, adjusted for baseline differences in the groups. Non-closure of the peritoneum during CS resulted in a significantly increased likelihood of adhesion formation in both meta-analyses—OR (95% CI): (i) 2.60 (1.48–4.56) and (ii) 4.23 (2.06–8.69). This systematic review has demonstrated that according to current data in the literature, there is some evidence to suggest that non-closure of the peritoneum after caesarean section is associated with more adhesion formation compared to closure.
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- Is peritoneal closure necessary?.Obstet Gynecol Suv. 1994; 49: 817-822
- Peritoneal closure, Guideline 15.Royal College of Obstetricians and Gynaecologists, United Kingdom2002
Bamigboye AA, Hofmeyr GJ. Closure versus non-closure of the peritoneum at caesarean section. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD000163. doi:10.1002/14651858.CD000163.
- Peritoneal closure—to close or not to close.Hum Reprod. 2001; 16: 1548-1552
- Abdominal adhesiolysis: inpatient care and expenditure in the United States in 1994.J Am Coll Surg. 1998; 186: 1-9
- Adhesions: prevention and complications in general surgery.Eur J Surg. 1997; 163: 169-174
- Peritoneal closure at primary caesarean delivery and adhesions.Obstet Gynaecol. 2005; 106: 275-280
- Closure vs non-closure of the visceral and parietal peritoneum at caesarean delivery:16 year study.Med Assoc Thai. 2004; 87: 1007-1011
- Non-closure versus closure of peritoneum during caesarean section: A randomized study.Eur J Obstet Gynaecol Reprod Biol. 2006; 128: 267-269
- Evaluation of combinations of procedures in Caesarean section.Int J Gynaecol Obstet. 1995; 48: 273-276
- Does closure of the peritoneum during caesarean section influence postoperative morbidity and subsequent bladder adhesion formation?.J Obstet Gynaecol. 1997; 17: 239-241
- Non-closure of peritoneum at caesarean delivery: Evaluation of the repeat caesarean sections.Wien Klin Wochenschr. 2001; 113: 451-453
- Incidence of significant adhesions at repeat caesarean section and relationship to method of prior peritoneal closure.J Reprod Med. 2005; 50: 659-662
- Incidence of adhesions at repeat caesarean delivery.Am J Obstet Gynecol. 2007; 196: e31-32
- Nonclosure of the peritoneum during caesarean section:longterm followup of a randomized controlled trial.Eur J Obstet Gynecol Reprod Biol. 2003; 108: 40-44
- Closure vs non-closure of the peritoneum at caesarean delivery.Int J Gynecol Obstet. 2006; 94: 103-107
- Prospective study of non-closure or closure of the peritoneum at caesarean delivery in 124 women: impact of prior peritoneal closure at primary caesarean on the interval time between first caesarean section and the next pregnancy and significant adhesion at second caesarean.J Obstet Gynaecol. 2006; 32: 396-402
- Parietal peritoneal closure at caesarean section revisited.J Obstet Gynaecol. 2007; 27: 159-160
- De Cherney A.H. Polan M.L. Montz F.J. Shimanuki T. diZerega G.S. Postsurgical mesothelial re-epithelialization. Reproductive Surgery Yearbook, Chicago1987
- The role of fibrinolysis in adhesion formation.Eur J Surg Suppl. 1997; 577: 24-31
- Fibrinolytic activity in amniotic fluid during late pregnancy.Acta Obstet Gynecol Scand. 1986; 65: 417-420
- The prevention of peritoneal adhesions by amniotic fluid.Ann Surg. 1930; 92: 281-293
- Peritoneal adhesions: etiology pathophysiology and clinical significance.Digest Sur. 2001; 18: 260-273
- Foreign material in postoperative adhesions.Ann Surg. 1996; 223: 242-248
- Caesarean section and subsequent fertility in Sub-Saharan Africa.BJOG. 2006; 113: 276-283
- Small bowel obstruction: a common problem.Adhes News Views. 2007; 11: 18-20
- Adhesion controversies: pelvic pain as a cause of adhesions, crystalloids in preventing them.J Reprod Med. 1996; 41: 19-26
- Laparoscopy in chronic abdominal pain; a prospective non-randomized long-term follow-up study.J Clin Gastroenterol. 2005; 39: 110-114
- Surgical and Clinical Research (SCAR) Group. Adhesion-related readmissions following gynaecological laparoscopy or laparotomy in Scotland: an epidemiological study of 24.046 patients.Human Reprod. 2004; 19: 1877-1885
- A review of the management of small bowel obstruction Members of the Surgical and Clinical Adhesions Research Study (SCAR).Ann R Coll Surg Engl. 1999; 81: 320-328
- Improvement of interobserver reproducibility of adhesion scoring system.Fertil Steril. 1994; 62: 984-988
The CAESAR Study [www.npeu.ox.ac.uk/trials/Caesar.html].
Published online: July 02, 2009
Accepted: June 7, 2009
Received in revised form: March 20, 2009
Received: August 5, 2008
© 2009 Elsevier Ireland Ltd. Published by Elsevier Inc. All rights reserved.