title: Should the visceral peritoneum at the bladder flap closed at cesarean sections? A post-partum sonographic and clinical assessment.
abstract: OBJECTIVE
  To compare cesarean section (CS) using open or closed visceral peritoneum of the bladder flap (BF) in relation to fluid collection in vesico-uterine space (VUS) by ultrasound (US) and clinical outcome.
  
  
  METHODS
  A prospective cohort of repeat CS in 474 in advanced first and second stage of labor was studied. All women underwent a Misgav Ladach CS, in local combined anesthesia. These were divided into two groups by surgical management of the BF at the time of CS: Group I (n = 262), with visceral peritoneum left open and Group II (n = 212), with visceral peritoneum closed. An US check for the fluid collections in the VUS was done in the third post-operative day. The two groups were also clinically compared for: intra-operative estimated blood loss, the need for post-CS pain killers, febrile morbidity and duration of hospital stay.
  
  
  RESULTS
  Visceral peritoneum (VP) closure resulted in a significant increase blood collections in the VUS (p < 0.05). VP closure resulted in a significantly higher morbidity in all the following parameters. Rate of BFHs, post-operative fever, need for post-operative analgesia, require antibiotic administration and prolonged hospitalisation (p < 0.05).
  
  
  CONCLUSIONS
  VP suturing of women requiring CS for dystocia is associated to increased rate of blood collection in the VUS, which could possibly explain the higher rate of puerperal complications in these patients. These data clearly indicate that suturing the VP of the BF in women undergoing CS for dystocia is contraindicated. This data could be probably extrapolated to all cesarean deliveries.
authors.affiliation: Department of Obstetrics and Gynecology, Santa Maria Hospital, Via A. De Ferraris 18-D, Bari, Italy. antoniomalvasi@gmail.com
authors.forename: Antonio
authors.initials: A
authors.lastname: Malvasi
authors.forename: Andrea
authors.initials: A
authors.lastname: Tinelli
authors.forename: Marcello
authors.initials: M
authors.lastname: Guido
authors.forename: Antonella
authors.initials: A
authors.lastname: Zizza
authors.forename: Dan
authors.initials: D
authors.lastname: Farine
authors.forename: Michael
authors.initials: M
authors.lastname: Stark
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000379:methods* / Q000534:rehabilitation*; D005260:Female; D006801:Humans; D010537:Peritoneum / Q000000981:diagnostic imaging* / Q000601:surgery*; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000453:epidemiology; D049590:Postpartum Period / Q000502:physiology; D011247:Pregnancy; D013524:Surgical Flaps / Q000473:pathology; D013536:Suture Techniques / Q000009:adverse effects; D014463:Ultrasonography; D001743:Urinary Bladder / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D014599:Uterus / Q000601:surgery; D055815:Young Adult