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Peritoneal closure at primary cesarean section decreases adhesion formation

      Objective

      To evaluate the effect of peritoneal closure at cesarean section on adhesion formation.

      Study design

      A prospective cohort of women undergoing repeat cesarean section was studied. Immediately after performing a first repeat cesarean section, surgeons scored the location and severity of adhesions. We then abstracted medical charts for previous surgical technique regarding peritoneal closure, closure of the bladder flap and rectus muscles, use of irrigation and antibiotics, and blood loss, operative times, postoperative complications, race, and insurance. Excluded were patients with other prior laparotomy, first postoperative wound breakdown, unavailable first postoperative course, or steroid-dependent disease. Chi-square and multi-variate logistic regression were used for analysis. We estimated that we needed 110 patients to obtain 80% power to detect a 50% reduction in adhesion formation when the peritoneum was left open.

      Results

      Among the 175 patients included, prior peritoneal closure was associated with significantly decreased adhesions of the omentum to fascia (RR = 0.35, P = 0.003), omentum to uterus (RR = 0.47, P = 0.04), and a trend toward decreased fascial to uterine adhesions (RR = 0.53, P = 0.057). Of note, patients with puerperal infections at the prior cesarean (RR = 2.98, P = 0.001) and those receiving public assistance (RR = 1.48, P = 0.004) had more adhesion formation. In the multivariate models we controlled for ethnicity, maternal age, prior infection, and public assistance and found that prior peritoneal closure had a fourfold protective effect for omental to fascial adhesions (OR .24, P = 0.005). Public assistance (OR 3.2, P = 0.05) and prior infection (OR 3.12, P = 0.03) were predictive of increased omental to uterine adhesions.

      Conclusion

      Peritoneal closure at primary cesarean section was associated with decreased adhesion formation. This effect was especially pronounced among higher risk patients such as those with puerperal infection. This question will benefit from prospective analyses.