Advantages Of Single Layer Closure Of Caesarean Section Over Conventional Technique-A Study

Dr. Ela Lodh M.D., FICOG, FICMCH, FICS Formerly Head of the Department of Obstetrics & Gynecology, IGM Hospital, Ex- Director of Tripura Health Services,Clinic,Agartala-   799001,Tripura,India.
  

Objective : The aim was to introduce a safe simple and cost-effective technique of Caesarean Section.

Methods : The study was conducted at IGM Hospital and private Maternity Homes at Agartala, India during the period from 1994 to 2002. In the study group 5000 women underwent caesarean section in single layer closure technique and another 5000 cases (control group) had section in the conventional method. Both the groups included primi and multi-gravida, elective and emergency cases with similar indications and in same age group. Also 200 nos. repeat section cases were studied out of which 100 cases had undergone previous caesarean section in single layer technique and another 100 cases had previous section in conventional method. The results were compared to see the advantages and postoperative outcome.

Technique : A transverse skin incision is made 2.5 – 3.0 cm above the symphysis.A nick is made in the rectus sheath which is stretched cranially and caudally. A hole is made with finger in the parietal peritoneum which is widened. Lower segment is incised. delivery of baby and placenta done as usua.Uterine wound is closed in single layer with continuous unlocked suture.Viseeral peritoneum is repaired. Parietal peritoneum is the stitched.Rectus sheath and skin are stitched as usual.

Results : In the study group mean operative time is 23 minutes, operative blood loos is minimal,IV fluid requirement is less, ambulation is earlier. Incidence of PPII,postoperative pain and morbidity is much less and the hospital stay is shortened.

Conclusion: Patients operated in this technique had faster post-operative recovery and are better able to take care of their babies. The single layer technique should be included in text books of today.

Title : Advantages of single layer closure of caesarean section over conventional technique – a study.

Introduction : This is a single layer closure of Caesarean section would conducted the study at Indira Gandhi Memorial Hospital,Agartala,India over a period of last 5 years. The aim of the study was to introduce simpler, safer and cost effective technique of Caesarean section with minimal post operative morbidity and faster recovery.

Materials and method : In this study 5000 cases of Caesarean section were done in single layer closure technique against a control of another 5000 cases of Caesarean section  conducted in the conventional method. Both the groups included primigravida to 5th gravida between the age group of 18 – 40 years, Both had similar indication of repeat sanction cases.

Steps of operation : A transverse skin incision is made 2.5-3.0 cm above the symphysis pubis of standard length only the skin and subcutis are cut and then a nick is made in the avascular midline upto the depth of the rectus sheath. The nick is then extended little bit on either side with the tip of the scalpel. The index fingers of both hands are introduced on  either side by the surgeon and the assistant and layer of the sheath are stretched caudally and cranially to expose the rectus muscles. The recti are then pulled laterally on either side by the surgeon and his assistant exposing the parietal peritoneum. A hole is made over the parietal peritoneum with the index finger and now it is stretched caudally and cranially keeping the bladder out of danger. An incision is made over the lower uterine segment after striping off the visceral peritoneum in usual manner. The baby and the placenta are delivered as usual. The uterus is exteriorized. The cut margins of the lower uterine segment are stitched in single layer with continuous unlocked sutures with chromic catgut No.1 thread. After that the visceral peritoneum is stitched. Uterus is compressed between the two hands and is put back in the abdominal cavity. Abdomen is cleaned after ensuring complete haemostasis. The parietal peritoneum is not stitched.Rectus sheath is stitched with vicryal No.1.Skin is repaired with nylon. A few stitches in the fatty layer are required in obese patients occasionally.  

Single Layer Closure Of Caesarean Section Over Conventional Technique
 - Deferent Steps

Post operative period : IV drip omitted 6 – 8 hours after the operation. Patients are allowed to seat and go to toilet on the same day. Analgesics required in the post operative period are minimal because of less postoperative pain. Antibiotics commonly given in a combination of two drugs used for 5 – 7 days. Patient is allowed oral fluid and biscuit on the same day of operation and on the first postoperative day she is given semisolid diet like khichuri etc.

Observations and results : These are shown in the tables plotted which are self explanatory. On the whole it has been observed that this modified technique is much better than the conventional one is regard to the postoperative morbidity, simplicity, cost effectiveness and short hospital stay. No significant difference is observed in the number of elective and emergency section cases in the two groups. Use of antibiotics in both the groups is almost same. In the study group, because of minimal post operative pain, requirement of analgesic is much less then the control group. In the repeat Caesarean section cases no adhesion has been found and the cases were as good as primigravida under going Caesarean section in contrast with the cases done in conventional method.

To introduce a safe, simple & cost effective technique of Cesarean Section

To introduce a safe, simple & cost effective technique of Cesarean Section (Child Pix)

Closure of uterine wound                                                                       

Study Group

(n=5000)

Control  Group

(n=5000)

Uterine wound closed in

Single layer

5000

(100%)

0

Extra Haemostatic suture

Required

253

(5.06%)

400

(8%)

Visceral peritoneum sutured

4985

(99.7%)

5000

(100%)

Visceral peritoneum unsutured

90

(1.8%)

0

(8%)

 Closure of abdominal cavity

Layers

Study group

(n=5000)

Control group

Parietal peritoneum

Not sutured in all

The cases

Sutured in

All the cases

Rectus sheath stitched

Sutured with vicryl

No:1 in all cases

Sutured with chromic

Catcut no:2

Fatty layer haemostasis

Occasionally required

 

Frequently required

Fatty layer apposition

Stitches

Occasionally required

In obese patients only

Multi stitches vern

Often required

Skin repair

            No difference

    No difference

Operation time and blood  loss 

 

Study group

(N=5000)

Control group

(N=5000)

Incision delivery internal

3.3 min

(mean 4 min)

5.7min

(mean 6 min)

Total operation time (skin to skin)

20.26min

(mean 23 min)

35.45 min

(mean 40 min)

Amount of blood loss

200-300ML

(average)

300-500 ML

(average)

Post operative recovery

Post operative

Study group

(N=5000)

Control group

(N=5000)

I.V fluid continue for

6.8 hrs (mean:7 hrs)

8.16 hrs(mean : 12 hrs)

Sitting in bed

7.9 hrs (mean : 8 hrs)

9.16 hrs(mean: 12.5 hrs)

Ambulation

On same day

On next day

 Post operative morbidity

 

Study group

(N=5000)

Control group

(N=5000)

P.P.H

24 Cases

(0.48%)

140 Cases

(3%)

Post partum pyrexia

200 Cases

(4%)

400 Cases

(8%)

Puerperal sepsis

0 Cases

(0%)

53 Cases

(1.06%)

Post operative pain

Negligible

Significant

Post operative condition of the wound

 

Study group

(n=5000)

Control group

(n=5000)

Stitch removed

On 5th  p.o.d

4900 (98%)

On 7th –8th p.o.d

4900(98%)

Hospital stay

5 days in

4940 Cases(98.8%)

7-9 days in

4910 Cases (98.2%)

Advantages 

Less time consuming
Less blood loss
Use of less I.V fluid
Use of less suture materials
Less instrumentation
Use of less analgesic
Faster post operative recovery
Early ambulation
Better  wound healing
Safer
Cost effective
Surgeon’s comfort
Patient’s friendly
Cosmetically better accepted 

Baby profile

 

Study group

(n=5000)

Control group

(n=5000)

Birth weight

                                           Same range for both the Groups

Apgar score

9/10 .10/10

7/10. 10/10

Re-coming in

Early

Late

Breast feeding

Early

Late

Conclusion

The single layer closure technique of caesarean section has been found to be safe, simple, cost effective and much better in all respect than the conventional method. Postoperative morbidity in this technique is much less. Because of the minimal post-operative pain and faster recovery patient becomes ambulatory much early and she is able to breastfeed and care of her baby earlier than in conventional method.

 



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