title: Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes.
abstract: BACKGROUND
  Caesarean section is a very common surgical procedure worldwide. Suturing the peritoneal layers at caesarean section may or may not confer benefit, hence the need to evaluate whether this step should be omitted or routinely performed.
  
  
  OBJECTIVE
  The objective of this review was to assess the effects of non-closure as an alternative to closure of the peritoneum at caesarean section on intraoperative and immediate- and long-term postoperative outcomes.
  
  
  METHODS
  We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 November 2013).
  
  
  METHODS
  Randomised controlled trials comparing leaving the visceral or parietal peritoneum, or both, unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section.
  
  
  METHODS
  Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked it for accuracy.
  
  
  RESULTS
  A total of 29 trials were included in this review and 21 trials (17,276 women) provided data that could be included in an analysis. The quality of the trials was variable. 1. Non-closure of visceral and parietal peritoneum versus closure of both parietal layersSixteen trials involving 15,480 women, were included and analysed, when both parietal peritoneum was left unclosed versus when both peritoneal surfaces were closed. Postoperative adhesion formation was assessed in only four trials with 282 women, and no difference was found between groups (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.76 to 1.29). There was significant reduction in the operative time (mean difference (MD) -5.81 minutes, 95% CI -7.68 to -3.93). The duration of hospital stay in a total of 13 trials involving 14,906 women, was also reduced (MD -0.26, 95% CI -0.47 to -0.05) days. In a trial involving 112 women, reduced chronic pelvic pain was found in the peritoneal non-closure group. 2. Non-closure of visceral peritoneum only versus closure of both peritoneal surfacesThree trials involving 889 women were analysed. There was an increase in adhesion formation (two trials involving 157 women, RR 2.49, 95% CI 1.49 to 4.16) which was limited to one trial with high risk of bias.There was reduction in operative time, postoperative days in hospital and wound infection. There was no significant reduction in postoperative pyrexia. 3. Non-closure of parietal peritoneum only versus closure of both peritoneal layersThe two identified trials involved 573 women. Neither study reported on postoperative adhesion formation. There was reduction in operative time and postoperative pain with no difference in the incidence of postoperative pyrexia, endometritis, postoperative duration of hospital stay and wound infection. In only one study, postoperative day one wound pain assessed by the numerical rating scale, (MD -1.60, 95% CI -1.97 to -1.23) and chronic abdominal pain d by the visual analogue score (MD -1.10, 95% CI -1.39 to -0.81) was reduced in the non-closure group. 4. Non-closure versus closure of visceral peritoneum when parietal peritoneum is closed.There was reduction in all the major urinary symptoms of frequency, urgency and stress incontinence when the visceral peritoneum is left unsutured.
  
  
  CONCLUSIONS
  There was a reduction in operative time across all the subgroups. There was also a reduction in the period of hospitalisation post-caesarean section except in the subgroup where parietal peritoneum only was not sutured where there was no difference in the period of hospitalisation. The evidence on adhesion formation was limited and inconsistent. There is currently insufficient evidence of benefit to justify the additional time and use of suture material necessary for peritoneal closure. More robust evidence on long-term pain, adhesion formation and infertility is needed.
authors.affiliation: Department of Obstetrics and Gynecology, School of Clinical Medicine, University of the Witwatersrand, South Africa and Delta State University, Nigeria, Faculty of Health Sciences, PO Box 1718, Johannesburg, South Africa, 2060.
authors.forename: Anthony A
authors.initials: AA
authors.lastname: Bamigboye
authors.forename: G Justus
authors.initials: GJ
authors.lastname: Hofmeyr
mesh_terms: D058107:Abdominal Wound Closure Techniques; D002585:Cesarean Section / Q000379:methods*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D061646:Operative Time; D010532:Peritoneal Diseases / Q000209:etiology; D010537:Peritoneum / Q000601:surgery*; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D013536:Suture Techniques; D000267:Tissue Adhesions / Q000209:etiology
references.citation: Eur J Surg Oncol. 1996 Jun;22(3):282-5
references.pmid: 8654613
references.citation: J Obstet Gynaecol Res. 2012 Oct;38(10):1235-9
references.pmid: 22845718
references.citation: Br J Surg. 1977 Oct;64(10):733-6
references.pmid: 336132
references.citation: Br J Surg. 1987 Feb;74(2):113-5
references.pmid: 3545368
references.citation: Br J Obstet Gynaecol. 1996 Jul;103(7):690-4
references.pmid: 8688397
references.citation: Cochrane Database Syst Rev. 2000;(2):CD000163
references.pmid: 10796163
references.citation: Acta Obstet Gynecol Scand. 1998 Aug;77(7):741-5
references.pmid: 9740522
references.citation: Int J Gynaecol Obstet. 2009 Feb;104(2):135-9
references.pmid: 19022441
references.citation: J Gynecol Obstet Biol Reprod (Paris). 2001 Jun;30(4):348-52
references.pmid: 11431614
references.citation: Acta Obstet Gynecol Scand. 1998 Jan;77(1):110-5
references.pmid: 9492730
references.citation: Acta Obstet Gynecol Scand. 1999 Jan;78(1):37-41
references.pmid: 9926890
references.citation: Gynakol Geburtshilfliche Rundsch. 1993;33 Suppl 1:264
references.pmid: 8118304
references.citation: Am J Obstet Gynecol. 2012 Jan;206(1):56.e1-4
references.pmid: 21924397
references.citation: Eur J Obstet Gynecol Reprod Biol. 2012 Nov;165(1):47-52
references.pmid: 22910336
references.citation: Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004662
references.pmid: 18254057
references.citation: Lancet. 2013 Jul 20;382(9888):234-48
references.pmid: 23721753
references.citation: BJOG. 2000 Feb;107(2):209-16
references.pmid: 10688504
references.citation: Obstet Gynecol. 1991 Feb;77(2):293-6
references.pmid: 1988896
references.citation: Natl Vital Stat Rep. 2001 Dec 27;49(13):1-16
references.pmid: 11793867
references.citation: Am J Surg. 1979 May;137(5):650-2
references.pmid: 453458
references.citation: BMC Pregnancy Childbirth. 2013 Nov 21;13:215
references.pmid: 24261693
references.citation: Am J Obstet Gynecol. 1996 Apr;174(4):1366-70
references.pmid: 8623871
references.citation: World J Surg. 1990 Mar-Apr;14(2):231-3; discussion 233-4
references.pmid: 2139269
references.citation: Br J Obstet Gynaecol. 1999 Mar;106(3):221-6
references.pmid: 10426640
references.citation: Eur J Obstet Gynecol Reprod Biol. 2002 Feb 10;101(1):31-5
references.pmid: 11803097
references.citation: Rev Med Chir Soc Med Nat Iasi. 2005 Oct-Dec;109(4):810-2
references.pmid: 16610179
references.citation: Obstet Gynecol. 1991 Jun;77(6):818-21
references.pmid: 2030849
references.citation: J Matern Fetal Med. 1996 Nov-Dec;5(6):366-9
references.pmid: 8972417
references.citation: Eur J Obstet Gynecol Reprod Biol. 2003 May 1;108(1):40-4
references.pmid: 12694968
references.citation: Int J Tissue React. 1986;8(5):355-9
references.pmid: 3781767
references.citation: BJOG. 2010 Oct;117(11):1366-76
references.pmid: 20840692
references.citation: J Gynecol Obstet Biol Reprod (Paris). 2002 Oct;31(6):572-6
references.pmid: 12407329
references.citation: Indian J Gastroenterol. 1986 Oct;5(4):251-3
references.pmid: 3536730
references.citation: J Obstet Gynaecol Res. 2009 Dec;35(6):1026-30
references.pmid: 20144167
references.citation: Int J Gynaecol Obstet. 2009 May;105(2):131-5
references.pmid: 19232595
references.citation: Am J Public Health. 1998 May;88(5):777-80
references.pmid: 9585744
references.citation: J Med Assoc Thai. 2004 Sep;87(9):1007-11
references.pmid: 15515998
references.citation: Int J Gynaecol Obstet. 2001 Feb;72(2):135-43
references.pmid: 11166746
references.citation: Hunan Yi Ke Da Xue Xue Bao. 2000 Oct 28;25(5):495-8
references.pmid: 12212131
references.citation: Acta Obstet Gynecol Scand. 1998 Oct;77(9):929-31
references.pmid: 9808382
references.citation: BMC Pregnancy Childbirth. 2007 Oct 22;7:24
references.pmid: 18336721
references.citation: Gynecol Obstet Fertil. 2005 Oct;33(10):745-9
references.pmid: 16154376
references.citation: Ginekol Pol. 2000 Oct;71(10):1250-4
references.pmid: 11143933
references.citation: Acta Chir Hung. 1994;34(1-2):79-86
references.pmid: 7604632
references.citation: Saudi Med J. 2000 Aug;21(8):759-61
references.pmid: 11423890
references.citation: Acta Obstet Gynecol Scand. 2000 Apr;79(4):326-7
references.pmid: 10746852
references.citation: BJOG. 2002 Jun;109(6):694-8
references.pmid: 12118650
references.citation: J Matern Fetal Neonatal Med. 2013 Jul;26(11):1128-31
references.pmid: 23350686
references.citation: Am J Perinatol. 1998;15(10):589-94
references.pmid: 9926882
references.citation: J Obstet Gynaecol. 2006 Jul;26(5):429-32
references.pmid: 16846869
references.citation: Int Urogynecol J. 2010 Jan;21(1):33-41
references.pmid: 19771385
references.citation: Obstet Gynecol Surv. 1994 Dec;49(12):817-22
references.pmid: 7885658
references.citation: Obstet Gynecol. 1996 Jan;87(1):40-3
references.pmid: 8532263
references.citation: Int J Gynaecol Obstet. 1995 Mar;48(3):273-6
references.pmid: 7781869
references.citation: Cochrane Database Syst Rev. 2003;(4):CD000163
references.pmid: 14583915