Comparison between extraperitoneal and transperitoneal cesarean section: Retrospective case-control study

Abstract

Introduction  The main advantage of extraperitoneal cesarean section (EXPCS) is not only less pain, faster recovery, and less potential for infection but also a possible lack of intraperitoneal adhesions.

Methods  In a 3-year period from 2019 to 2022, 88 EXPCSs were performed. A comparison was made with 90 patients who underwent a standard transperitoneal cesarean section (TPCS). For both groups, the inclusion criterion was uterine inertia and prolonged labor as an indication for cesarean section. Only pregnant women from 37 to 42 weeks were included. After this, 51 patients remained in the EXPCS arm, and 49 remained in the TPCS arm.

Results  No statistical difference was found in gestational weeks, newborn weight, Apgar score, erythrocyte (Er), hemoglobin (Hgb), and hematocrit (Htc) values and duration of operative time between the EXPCS and TPCS groups. Leukocytes, C-reactive protein (CRP) with fever higher than >38°C on the third postoperative day were found statistically significantly (p=0.005) higher in the TPCS group. The usage of tramadol + metamizole at 3, 6, and 9 hours after delivery and diclofenac at 6, 12, and 18 hours after surgery was statistically significantly (p<0.05) higher in the TPCS group. On the visual analog scale (VAS) 24 hours after surgery, a statistically significant difference was found (p = 0.001) between the two groups. In the small group of patients who underwent a TPCS section after an EXPCS, intraperitoneal adhesions were not found; in another group of patients who underwent a TPCS twice, adhesions were found in 12 patients; Fisher's exact test (p=0.04).

Conclusion  The protective effect of EXPCS for infection could be proven in prolonged delivery. EXPCS could be a good solution in the fight against adhesions and infection in women who undergo second, third, or even fourth cesarean sections.

Keywords

cesarean section - obstetrics - uterus

Publication History

Received: 11 December 2023

Accepted after revision: 16 May 2024

Article published online:
16 July 2024

• References

• 1 Boerma T, Ronsmans C, Melesse DY. et al. Global epidemiology of use of and disparities in caesarean sections. Lancet 2018; 392: 1341-1348
• 2 Betran AP, Ye J, Moller AB. et al. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health 2021; 6: e005671
• 3 Gui B, Danza FM, Valentini AL. et al. Multidetector CT appearance of the pelvis after cesarean delivery: normal and abnormal acute findings. Diagn Interv Radiol 2016; 22: 534-541
• 4 Levin D, Tulandi T. Dense adhesions between the uterus and anterior abdominal wall: a unique complication of Cesarean delivery. Gynecol Surg 2011; 8: 415-416
• 5 Mascarello KC, Matijasevich A, Barros AJD. et al. Repeat cesarean section in subsequent gestation of women from a birth cohort in Brazil. Reprod Health 2017; 14: 102-105
• 6 Nisenblat V, Barak S, Griness OB. et al. Maternal complications associated with multiple cesarean deliveries. Obstet Gynecol 2002; 108: 21-26
• 7 Arlier S, Seyfettinoğlu S, Yilmaz E. et al. Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section. Arch Gynecol Obstet 2017; 295: 303-311
• 8 Velin L, Umutesi G, Riviello R. et al. Surgical site infections and antimicrobial resistance after cesarean section delivery in rural Rwanda. Ann Glob Health 2021; 87: 77
• 9 Traoré Y, Téguété I, Bocoum A. et al. Infectious complications after cesarean delivery: trends of incidences, risk factors, and prognosis in a third health level center in Africa. Case of Gabriel Touré Teaching Hospital. J Obstet Gynecol 2018; 8: 10-19
• 10 Mahalingam N, Manivannan B, Khamari B. et al. Detection of antibiotic resistance determinants and their transmissibility among clinically isolated carbapenem-resistant Escherichia coli from South India. Med Princ Pract 2018; 27: 428-435
• 11 Bogdanović G, Cerovac A, Cerovac E. et al. Bacterial causes and antibiotics susceptibility profile of surgical site infection following cesarean section. Clin Exp Obstet Gynecol. 2022 . 49. 90
• 12 Acosta CD, Knight M. Sepsis and maternal mortality. Curr Opin Obstet Gynecol 2013; 25: 109-116
• 13 Edwards W, Dore S, van Schalkwyk J. et al. Prioritizing maternal sepsis: National adoption of an obstetric early warning system to prevent morbidity and mortality. J Obstet Gynecol Can 2020; 42: 640-643
• 14 Antoine C, Young BK. Cesarean section one hundred years 1920–2020: the Good, the Bad and the Ugly. Journal Perinatal Med 2020; 49: 5-16
• 15 Li P, Wang L, Qian X. et al. A study of uterine inertia on the spontaneous of labor using uterine electromyography. Taiwan J Obstet Gynecol 2021; 60: 449-453
• 16 Bačić B, Hrgović Z, Cerovac A. et al Extraperitoneal cesarean section after two medial laparotomies, anus prater, and surgical treatment of the rectovaginal fistula in a patient with Crohn's disease: A case report. Z Geburtshilfe Neonatol 2023; 6 Online ahead of print
• 17 Riley P. Extraperitoneal cesarean section. Obstet Gynecol 1981; 57: 265-266
• 18 Tappauf C, Schest E, Reif P. et al. Extraperitoneal versus transperitoneal cesarean section: a prospective randomized comparison of surgical morbidity. Am J Obstet Gynecol 2013; 209: 338.e1-8
• 19 Ji C, Chen M, Qin Y. Extraperitoneal versus transperitoneal cesarean section: a retrospective study. Postgrad Med 2022; 28: 1-5
• 20 Yesilbas C, Erenel H. Extraperitoneal versus transperitoneal cesarean section: a retrospective analysis. Perinatal J 2017; 25: 38-42
• 21 Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nur Health 1990; 13: 227-236
• 22 Miyazaki K, Jwa SC, Katayama E. et al. Postoperative C-reactive protein as a predictive marker for surgical site infection after cesarean section: Retrospective analysis of 748 patients at a Japanese academic institution. PloS One 2022; 17: e0273683
• 23 Mertens K, Muys J, Jacquemyn Y. Postpartum C-reactive protein: A limited value to detect infection or inflammation. Facts Views Vis Obgyn 2019; 11: 243-250
• 24 Rosene K, Eschenbach DA, Tompkins LS. et al. Polymicrobial early postpartum endometritis with facultative and anaerobic bacteria, genital mycoplasmas, and Chlamydia trachomatis: treatment with piperacillin or cefoxitin. J Infect Dis 1986; 153: 1028-1037
• 25 Tulandi T, Lyell DJ. Classification of intra-abdominal adhesions after cesarean delivery. Gynecol Surg 2013; 10: 25-29
• 26 Senturk MB, Kilicci C, Doğan O. et al. I. Comparison of extra-peritoneal and intra-peritoneal cesarean technique: a prospective randomised trial. Clin Exp Obstet Gynecol 2018; 15: 756-751
• 27 Bebincy DS, Chitra J. Extraperitoneal versus transperitoneal cesarean section in surgical morbidity in a tertiary care centre. Int J Reprod Contracept Obstet Gynecol 2017; 6: 3397-3399
• 28 Karaaslan O, Türkyılmaz G, Simsek E. Extraperitoneal cesarean, is it safe and comfortable?. East J Med 2020; 25: 530-534
• 29 Zabransky F, Grossmannova H. Extraperitoneal cesarean section – an alternative or routine?. Ceska gynekologie 2001; 66: 187-189
• 30 Perry AK, Rossi RM, DeFranco EA. Severe adverse maternal outcomes associated with chorioamnionitis. Am J Obstet Gynecol 2019; 3: 100027
• 31 Mark SP, Croughan-Minihane MS, Kilpatrick SJ. Chorioamnionitis and uterine function. Obstet Gynecol Oncol 2000; 95: 909-912
• 32 Hagglund L, Christensen KK, Christensen P. et al. Risk factors in cesarean section infection. Obstet Gynecol 1983; 62: 145-150
• 33 Dimassi K, Halouani A, Kammoun A. et al. The extraperitoneal French AmbUlatory cesarean section technique leads to improved pain scores and a faster maternal autonomy compared with the intraperitoneal Misgav Ladach technique: A prospective randomized controlled trial. PloS One 2021; 16: e0245645
• 34 Ding Y, Zhu F, Tao G. Clinical observation of improved passing peritoneum extraperitoneal cesarean sectron. Hunan Yi Ke Da Xue Xue Bao 1997; 22: 434-436
• 35 Seyam E, Ibrahim EM, Youseff AM. et al. Laparoscopic management of adhesions developed after peritoneal nonclosure in primary cesarean section delivery. Obstet Gynecol Int 2018; 2018: 6901764
• 36 Habek D, Cerovac A, Luetić A. et al. Modified Stark's (Misgav Ladach) caesarean section: 15-year experience of the own techniques of caesarean section. Eur J Obstet Gynecol Reprod Biol 2020; 247: 90-93
• 37 CORONIS Trial Collaborative Group. The CORONIS Trial. International study of caesarean section surgical techniques: a randomised fractional, factorial trial. BMC Pregnancy Childbirth 2007; 7: 24
• 38 Myers SA, Bennett TL. Incidence of significant adhesions at repeat cesarean section and the relationship to method of prior peritoneal closure. J Reprod Med 2005; 50: 659-662
• 39 Ten Broek RPG, Kok-Krant N, Bakkum EA. et al. Different surgical techniques to reduce post-operative adhesion formation: a systematic review and meta-analysis. Hum Reprod Update 2013; 19: 12-25
• 40 Lyell DJ, Caughey AB, Hu E, Daniels K. Peritoneal closure at primary cesarean delivery and adhesions. Obstet Gynecol 2005; 106: 275-280
• 41 Cheong YC, Premkumar G, Metwally M. et al. To close or not to close? A systematic review and a meta-analysis of peritoneal non-closure and adhesion formation after caesarean section. Eur J Obstet Gynecol Reprod Biol 2009; 147: 3-8