Postoperative morbidity in the morbidly obese parturient woman: supraumbilical and low transverse abdominal approaches

OBJECTIVE: Our purpose was to determine the differences in postoperative morbidity in obese women who had a supraumbilical or a Pfannenstiel incision at cesarean delivery. STUDY DESIGN: A case-control retrospective review was conducted of all patients who were at >150% ideal body weight when undergoing cesarean delivery between 1989 and 1995 by means of either a supraumbilical or a Pfannenstiel incision. Patients were excluded if medical records were unavailable. A total of 15 women who had a supraumbilical incision and 54 who had a low transverse incision were included in the analysis. Antenatal complications were examined, as were age, weight, and training level of the surgeon. Postoperative complications were then compared. RESULTS: The groups were similar in age and antepartum complications. However, mean weight and percentage of ideal body weight in the supraumbilical group were both higher (P <.00001 and P <.0001, respectively), with the supraumbilical group 83 lb heavier on average. No significant differences were seen in any postoperative complication. CONCLUSION: Postoperative morbidity in morbidly obese women undergoing cesarean delivery does not differ between a supraumbilical approach and the low transverse abdominal incision.     

Surgical incision for cesarean section

Ninety-seven women undergoing cesarean section were delivered through a muscle-cutting Maylard or a Pfannenstiel abdominal incision. In these two similar groups of women, the mean Maylard incision length was significantly greater (18.3 +/- 4.5 cm) than that of the Pfannenstiel incision (14.0 +/- 2.1 cm), with no difference in operative morbidity. Difficulty with infant delivery was significantly less frequent with both the Maylard and Pfannenstiel when the incision was at least 15 cm in length. These results suggest that cesarean delivery is performed optimally with an adequate surgical incision, and that the Maylard incision is a safe option which should be strongly considered when risk factors (eg, macrosomia, twins) demand maximal surgical exposure for nontraumatic abdominal delivery.     

Joel-Cohen or Pfannenstiel incision at cesarean delivery: does it make a difference?

OBJECTIVE: To evaluate whether the technique to open the abdomen might influence the operative time and the maternal and neonatal outcome. METHODS: All consecutive women who underwent a cesarean section at a gestational age greater than or equal to 32 weeks were randomly allocated to have either the Joel-Cohen or the Pfannenstiel incision. Exclusion criteria were two or more previous cesarean sections and previous longitudinal abdominal incision. During the study period 366 patients underwent a cesarean delivery. Of these patients, 56 did not meet the inclusion criteria. The remaining patients were allocated to the Joel-Cohen (n = 152) group and to the Pfannenstiel (n = 158) group. Extraction time was defined as the time interval from skin incision to the clamping of the umbilical cord. RESULTS: The total operative time was similar in both groups [Joel-Cohen 32 min (12-60) vs. Pfannenstiel 33 min (18-70)]. The extraction time was shorter in the Joel-Cohen group than in the Pfannenstiel group [190 s (60-600) vs. 240 s (50-600), p = 0.05]. This remained statistically significant after adjustment for confounding variables (Hazard = 1.26, p = 0.05). No difference was found between groups in terms of intraoperative and postoperative complications. No difference was found in the neonatal neurodevelopmental assessment at 6 months of age in relation to the abdominal incision performed. CONCLUSION: The Joel-Cohen method of opening the abdomen at cesarean delivery is faster then the Pfannenstiel technique at delivering the fetus. However, considering the absence of benefits to the mother and the fetus there is no clear indication for performing a Joel-Cohen incision.     

Risk factors for bladder injury in patients with a prior hysterotomy

OBJECTIVE: To estimate the rate of and risk factors for bladder injury in vaginal birth after cesarean (VBAC) candidates. METHODS: Between 1995 and 2000, a 17-center, retrospective cohort study was performed, evaluating women with prior cesarean delivery for delivery mode-specific morbidity during subsequent pregnancy. Trained nurses extracted information from medical records on demographics, medical and obstetric history, pregnancy, and delivery. This secondary analysis examines the rate and risk factors for bladder injury, defined as having occurred if identified and recorded by the physician at delivery. Univariable and multivariable analyses were performed. RESULTS: Of 25,005 patients with at least one prior cesarean delivery, 107 (0.43%) sustained a bladder injury, and 91.6% (n=98) of these occurred without concurrent uterine rupture. Bladder injury risk was not affected by delivery mode: VBAC trial compared with elective cesarean delivery (0.44% compared with 0.42%, adjusted odds ratio [OR] 1.36, 95% confidence interval [CI] 0.85-2.19). For the women who undertook a VBAC trial and did not experience a uterine rupture, failure to deliver vaginally was the only predictor of bladder injury (0.86% compared with 0.22%, adjusted OR 4.61, 95% CI 2.70-8.11). In women who elect repeat cesarean delivery, greater than one prior cesarean delivery was significantly associated with bladder injury (0.68% compared with 0.29%, adjusted OR 2.40, 95% CI 1.30-4.43). CONCLUSION: Risk of bladder injury in women with a prior cesarean delivery is not affected by planned mode of delivery. Although rare, bladder injury in women undergoing VBAC is strongly associated with a failed VBAC trial. A heightened awareness for bladder injury is warranted when performing repeat cesarean deliveries in the setting of failed VBAC attempts. LEVEL OF EVIDENCE: II.     

The legendary superior strength of the Pfannenstiel incision: a myth?

OBJECTIVE: This study was undertaken to determine whether there is a difference in the frequency of fascial dehiscence between midline vertical lower abdominal and Pfannenstiel incisions among women undergoing obstetric and gynecologic operations. STUDY DESIGN: A case-control study of 48 cases of fascial dehiscence complicating 17, 995 major operations (8950 cesarean deliveries and 9405 gynecologic procedures) during a 6-year period at Wayne State University Hutzel Hospital, Detroit, was performed. Univariate analysis identified significant independent variables related to fascial dehiscence. Stepwise logistic regression analysis then identified those risk factors that were independently associated with fascial dehiscence. RESULTS: Among the 48 patients who underwent repair of fascial dehiscence after a major obstetric or gynecologic operation, 27 were from the obstetric service and 21 were from the benign and cancer gynecologic services. Wound dehiscence occurred in 10 vertical incisions and 17 Pfannenstiel incisions among the obstetric patients and in 12 vertical and 9 Pfannenstiel incisions among the gynecologic patients. The risk for dehiscence with vertical lower abdominal incisions was not increased with respect to that associated with Pfannenstiel incisions (P =.39, 2-tailed). This finding was true for all patients (odds ratio, 1.3; 95% confidence interval, 0.7-2.6), obstetric patients (odds ratio, 1.3; 95% confidence interval, 0.5-3.4), and gynecologic patients (odds ratio, 1.5; 95% confidence interval, 0.5-4.0). Forty-seven of the 48 case patients had documented wound infections, compared with 1 of the 144 control subjects (P <.0001, odds ratio, 37.8; 95% confidence interval, 14.8-96.8). CONCLUSION: Wound infection was the most important risk factor for fascial dehiscence among women who underwent major obstetric and gynecologic operations. Our results do not support the long-held belief that Pfannenstiel incisions are stronger than lower abdominal vertical incisions and reduce the risk for fascial dehiscence.     

Risk factors for bladder injury during cesarean delivery

OBJECTIVE: To identify risk factors for bladder injury during cesarean delivery so as to inform patients and practitioners of these risks. METHODS: We conducted a case-control study of women undergoing cesarean delivery at Women and Infants Hospital between January 1995 and December 2002. Cases were women with bladder injuries at the time of cesarean delivery. Two controls per case were selected randomly. Medical records were reviewed for demographic and clinical data to compare cases and controls. RESULTS: Forty-two bladder injuries were identified among 14,757 cesarean deliveries (incidence of 0.28%). Prior cesarean delivery was more prevalent among cases than controls (67% versus 32%, P < .01). The adjusted risk for bladder injury associated with prior cesarean delivery was 3.82 (95% confidence interval 1.62-8.97). Statistically significant differences (P values < or = .01) between cases and controls were found in emergent timing of delivery (31% versus 11%), labor before cesarean (83% versus 61%), attempted vaginal birth after cesarean (64% versus 22%), concurrent uterine rupture (14% versus 0%), adhesions (60% versus 10%), age (33.6 versus 29.3 years), and body mass index (29.9 versus 33.0 kg/m2). No differences were found among type of uterine incision, labor induction, chorioamnionitis, fetal position, gestational age, or maternal illnesses. CONCLUSION: Prior cesarean delivery is a risk factor for bladder injury at the time of repeat cesarean delivery. Patients should be counseled regarding this risk, particularly in the setting of increasing rates of elective primary cesarean delivery.     

Cesarean section by the Misgav Ladach+ with the abdominal opening surgery by the Joel Cohen method

The purpose of this study was to compare 90 Misgav-Ladach cesarean section by the Joel-Cohen method with 45 others with Pfannenstiel incision. The Misgav-Ladach technique involves the Joel-Cohen method, that is a superficial transverse cut in the cutis, a small midline incision in the fascia, then blunt preparation of deeper layers, including the peritoneum, followed by manual transverse traction applied to tear the recti muscles and subcutis. The uterus is also opened using the blunt preparation after a small cut in the midline. After the delivery of the fetus and placenta the uterus is lifted through the incision onto the draped abdominal wall. Then the uterus is closed with one layer of continuous vicryl suture. The abdomen is closed by a continuous suture of fascia, and widely spaced silk stitches of the skin. We sometimes use continuous suture of the skin. We do not close visceral and parietal peritoneum, recti muscles and subcutis. In our experience Misgav-Ladach method is 50% less time consuming, it reduces blood loss by about 250 ml. and allows for a much faster delivery of the fetus than Pfannenstiel method. The post operative outcome of the two methods is similar. Using the blunt preparation in the Joel-Cohen method causes less trauma and shortens convalescence time. We therefore recommend Misgav-Ladach method for cesarean section.     

Comparative study of the 'Misgav Ladach' and traditional Pfannenstiel surgical techniques for cesarean section

AIM: The aim of this study was to evaluate the advantages of the Misgav Ladach surgical technique compared to traditional cesarean section. METHODS: A prospective randomized trial of 111 women undergoing cesarean section was carried out in the Pula General Hospital. Forty-nine operations were performed using the Pfannenstiel method of cesarean section, 55 by the Misgav Ladach method and 7 by lower midline laparotomy. RESULTS: It was proved that the cases where the Misgav Ladach method was implemented, compared to the Pfannenstiel method, showed a significantly shorter delivery/extraction and operative time (P=0.0009), the incision pain on the second postoperative day was significantly lower (0.021), we recorded a quicker stand up and walking time (P=0.013), significantly fewer analgesic injections and a shorter duration of analgesia were required (P=0.0009) and the bowel function was restored to normal sooner (P=0.001). CONCLUSION: The Misgav Ladach method of cesarean section has advantages over the Pfannenstiel method in so far as it is significantly quicker to perform, with diminished postoperative pain and less use of postoperative analgesics. The recovery of physiologic function is faster. No differences were found in intraoperative bleeding, maternal morbidity, scar appearance, uterus postoperative involution and the assessment of the inflammation response to the operative technique.     

Resident education regarding technical aspects of cesarean section

OBJECTIVE: To survey obstetric/gynecologic residents around the country regarding different technical aspects of and indications for cesarean section, trends in vaginal birth after cesarean (VBAC) and patient choice of cesarean. STUDY DESIGN: A questionnaire was designed to address the above issues and selected demographic information. The questionnaire was sent by e-mail to all the residency programs in the country. The first 400 responses were analyzed. RESULTS: Although a midline vertical incision is considered faster for entry into the abdomen, 77% of residents use a Pfannenstiel incision for urgent/emergency cesarean sections. Fifty-five percent of respondents use single-layer closure of the uterine incision, 37% use double-layer closure, while 11% use single-layer closure only in patients undergoing concomitant sterilization. When questioned regarding a trial of labor, one-third of respondents stated that they would not induce labor in patients with a prior cesarean if the patients did not go into labor spontaneously but offer repeat cesarean for fear of a uterine rupture. Further, 42% said that they would never offer VBAC for an undocumented scar, 12% would and 45% would depending on the history. Regarding the issue of cesarean section by patient request, 94% would not offer an elective cesarean section for uncomplicated primigravidas, while 6% would. However, if a well-informed patient desired an elective cesarean delivery, the majority of residents would respect the patient's request. CONCLUSION: There is wide variation in the way residents are trained regarding different technical aspects of and indications for cesarean section, choice of repeat cesarean versus VBAC and patient choice of cesarean. Recent trends in the literature are not always reflected in reported practice patterns.     

The Pfannenstiel incision as a source of chronic pain

OBJECTIVE: To estimate prevalence, risk factors, and etiology of post-Pfannenstiel pain syndromes. METHODS: All women (n=866) with a Pfannenstiel incision for cesarean delivery or abdominal hysterectomy performed between January 2003 and December 2004 received a questionnaire evaluating pain located in the Pfannenstiel region. A multivariate logistic regression analysis was done to determine predictors for chronic pain development. Patients with moderate or severe pain were interviewed and underwent a physical examination. RESULTS: The response rate was 80% (690 of 866 patients). Subsequent to a follow-up after 2 years, one third (223 of 690) experienced chronic pain at the incision site. Moderate or severe pain was reported by 7%, and in 8.9% of respondents, pain impaired daily activities. Numbness, recurrent Pfannenstiel surgery, and emergency caesarean delivery were significant predictors of chronic pain. Nerve entrapment was present in over half the examined patients with moderate-to-severe pain (17 of 32). CONCLUSION: Chronic pain occurs commonly after a Pfannenstiel incision. Nerve entrapment was found to be a frequent cause of moderate-to-severe pain.     

Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion

OBJECTIVE: To determine the frequency of peritoneal and visceral adhesions to the umbilical region according to past surgical history and to estimate the risk of bowel injury with blind insertion of the principal trocar-cannula. DESIGN: Prospective, unicentric study by a single operator. SETTING: Clinique Saint-Sernin and Polyclinique de Bordeaux, Bordeaux, France. PATIENT(s): Eight hundred fourteen patients undergoing diagnostic or operative laparoscopy were classified into four groups based on their history of abdominal surgery: group I (n = 469), no previous abdominal surgery; group II (n = 125), prior laparoscopic surgery; group III (n = 131), previous laparotomy with a horizontal supra-pubic incision; group IV (n = 89), previous laparotomy with a midline incision. INTERVENTION(s): Initial microlaparoscopy performed through the left upper quadrant of the abdomen, inspection of the anterior abdominal wall and particularly the umbilical area for the presence of adhesions. Patients who had adhesions were assessed as to whether or not they were at significant risk of injury from blind insertion of the principal trocar. MAIN OUTCOME MEASURE(s): Incidence of umbilical adhesions and the potential risk of bowel injury with blind insertion of the umbilical (principal) trocar. RESULT(s): Umbilical adhesions were found in 9.82% of the 814 cases. The rates of umbilical adhesions were as follows: group I, 0.68%; group II, 1.6%; group III, 19.8%; and group IV, 51.7%. Severe adhesions with potential risk of bowel injury with blind insertion of the umbilical trocar in the four groups were 0.42%, 0.80%, 6.87%, and 31.46%, respectively. CONCLUSION(s): Women with previous laparotomy have a higher incidence of umbilical adhesions, especially in case of midline incision. Preliminary inspection of the umbilical area with a microlaparoscope and insertion of the umbilical trocar under direct vision are recommended for patients at risk for adhesions to reduce complications associated with insertion of the principal (umbilical) trocar.     

The obstetrical history in patients with Pfannenstiel scar endometriomas--an analysis of 81 patients

INTRODUCTION: The participation of immune tolerance during pregnancy was suggested to be an important factor predisposing to the implantation of decidual cells after cesarean section in Pfannenstiel scar. Delivery at term is related to the termination of immune tolerance to fetal antigens that is maintained throughout pregnancy. Substantial proportion of cesarean section deliveries is performed before the onset of true term labor. The aim of this study was to analyze the clinical symptoms of spontaneous beginning of labor in pregnant women in whom cesarean sections were performed and in whom Pfannenstiel scar endometriomas were observed during follow-up. MATERIALS AND METHODS: We have retrospectively analyzed 81 patients following the surgical removal of scar endometrioma after cesarean section. Obstetrical histories of cesarean sections in the number of 5,370 preceding the occurrence of the scar endometrioma were analyzed. These data were collected in six different Gynecological and Obstetrical wards in Malopolska Province in Poland. Analysis of data was started by the retrospective evaluation of regular uterine contractions, uterine cervix ripening before cesarean section and the indications for surgery. RESULTS: In 67 women from the group of 81 patients cesarean sections were performed with unripe uterine cervix and without the presence of regular uterine contractions. Elective indications for cesarean sections were predominant in this group of women. The relative risk of scar endometriomas occurrence following cesarean sections performed before onset of labor in comparison to cesarean sections following spontaneous onset of labor was statistically significantly higher [RR = 2.16, 95% CI = 1.21-3.83; OR = 2.18, 95% CI = 1.22-3.89]. CONCLUSIONS: Cesarean section performed before spontaneous onset of labor may increase substantially the risk of occurrence of scar endometriomas.     

Laparoscopic tubal sterilization after two or more cesarean sections

STUDY OBJECTIVE: To determine the safety of laparoscopic tubal sterilization in women who have had two or more cesarean sections. DESIGN: Retrospective study (Canadian Task Force classification III). SETTING: Private clinic and hospitals. PATIENTS: Two hundred ten consecutive women. INTERVENTION: Laparoscopic tubal sterilization. MEASUREMENTS AND MAIN RESULTS: The procedures were done with no difficulty in all but two women. In addition to the two failures, one woman experienced bladder trauma. CONCLUSION: Laparoscopic sterilization after several cesarean sections is possible and is associated with low morbidity. Scarring from cesarean sections should not be a contraindication if extra care is taken.     

Maternal morbidity associated with multiple repeat cesarean deliveries

OBJECTIVE: Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries. METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery. LEVEL OF EVIDENCE: II-2.     

Effect of type of anesthesia on blood loss at elective repeat cesarean section.

It has recently been reported that the use of halogenated agents during balanced general anesthesia may result in an increase in blood loss associated with cesarean section. This report has been criticized for failure to control for a variety of other factors that may have contributed to the increased blood loss, particularly the indication for and type of cesarean section. The present study was designed in an attempt to resolve this criticism. Blood loss was evaluated in uncomplicated patients undergoing elective repeat cesarean section under either general anesthesia using a halogenated agent (isoflurane) or regional anesthesia (spinal/epidural). All 117 singleton term, nonlaboring women underwent repeat low transverse cesarean section performed through a midline abdominal incision. Exclusion criteria included maternal medical complications, abnormal placentation, polyhydramnios, presence of uterine leiomyomas, and intraoperative complications. Seventy-five patients (64%) received regional and 42 (36%) received general anesthesia. A greater proportion of women undergoing general anesthesia experienced a postoperative decrease in hematocrit of 5 vol% or more compared with patients receiving regional anesthesia (10 of 42 versus 5 of 75, p = 0.018). Thus, we conclude that women undergoing uncomplicated elective repeat cesarean section under general anesthesia supplemented with a halogenated agent are at risk for increased blood loss compared with those women receiving regional anesthesia. However, the increased blood loss was not clinically significant in this study, since none of the patients required transfusion.     

Bladder injuries during cesarean section in a University Hospital: a 25-year review

Objectives  The objective was to determine the prevalence of bladder injury during cesarean section (CS) and identify the risk factors causing these injuries, their management and the outcome. Methods  We retrospectively reviewed the medical records of all the patients who had bladder injury during CS over a period of 25 years (1983–2007) at the King Fahad Hospital, Al-Khobar, Saudi Arabia. Demographic data, obstetric, surgical details, mechanism of injury, anatomic location, diagnosis, management and outcome were assessed. Results  Thirty-four cases of bladder injury were identified among 7,708 cesarean deliveries performed during this period with an overall incidence of 0.44%. Primary CS was found in 41.2% of the patients and 58.8% had repeat CS giving an incidence of 0.27 and 0.81%, respectively. Bladder injury occurred when surgical difficulties were encountered during opening of the peritoneal cavity and while developing the bladder flap over the lower uterine segment, mainly due to adhesions and scar tissue resulting from previous abdominal surgery. All the bladder injuries were recognized intraoperatively and repaired with an overall satisfactory outcome. Repeat CS and presence of adhesions were found to be statistically significant risk factors in the study, while operator experience and emergency nature of the CS were considered risk factors in a few cases of bladder injury. Conclusions  Data presented in this study indicates that bladder injury when adequately repaired is rarely associated with any complications. Multiple cesarean deliveries is a significant risk factor for bladder injury at the time of repeat CS and patients should be counseled regarding this risk before surgery.     

Peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri

Objective

To evaluate the safety of abdominal myomectomy for very large fibroid uteri, and to assess the effect of relevant confounding variables on the occurrence of major peri-operative complications.

Study design

A cohort study of 200 abdominal myomectomies for fibroid uteri of 16 gestational weeks or greater. Logistic regression analysis was used to examine the influence of important clinical variables on the risk of complications. A systematic literature search was conducted for evidence related to peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri.

Results

The mean (±standard deviation) uterine size was 21 ± 5 weeks. The overall rate of major complications was 30%. Peri-operative bleeding necessitating blood transfusion occurred in 49 (24.5%) cases. During surgery, two patients had bowel injury, two had bladder injury, seven women returned to theatre and two (1%) had hysterectomy. Four patients were re-admitted within 14 days of surgery. Multivariable logistic regression analysis showed that the risk of major complications was significantly higher in cases with a uterine size of 20 gestational weeks or more [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.1–10.2; p = 0.03], where 10 or more fibroids were removed (OR 3.5, 95% CI 1.1–10.8; p = 0.05) and where midline skin incision was required (OR 6.1, 95% CI 1.7–22.3; p = 0.006). On comparison of primary vs repeat abdominal myomectomy, there was significantly higher blood loss (mean 1023 ± 1112 ml vs 579 ± 787 ml; p = 0.02) and risk of major complications in the repeat myomectomy group (40% vs 5%; p < 0.001). The systematic review identified only one study that reported a comparable risk of major complications related to abdominal myomectomy for very large fibroid uteri.

Conclusion

The risk of organ injury, hysterectomy, re-operation or hospital re-admission after abdominal myomectomy for very large fibroid uteri is low, but the procedure is associated with a significant risk of bleeding necessitating blood transfusion. This risk is increased after repeat myomectomy, and in patients with a uterine size of 20 gestational weeks or larger, requiring removal of 10 or more fibroids, and requiring a midline skin incision.     

不同术式剖宫产术后二次开腹手术时盆腹腔粘连情况比较

目的 探讨Stark式剖官产术后腹膜及膀胱腹膜反折愈合及粘连发生情况。方法 采用回顾性分析的方法,对剖宫产术后二次开腹手术患者腹膜及膀胱腹膜反折粘连发生情况进行观察。其中,Stark式剖官产术后二次开腹手术89例（A组）,下腹纵切口式剖宫产术后二次开腹手术212例（B组）．Pfannenstiel切口式剖宫产术后二次开腹手术52例（C组）。比较3组患者剖宫产术后腹壁切口愈合情况以及腹直肌、腹膜、大网膜、膀胱腹膜反折愈合及粘连发生情况。结果 （1）腹壁切口愈合良好,瘢痕纤细：A组86．5％（77／89）,B组29．3％（62／212）,C组75．0％（39／52）;（2）腹直肌粘连：A组25．8％（23／89）,B组53．8％（114／212）,C组13．5％（7／52）;（3）大网膜粘连：A组13．5％（12／89）,B组56．1％（119／212）,C组25．0％（13／52）;（4）腹膜粘连：A组15．7％（14／89）,B组46．2％（98／212）,C组11．5％（6／52）;（5）腹膜未愈合：仅C组有1例,A组与B组均为0;（6）膀胱腹膜反折粘连：A组15．7％（14／89）,B组55．2％（117／212）,C组13．5％（7／52）。腹壁切口愈合及腹直肌、大网膜、腹膜、膀胱腹膜反折粘连情况,A组明显优于B组,两组比较,差异有统计学意义（P〈0．05）;A组与C组比较,差异无统计学意义（P〉0．05）。结论 Stark式剖宫产在腹壁切口愈合,减少腹直肌、大网膜、腹膜、膀胱腹膜反折粘连方面明显优于下腹纵切口式剖宫产;虽然与Pfannenstiel切口式剖宫产相比,差异无显著性,但Stark式剖宫产具有诸多公认的优点,值得推广。     

A comparative study of the cosmetic appeal of abdominal incisions used for hysterectomy

Objective To assess the cosmetic appeal of abdominal incisions used for hysterectomy.
Design A comparative study.
Setting St James's University Hospital, Leeds
Participants One hundred women, including 50 consecutive women attending a gynaecology clinic for the first time and 50 hospital staff.
Results Sixty-eight percent of women preferred a Pfannenstiel incision as the incision of first choice, while 31% chose the laparoscopic assisted vaginal hysterectomy incisions (LAVH). When women who had undergone previous abdominal surgery were compared with women with no previous surgery, there was a significant difference in their choice (80% Pfannenstiel, 18% LAVH compared with 54% Pfannenstiel, 45% LAVH).
Conclusions In gynaecological surgery there is already a cosmetically-favoured incision. One cannot assume that if a gynaecologist uses a minimally invasive surgical technique at hysterectomy that this will be cosmetically acceptable to the woman. Gynaecologists should not use cosmetic appeal in counselling women for LAVH and should concentrate on the other proven benefits of minimally invasive surgery.     

Pregnancy induced hypertension in women with gestational carbohydrate intolerance: the diagest study

OBJECTIVE: To compare the intensity of postcesarean pain between closure and nonclosure of peritoneum in the women with a midline incision and one previous cesarean section. STUDY DESIGN: The setting was an obstetrics unit of a university teaching hospital. A double-blind randomized trial was performed on 60 pregnant women with a midline incision and one previous cesarean section who underwent elective repeated cesarean section. Thirty women each were allocated to the "closure" group and the "nonclosure" group. The principal outcome measure was the postcesarean pain assessed by visual analog scale (VAS). RESULTS: There was no difference in postoperative pain for closure and nonclosure of peritoneum groups in repeated cesarean patients; while resting (P=0.8), while moving in bed (P=0.94), and while walking (P=0.52). The use of opiate (P=0.27) and oral analgesics (P=0.37) also suggested no difference. No differences were found in duration of the operation, incidence of postoperative complications, time of returned bowel function, and length of the hospital stay. CONCLUSION: The VAS showed no difference in postcesarean pain between closure and nonclosure of peritoneum.