This letter argues that the practice of nonclosure of visceral and parietal peritoneum during cesarean delivery cannot be justified based on existing evidence. Historically, both layers of peritoneum were closed due to the rational belief that leaving raw surgical areas exposed leads to adhesion formation. While guidelines now recommend nonclosure based on short-term outcomes like reduced analgesic use, randomized trials have also found equal numbers that contradict these findings. The author argues that peritoneal closure should be recommended to prevent adhesion formation without need for further randomized trials, as observational studies also support this conclusion.

1. Can the practice of nonclosure of visceral and parietal
peritoneum during cesarean delivery be justified?
TO THE EDITORS: The review by Walfisch et al1
alongside
many other reviews draws out the debate on the peritoneal
closure/nonclosure during cesarean delivery. Any discussion
on pathophysiologic adhesion-formation most importantly
should include that the denuded and surgically traumatized
areas on the uterus and abdominal wall undergo invariable
inflammatory reaction commencing the process of adhesion-
formation and that the restoration of peritoneal continuity
seems a natural barrier against this.2
Historically, both
visceral and parietal peritoneum were closed1
because of
rational reasoning and careful observation that exposed raw
areas in the peritoneal cavity lead to adhesion-formation.
Subsequently, guideline groups recommended nonclosure of
peritoneum for clinically irrelevant short-term outcomes
such as saving a handful of minutes (in an operation that
takes only 30 minutes) or reduced analgesic requirement in
24-48 hours, which is an unimportant surrogate outcome
completely unrelated to the purpose of peritoneal closure;
findings have also been contradicted by an equal number of
randomized controlled trials (RCTs). Such misapplication
of evidence-based medicine has been a subject of current
debate.3
Hence, it could be argued that peritoneal closure
should not have been abandoned in the first place without
robust evidence that it does not reduce or increases the
incidence of adhesion formation. The argument that perito-
neal closure (taking the most basic care) could cause tissue
damage, necrosis, and foreign body reactionecausing adhe-
sions1
(especially with modern sutures) is not supported,
even by wider surgical experience/observation.
Walfisch et al1
quite rightly quote other metaanalyses of
RCTs and observational studies that provide robust evidence
of reduction of all grades of adhesions with peritoneal
closure.2
Omental adhesions to parietal peritoneum may
not be of much consequence; however, cases of extensive
dense adherence of the lower part of the uterus to anterior
abdominal wall have been observed by the author and
others4
that leads to pain, dyspareunia, possible subfertility,
and significant operative difficulty during further surgery.
These are most likely attributed to nonclosure of perito-
neum.4
The RCTs that deal with surgical techniques have
particular limitations and difficulties, particularly an attri-
tion rate as seen in the trial in which only 97 of 533 women
had a repeat cesarean delivery1
; hence, pragmatic observa-
tional studies can be equally informative. Thus, the suturing
of peritoneum during cesarean deliveries should now be
recommended based on the existing evidence, without
waiting for long-term results of any more RCTs. If perito-
neal layers are sutured, there seems no need for synthetic
adhesion barriers for which there is no reasonable evidence,
as rightly concluded in the review.1
-
Q2Shashikant L. Sholapurkar, MD, DNB, MRCOG
Q1Department of Obstetrics and Gynaecology
Royal United Hospital Bath NHS Foundation Trust
Bath, United Kingdom
The author reports no conflict of interest.
REFERENCES
1. Walfisch A, Beloosesky R, Shrim A, Hallak M. Adhesion prevention
after cesarean delivery: evidence, and lack of it. Am J Obstet Gynecol
2014;211:446-52.
2. Sholapurkar SL. Increased incidence of placenta praevia and accreta
with previous caesareans: a hypothesis for causation. J Obstet Gynaecol
2013;33:806-9.
3. Greenhalgh T, Howick J, Maskrey N. Evidence Based Medicine
Renaissance Group. Evidence based medicine: a movement in crisis?
BMJ 2014;348:g3725.
4. El-Shawarby SA, Salim R, Lavery S, Saridogan E. Uterine adherence
to anterior abdominal wall after caesarean section. BJOG 2011;118:
1133-5.
ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.
2014.12.008
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Letter to the Editors ajog.org
COR 5.2.0 DTD Š YMOB10166_proof Š 20 December 2014 Š 3:57 pm Š ce