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Epcs presentation 2013
1) The document describes the operative technique for an extraperitoneal cesarean section. 2) A review of over 54 studies from 1940-2012 including over 18,000 cesarean sections found that the extraperitoneal approach was commonly used with a Pfannensteil or Joel-Cohen incision. 3) The technique typically involves blunt dissection of the bladder, ligation of vessels without cutting, and no need to empty or drain the bladder.
Epcs presentation 2013
- 1. Extraperitoneal Cesarean Section: OperativeTechnique ~approach to the extraperitoneal lower uterine segment~ Hedric B. Hanson M.D. Anchorage, Alaska Disclosures: None
- 2. Hedric B. HansonMD Anchorage, Alaska Presented Maricopa Medical Center February 1, 2013
- 3. Mortality Brief CD History 1800- 1900 1900-20002000 IPCS+AntibioticEPCS EBM
- 4. 4 4Berghella V. Etal. Evidence-based surgery for Cesarean Delivery, Am J Obstet Gynec (2005); 193: 1610 MOST surgical decisions during CD LACK evidence-based guidance
- 5. 5 The Joel-Cohen incisionappears to have advantages compared with the Pfannensteil incision.1 Blunt uterine incision expansion2 Prophylactic antibiotics Spontaneous placental removal Non-closure of both parietal and visceral peritoneum Subcutaneous closure or drainage if > 2 cm thickness SOME surgical decisions during CD have evidence- based guidance Berghella V. Et al. Evidence-based surgery for Cesarean Delivery, Am J Obstet Gynec (2005); 193: 1610
- 6. 6 6 ...lacks rigorous criticalanalysis! USPSTF Recommendation: I Quality: Poor Opening Peritoneum Berghella V. Et al. Evidence-based surgery for Cesarean Delivery, Am J Obstet Gynec (2005); 193: 1610 The Critical Question in CD
- 7. 7 7 .IS NOT MENTIONED! THEEXTRAPERITONEAL SPACE The ANOTHER Step in CD
- 8. Focus • Anatomy • ReviewWorld Resources 1940-2012 • Operative Technique~ Dr. Fauck’s Video • Implications~
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- 10. The Abdominal Wall •Dissection of layers-blunt vs sharp
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- 14. 1414 The Blanket The BlanketMethod: a Novel Method of Teaching Peritoneal Relations of Female Reproductive Organs
- 15. 1515 The Blanket -size ofuterus changes relationships-
- 16. 1616 UB Gravid Uterus R The Blanket~CHANGESWITH GRAVID UTERUS
- 17. 1 7 17 Anatomical Relationships Changes inthe Lower Uterine Segment Growth of the Gravid Uterus
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- 19. 1 9 19 Level of Cervixin Non-pregnant Female
- 20. 2 0 20 Level of LowerUterine Segment @ Term
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- 24. ★ Bladder isthe problem blocking access! ★ Bladder displacement: • Supravesical approach • Paravesical approach Bladder
- 25. This is theproblem……. 25
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- 28. Displacement of Bladder 28 LowerUterine Segment Peritoneal Reflection
- 29. 2 9 29 The Retrospective Review WorldResources 1940 to 2012 hyperlink
- 30. 3030 Study Design: Sources PubMed China National Infrastructure Database Selection Criteria: Operative Expertise Volume Incision-to-Delivery (IDT) Operative Time (OT) >15 cases <10 minutes <45 minutes Selection Criteria: Operative Description Approach Dissection Ligaments Fascia Bladder Drains
- 31. 31 Articles Identified Database Search PubMed (n=117) Additional articles identified from other sources (n=6) Articles Screened (n=216) Articles Excluded (n=83) Articles Assessed for Eligibility (N=133) Articles Excluded (Criteria of Review) (n=79) Full-Text Articles Fully Eligibility (N=40) Studies included but missing data criteria: (N=14) Studies Included in Review (N=54) Articles Identified Database Search Chinese National Knowledge Infrastructure Database (n=93) Figure 1. Flow Diagram of Selection Process
- 32. Papers from 1988-2012 CountryArticles (Number) Extraperitoneal CD China 28 8,884 India 2 5,328 Bulbaria 1 151 US 0 0 54 Papers reviewed
- 33. 3333 Summary of Results Sources54 Articles Operative Expertise Volume IDT OT Bladder Injury Operative Description Descriptive Narrative Found CD Approach Dissection Ligaments Peri-Uterine Fascia Bladder Drainage
- 34. 9 Results Sources 54 Articles(>18,000 cases) Operative Expertise Volume 15-3658 IDT (min) 2-13 OT (min) 12-45 Bladder Injury 0-12.5% Author Date Language ## CDa Approachb OTc IDd Bladder Injury % Pf JC Para Supra
- 35. 8 Table 1. OperativeData Author Date Languag e ## CDa Approachb OTc IDd Bladder Injury % Pf JC Para Supra Irwin7 1940 English 32 PF PV 45 12.5 Stearns8 1943 English 16 SV 18.7 Waters9 1944 English 250 PF/V SV 36 1.6 English 180 PF/V PV Norton10 1946 English 160 PF/V SV 5.6 Ricci11 1946 English 175 V PV 45 3.4 Caccierelli12 1948 English 100 PF SV 30 0 Anz,Ward13 1950 English 32 PF PV 3.3 Bourgeois14 1950 English 41 V SV 4.2 Gilbert15 1953 English 57 PV SV 0 Paternite16 1954 English 91 V PV 35 10 2 Marr JP17 1958 English 125 V PV 45 5.7 Durfee R18 1960 English 100 PF SV 40 11 0 Wu C19 1972 English 170 PF PV 35 10 1 Joschko20 1974 English 254 PF PV 36.2 7.2 3.5 Hanson21 1978 English 45 PF PV 29 6.9 2 Perkins22 1978 English 50 PF PV 35 10 0 23 Author Date Languag e ## CDa Approachb OTc IDd Bladder Injury % Pf JC Para Supra
- 36. 8 Table 1. OperativeData Hanson21 1978 English 45 PF PV 29 6.9 2 Perkins22 1978 English 50 PF PV 35 10 0 Morozov23 1981 Czech 560 PF PV 47 6.6 0 Chemukha24 1982 Russian 300 PF PV 40 7.8 0.6 Wallace25 1983 English 91 PF PV 38 9 2 Hanson26 1983 English 345 PF PV 21 6.5 0.3 English 16 PF PV 20 3.5 0 English 31 PF PV 22 6 0 English 61 PF PV 24 5 0 Liu Z27 1988 Chinese 1342 PF PV 34 16 0 Duvenaishki28 1991 Bulgarian 151 PF PV 40 4 0 Li Yalin29 1996 Chinese 578 PF PV 40 2 Qiu X30 1997 Chinese 800 PF PV 29 2.2 0 Chinese 80 PF SV 40 2 7.5 Wang M31 1998 Chinese 249 PF PV 33 7 0 Rao R32 1999 English 3628 PF PV 30 10 0.1 Kang R33 2000 Chinese 100 PF SV 28 4 0 Yang X34 2000 Chinese 150 PF PV 38 12.5 0 Liu H35 2000 Chinese 237 PF PV 46 9 0 Li X36 2000 Chinese 364 PF PV 29 11 0 Lu Y37 2000 Chinese 165 PF PV 30 5 0 Li D38 2001 Chinese 200 PF PV 40 13 0 Meng J39 2002 Chinese 380 JCPV 24 7 0 Chinese 151 PF SV 40 15 0 40 Author Date Languag e ## CDa Approachb OTc IDd Bladder Injury % Pf JC Para Supra
- 37. 8 Table 1. OperativeData Liu H35 2000 Chinese 237 PF PV 46 9 0 Li X36 2000 Chinese 364 PF PV 29 11 0 Lu Y37 2000 Chinese 165 PF PV 30 5 0 Li D38 2001 Chinese 200 PF PV 40 13 0 Meng J39 2002 Chinese 380 JCPV 24 7 0 Chinese 151 PF SV 40 15 0 Liang H40 2002 Chinese 126 PF SV 36 16 0 Zeng Y41 2002 Chinese 105 PF PV 38 10 Yin G42 2002 Chinese 2436 PF PV 33 0 Wei Y43 2002 Chinese 155 PF PV 55 13.6 0 2002 Chinese 181 Vert PV 44 8 0 Hzu Y44 2004 Chinese 398 PF PV 35 0 Yang W45 2004 Chinese 130 PF PV 30 5 0 Chinese 110 JCPV 41 9.7 0 Ruan Y46 2004 Chinese 464 PF PV 23 5.9 0 Xie R47 2005 Chinese 140 PF PV 35 6 0 Li Y48 2006 Chinese 206 PF PV 44 13.5 0 Li M49 2008 Chinese 140 JCPV 23 4 0 Fan Y50 2008 Chinese 198 PF PV 35 5.9 0 Desari D51 2009 English 1000 PF PV 12 2 0 Zhao R52 2010 Chinese 148 PF PV 51 5 0 Zhang X53 2010 Chinese 225 PF PV 38.6 4 0 Li Y54 2011 Chinese 234 PF PV 23 7.1 0 Zhang H55 2010 Chinese 178 PF PV 40 9 0 Li R56 2010 Chinese 120 JCPV 28 9.2 0 Author Date Languag e ## CDa Approachb OTc IDd Bladder Injury % Pf JC Para Supra
- 38. 8 Table 1. OperativeData Desari D51 2009 English 1000 PF PV 12 2 0 Zhao R52 2010 Chinese 148 PF PV 51 5 0 Zhang X53 2010 Chinese 225 PF PV 38.6 4 0 Li Y54 2011 Chinese 234 PF PV 23 7.1 0 Zhang H55 2010 Chinese 178 PF PV 40 9 0 Li R56 2010 Chinese 120 JCPV 28 9.2 0 Chinese 100 PF PV 42 16 0 Yang H57 2011 Chinese 151 PF PV 14.2 0 Author Date Languag e ## CDa Approachb OTc IDd Bladder Injury % Pf JC Para Supra
- 39. 11 Results Sources 54 Articles OperativeDescription Descriptive Narrative Found CD Technique Approach Dissection Ligaments Peri-Uterine Fascia Bladder Drainage Pfannensteil Para- vesical Blunt Stretch Not Necessary Empty Not Necessary Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBlunt Sharp Stretch Cut No Yes Empty Fill No Yes Joel Cohen Supravesical Sharp Cut/Divide Incise Fill & Empty Drain
- 40. 10 Author CDa ApproachbDissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBlunt Sharp Stretch Cut No Yes Empty Fill No Yes Irwin7 PF PV + + + + + Stearns8 PF SV + + + + + Waters9 PF or V SV + + + + + PV + + + + + Norton10 V PV + + + + + Ricci11 V SV + + + + Caccierelli12 V PV + + + + Anz,Ward13 V PV + + + + + Bourgeois14 V SV + + + + Gilbert15 PF SV + + + + + Paternite16 V PV + + + + + Marr JP17 V SV + + + + Durfee R18 PF PV + + + Wu C19 PF PV + + + + + Joschko20 PF PV + + + + + Hanson21 PF PV + + + + + Perkins22 PF PV + + + + + Morozov23 PF PV + + + + + Table 2. Surgical Technique DataAuthor CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBlunt Sharp Stretch Cut No Yes Empty Fill No Yes
- 41. Joschko20 PF PV+ + + + + Hanson21 PF PV + + + + + Perkins22 PF PV + + + + + Morozov23 PF PV + + + + + Chemukha24 PF PV + + + + + Wallace25 PF PV + + + + + Hanson26 PF PV + + + + + PF PV + + + + + PF PV + + + + + PF PV + + + + + Liu Z27 PF PV + + + + + Duvenaishki28 PF PV + + + + + Li Yalin29 PF PV + + + + + Qiu X30 PF PV + ++ + + PF SV+ ++ + + Wang M31 PF PV + + + + + Rao R32 PF PV + + + + + Kang R33 PF SV ++ + + + Yang X34 PF PV + ++ + + Liu H35 PF PV + + + + + Li X36 PF PV + + + + + Lu Y37 PF PV + + + + + Li D38 PF PV + + + + + 39 10 Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBlunt Sharp Stretch Cut No Yes Empty Fill No Yes
- 42. Liu H35 PFPV + + + + + Li X36 PF PV + + + + + Lu Y37 PF PV + + + + + Li D38 PF PV + + + + + Meng J39 JC PV + + + + + PF SV + + + + + Liang H40 PF SV+ + + + + Zeng Y41 PF PV + ++ + + Yin G42 PF PV + + + + + Wei Y43 PF PV + ++ + + Vert PV + ++ + + Hzu Y44 PF PV + + + + + Yang W45 PF PV + + + + + JC PV + + + + + Ruan Y46 PF PV + + + + + Xie R47 PF PV + + + + + Li Y48 PF PV + + + + + Li M49 JC PV + + + + + Fan Y50 PF PV + + + + + Desari D51 PF PV + + + + + Zhao R52 PF PV + + + + + Zhang X53 PF PV + + + + + Li Y54 PF PV + + + + + 55 10 Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBlunt Sharp Stretch Cut No Yes Empty Fill No Yes
- 43. Desari D51 PFPV + + + + + Zhao R52 PF PV + + + + + Zhang X53 PF PV + + + + + Li Y54 PF PV + + + + + Zhang H55 PF PV + + + + + Li R56 JC PV + + + + + PF PV + + + + + Yang H57 PF PV + + + + + 43 10 Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBlunt Sharp Stretch Cut No Yes Empty Fill No Yes
- 44. 4444 M. Fauck’s ExtraperitonealCesarean Section
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- 50. 5050 Exit to Peritoneum Youhave choices!
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- 52. Live Births CDRate % Cesarean Delivery China 16,486,000 50 8,243,000 6.4 X India 27,165,000 9 2,444,850 1.9 X USA 4,301,000 30 1,290,300 1.0 X Where are the CD being done?
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- 54. 54 EBM~Technique for EPCS RCS EBM USA EBM China BluntMinimalism (Joel-Cohen) None Comparative Studies Favor Blunt Minimalism (Joel-Cohen ) Extraperitoneal CD Sharp Invasive (Pfannenstiel )
- 55. 55 Is being studieselsewhere
- 57. Like two worlds 1988-20121940-1983
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Editor's Notes
- #3 But first some background!Why did I spend my time researching a old procedure relegated to history? Which I had performed in practice for a quarter of a centuryPCOGS (2011 in Bend, Oregon)— two papers (1) abhesions prevention (2) IDT with prior c-sectionsI had asked about consider EPCS??Collequges asked be to talk about it! But only way was to do a little paper. A review of the operative procedure. Not a commentary or rehass of history epcsvs IPCS. So I had finished paper last May….ready to enjoy a summer in AlaskaI had indentified the experienced obstetrians and their preferred approach to the EP LUSThe Written Word is supplement by excellent YouTube videos of execution of the EPCSSo usually my young audience have tuned out and access the YouTube video as the lecture proceedsReturn from the lake, the Hanson’s household in Alaska had a young vistor from Bejing…….doctoral student in philosoophyDinner followed by breakfastWe evaluate the Chinese literature accessing the Chinese National Infrastructure Database…Articles not available on PubMed..that is really the story of this little talkA country doing 6X the number of CS as in the USEBM Questions are being answered by their research
- #12 We are all farmiliar with this step As the rectus muscles are seperated, transversal fascia is piereces and the loose areolar tissue of the EPS is encountered
- #24 Demonstation
- #25 Exposure of the EP LUS is is the critical issueThe Problem is the Bladder>>>> Midline Blocking Position
- #26 The Bladder Blocks AccessMidline blocking position
- #27 One approach is SUPRAVESCIALTediousDifficultyTime consumingBladder injury 10% commonNot recommended; rare proponents since 1940’s
- #28 The problem is the bladder: DISPLACED TO EXPOSEDisplacing: by finger dissection using natural tissue planesSwepting: from harms way, BYStreching: the umbilical ligaments & urachusExposing the LUSMuch easier, saver less tedinous and less with bladder injury rate similar to the IPCSPreferred METHOD
- #29 This is the left paravesical spaceThe lower uterine segment acts as a backstop for the dissectionPeriotneal reflection superiorlyUmbilical ligament defines lateral border of bladder…which is ..streched as bladder is displace off midline
- #30 This is the data that I collected
- #34 This is a summary form that will be used to tabulate findings:Experience surgeonsPreferred technques
- #46 8 minutes by Dr. MichaelFauckIn my review of the world resources, I found really excellent YouTube videos demonstrating the EPCS! I focused on 4 (one French and 3 India video and together had received 150,000 hits). I will call your attention to two:The best professional video is by Dr. Faulk which I will show you! 2. The 2nd is Dr. Desari video of his presentaiton at the 19th FIGO meeting in South Africia—he present 1000 cases of EpCS with IDT-2 minutes and OT of 12 minutes
- #51 THERE IS LOTS OF EXPERIENCE IN THIS WORLDOutside the US
- #52 Chineselitature is difficulty to translate…………comparative studies may not met Western standardsHOWERE THE CRITCAL QUESTIONS OF ENTRY INTO THE PERITONEAL CAVITY FOR CD THIS STUDIES ARE NOT BEING DONE IN THE US