is it better to do peritonization or not during caesarean section?
because in our hospital (in sudan) we do peritonization but women later came complain of pain because of adhesions...
no need for peritonization i want the management of cervical ectopic pregnancy
Management options may be surgical or medical:
Systemic methotrexate is the initial treatment protocol. Resistant cases with persistent fetal cardiac-activity may be offered intraarterial or intrasac-methotrexate with intracardiac-potassium chloride.
Surgical interventions include cervical-circlage, intracervical-balloon-tamponade, vaginal packing after dilatation-curettage, ligation of the internal-iliac-artery and lastly hysterectomy.
FOR SOME YEARS WE HAVE ABANDONED PERITONIZATION AND THE INCIDENCE OF POST OP PAIN HAS NOT BEEN ANY MORE FREQUENT.SOME OF OUR CASES HAVE COME BACK FOR REPEAT SECTIONS. WE ARE YET TO IDENTIFY ANY INCREASE IN ADHESION RATES AMONG SUCH CASES
there is increased in adhesion rates among cases of repeated sections,in some cases of third or fourth scars we can not identify the lower uterine segment,and we do window operation to take the baby out
To restore the surgical anatomy and to reapproximate the tissues peritonization must be done.
It is much better to gently close the parietal peritoneum after CS and so restore the anatomical planes and keep the omentum where it ought to be - inside the peritoneal cavity. Since peritonization was abandoned I have come across many problems not encountered when it was routine - loss of the anatomical planes with omentum everywhere making entry into the peritoneal cavity extremely difficult and time consuming, and even incisional hernia.
Association between peritoneal closure at primary cesarean section and significant adhesions at second cesarean section
J Surg Pak Jun 2007;12(2):56-9.
Objective: To evaluate impact of peritonization at primary cesarean section in terms of abdominopelvic adhesions at second cesarean section. Study design: A randomized trial. Patients & Methods: Women undergoing first cesarean delivery were randomized to either closure of both the visceral and parietal peritoneum (Group A, n =150) or non closure (Group B, n=150). At second cesarean, the variety and frequency of adhesions were examined. Results: The incidence of adhesions in the closure group was significantly higher than in the non closure group (p<0.05 ). The mean total operating time and the mean interval from skin incision to delivery in the closure group was significantly longer than in the non closure group ( P <0.05, P<0.05 respectively) at second cesarean section. Conclusions: Peritoneal closure in cesarean delivery is associated with significant adhesion formation. The practice of non-closure of peritoneum is therefore recommended.
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I have been doing Caesarean sections since 1982, but in the last few years have done some of the most difficult entries I have ever had to - the front of the uterus has been completely adherent to the back of the rectus sheath, never mind the omentum. There have also been some incidences of bowel entrapment between the muscle, leading to obstruction and perforation. I think this is due to not closing the parietal peritoneum and I would very much like a national survey to be done - I have contacted the Scottish QIS to obtain an audit form but haven't got around to it yet. Anyone else out there interested/concerned?
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David J R Hutchon
I too have done caesarean sections for 30 years and have noted some unusual adhesions and repair of the anterior abdominal wall after non-closure of the parietal peritoneum. I have seen several cases where the recti were so separated there was peritoneum over both sides of the rectus muscles and over the back of the rectus sheath. This was causing compression of the bowel which had entered this "hernia".
I think closure of the lower segment peritoneum can cause more adhesions but if there is oozing this is preferable to a continuous ooze into the peritoneum so close is when there is any question of haemostasis.
For the parietal peritoneum at Pfannensteil/low transverse incision surgical principles tell us that closure of the peritoneum without any support simply interferes with the healing. However with "mass closure" ie including the rectus muscle, the gap between the muscles is occluded and the blood supply to the peritoneum maintained.
I have seen both schools one preferring to close and other not.
But, personally I think that peritonization is not essential we can cut short the time as well as post operative adhesions and future need for laparoscopy for chronic pelvic pain thereby cutting the costs of all these things.
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I have been ddoing CS since 1983. I used to close both parietaland visceral peritoneum. I worked as SHO and two years later as Registrar in the same hospital I saw some of my primary sections with very little scarring or high bladder adhesion toabdo wall or omentum under the sheath.I have also seen several cases of primary bleeding from the perfortors under the sheath that was diagnosed very late as the blood drained in the peritoneal cavity and only when the blood loss was major the patient presents with shoick.If the parietal/abdominal peritoeum is closed any bleeding under the sheath will cause pain from the stretching of the peritoneum and sheath due to the limited subsheath space.
It is now widespread among new obstetricians not to close any of the two layers. I see more omentum in the subsheath space and encounter difficulty accessing the peritoneal than previously.I always close the abdominal peritoneum.
I have been doing caesarean sections since 1985, and have formed the impression that closure of the visceral peritoneum actually factilitates repeat ceasarean- by reducing adhesion formation. This was particularly the case when, for an interval of some years, I used a single-layer, continuous locking technique to close the uterus, without peritoneal closure. Not infrequently, at repeat caesarean in this group I found dense and troublesome adhesions. I reverted to double layer closure together with visceral peritoneal closure about six years ago, and have virtually stopped seeing adhesions in my own repeat caesarean sections since. This includes adhesions to bladder and anterior abdomainal wall.
I also wonder if closure of the parietal peritoneum, which I do not routinely do, would facilitate entry after the 3rd or 4th caesarean.
I think the word ( must) is inappropriately used in your statement Dr. Asma and it even contradict the RCOG guideline.
I stopped peritonization long ago also and I had a perfect clean repeat section with minimal adhesions in most of the cases. I did not carry a formal comparative study but a good case load is available by now.
hello iread about peritonization &ifound some repot said that peritonization may increase risk of adhesion itis true >>>>.please iwant information