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Extraperitoneal versus transperitoneal cesarean section: a prospective randomized comparison of surgical morbidity

      Objective

      We sought to test the hypothesis that an extraperitoneal cesarean section (ECS) technique reduces postoperative pain without increasing intraoperative and postoperative complications.

      Study Design

      In a single-center, single-blinded prospective trial we randomized 54 patients with an indication for primary or first repeat cesarean section at term pregnancy to an ECS (n = 27) or transperitoneal cesarean section (TCS) (n = 27) procedure. Patients with suspected abnormal placentation, a history of >1 cesarean section, or major abdominal surgery were excluded. The primary endpoint of the study was maximum abdominal pain measured by numeric rating scale ranging from 0–10.

      Results

      Patients after ECS had significantly less maximum surgical site pain than patients after TCS. Median peak pain scores on postoperative day 1 were 4.00 (interquartile range, 3.00–5.00) for ECS and 5.00 (interquartile range, 4.00–7.00) for TCS, respectively (P = .031). Analgesic requirements, intraoperative nausea, and postoperative shoulder pain were significantly less after ECS. Overall operative time was significantly shorter in ECS, with no difference in delivery time. No bladder injury occurred in either group. There were no differences in estimated blood loss and neonatal outcome. Urogenital distress, urinary tract infection, and bowel dysfunction did not differ at discharge from hospital and 6 weeks after.

      Conclusion

      An extraperitoneal approach to cesarean section appears to reduce postoperative pain, usage of analgesics, and intraoperative nausea without an increase in significant complications.

      Key words

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      References

        • Martin J.A.
        • Hamilton B.E.
        • Ventura S.J.
        • et al.
        Births: final data for 2009.
        Natl Vital Stat Rep. 2011; 60: 1-70
        • Eisenach J.C.
        • Pan P.
        • Smiley R.M.
        • Lavand'homme P.
        • Landau R.
        • Houle T.T.
        Resolution of pain after childbirth.
        Anesthesiology. 2013; 118: 143-151
        • O'Dwyer V.
        • Hogan J.L.
        • Farah N.
        • Kennelly M.M.
        • Fitzpatrick C.
        • Turner M.J.
        Maternal mortality and the rising cesarean rate.
        Int J Gynaecol Obstet. 2012; 116: 162-164
        • Holmgren G.
        • Sjöholm L.
        • Stark M.
        The Misgav Ladach method for cesarean section: method description.
        Acta Obstet Gynecol Scand. 1999; 78: 615-621
        • Bates Jr., G.W.
        • Shomento S.
        Adhesion prevention in patients with multiple cesarean deliveries.
        Am J Obstet Gynecol. 2011; 205: S19-S24
        • Sikirica V.
        • Broder M.S.
        • Chang E.
        • Hinoul P.
        • Robinson D.
        • Wilson M.
        Clinical and economic impact of adhesiolysis during repeat cesarean delivery.
        Acta Obstet Gynecol Scand. 2012; 91: 719-725
        • Lyell D.J.
        • Caughey A.B.
        • Hu E.
        • Blumenfeld Y.
        • El-Sayed Y.Y.
        • Daniels K.
        Rectus muscle and visceral peritoneum closure at cesarean delivery and intraabdominal adhesions.
        Am J Obstet Gynecol. 2012; 206: 515.e1-515.e5
        • Tollånes M.C.
        • Melve K.K.
        • Irgens L.M.
        • Skjaerven R.
        Reduced fertility after cesarean delivery: a maternal choice.
        Obstet Gynecol. 2007; 110: 1256-1263
        • Ten Broek R.P.G.
        • Kok-Krant N.
        • Bakkum E.A.
        • Bleichrodt R.P.
        • Van Goor H.
        Different surgical techniques to reduce post-operative adhesion formation: a systematic review and meta-analysis.
        Hum Reprod Update. 2013; 19: 12-25
        • Kapustian V.
        • Anteby E.Y.
        • Gdalevich M.
        • Shenhav S.
        • Lavie O.
        • Gemer O.
        Effect of closure versus nonclosure of peritoneum at cesarean section on adhesions: a prospective randomized study.
        Am J Obstet Gynecol. 2012; 206: 56.e1-56.e4
        • Alpay Z.
        • Saed G.M.
        • Diamond M.P.
        Postoperative adhesions: from formation to prevention.
        Semin Reprod Med. 2008; 26: 313-321
        • Lehmann V.
        Der Kayserliche Schnitt. Die Geschichte einer Operation.
        Schattauer, Stuttgart2006
        • Latzko W.
        Der extraperitoneale Kaiserschnitt.
        Wien Klin Wochenschr. 1909; 22: 478-482
        • Cacciarelli R.A.
        Extraperitoneal cesarean section; a new paravesical approach.
        Am J Surg. 1949; 78: 371-373
        • Norton J.F.
        A paravesical extraperitoneal cesarean section technique; with an analysis of 160 paravesical extraperitoneal cesarean sections.
        Am J Obstet Gynecol. 1946; 51: 519-526
        • Waters E.G.
        Supravesical extraperitoneal cesarean section: Waters' type.
        Clin Obstet Gynecol. 1959; 2: 985-998
        • Wallace R.L.
        • Eglinton G.S.
        • Yonekura M.L.
        • Wallace T.M.
        Extraperitoneal cesarean section: a surgical form of infection prophylaxis?.
        Am J Obstet Gynecol. 1984; 148: 172-177
        • Hanson H.B.
        Current use of the extraperitoneal cesarean section: a decade of experience.
        Am J Obstet Gynecol. 1984; 149: 31-34
        • Zábranský F.
        • Grossmannová H.
        Extraperitoneal cesarean section–an alternative or routine?.
        Ceska Gynekol. 2001; 66: 187-189
        • Zábranský F.
        Some recent observations on the extraperitoneal cesarean section.
        Zentralbl Gynakol. 1985; 107: 574-576
      1. Fauck M. Ambulatory cesarean section, 2009. Available at: http://www.youtube.com/watch?v=dvCXhQU0eqE&feature=youtube_gdata_player. Accessed June 12, 2011.

        • Joschko R.
        Comparison of the intra- and postoperative course in 254 extraperitoneal and 102 intraperitoneal cesarean sections [in German].
        Zentralbl Gynakol. 1974; 96: 1553-1562
        • Williamson A.
        • Hoggart B.
        Pain: a review of three commonly used pain rating scales.
        J Clin Nurs. 2005; 14: 798-804
        • Schug S.
        • Auret K.
        Clinical pharmacology: principles of analgesic drug management.
        in: Sykes N. Bennett M.I. Yuan C.-S. Clinical pain management: cancer pain. 2nd ed. Hodder Arnold;, London2008: 104-122
        • Hicks C.L.
        • von Baeyer C.L.
        • Spafford P.A.
        • Van Korlaar I.
        • Goodenough B.
        The faces pain scale–revised: toward a common metric in pediatric pain measurement.
        Pain. 2001; 93: 173-183
        • Holdgate A.
        • Asha S.
        • Craig J.
        • Thompson J.
        Comparison of a verbal numeric rating scale with the visual analogue scale for the measurement of acute pain.
        Emerg Med. 2003; 15: 441-446
        • Chanques G.
        • Viel E.
        • Constantin J.M.
        • et al.
        The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales.
        Pain. 2010; 151: 711-721
      2. WHO. WHO's pain ladder. Available at: http://www.who.int/cancer/palliative/painladder/en/. Accessed April 30, 2012.

      3. German National Working Group of Scientific Medical Societies (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V.). S3-Leitlinie, Behandlung akuter perioperativer und posttraumatischer Schmerzen—. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften eV AWMF, Reg. 2008;(041/001). Available at: http://www.awmf.org/uploads/tx_szleitlinien/041-001_S3_Behandlung_akuter_perioperativer_und_posttraumatischer_Schmerzen_aktualisierte_Fassung_04-2009_05-2011.pdf. Accessed May 14, 2012.

        • Maier C.
        • Nestler N.
        • Richter H.
        • et al.
        The quality of pain management in German hospitals.
        Dtsch Arztebl Int. 2010; 107: 607
        • American Society of Anesthesiologists
        Practice guidelines for acute pain management in the perioperative setting.
        Anesthesiology. 2012; 116: 248-273
        • Shumaker S.A.
        • Wyman J.F.
        • Uebersax J.S.
        • McClish D.
        • Fantl J.A.
        Health-related quality of life measures for women with urinary incontinence: the incontinence impact questionnaire and the urogenital distress inventory; continence program in women (CPW) research group.
        Qual Life Res. 1994; 3: 291-306
        • Altman D.
        • Väyrynen T.
        • Engh M.E.
        • Axelsen S.
        • Falconer C.
        Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse.
        N Engl J Med. 2011; 364: 1826-1836
        • Uebersax J.S.
        • Wyman J.F.
        • Shumaker S.A.
        • McClish D.K.
        Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory.
        Neurourol Urodyn. 1995; 14: 131-139
        • Bjelic-Radisic V.
        • Dorfer M.
        • Tamussino K.
        • Greimel E.
        Psychometric properties and validation of the German-language King's health questionnaire in women with stress urinary incontinence.
        Neurourol Urodyn. 2005; 24: 63-68
        • Bjelic-Radisic V.
        • Dorfer M.
        • Tamussino K.
        • et al.
        The incontinence outcome questionnaire: an instrument for assessing patient-reported outcomes after surgery for stress urinary incontinence.
        Int Urogynecol J Pelvic Floor Dysfunct. 2007; 18: 1139-1149
        • Walsh C.A.
        Evidence-based cesarean technique.
        Curr Opin Obstet Gynecol. 2010; 22: 110-115
        • Berghella V.
        • Baxter J.K.
        • Chauhan S.P.
        Evidence-based surgery for cesarean delivery.
        Am J Obstet Gynecol. 2005; 193: 1607-1617
        • Wood R.M.
        • Simon H.
        • Oz A.U.
        Pelosi-type vs traditional cesarean delivery: a prospective comparison.
        J Reprod Med. 1999; 44: 788-795
        • Tuuli M.G.
        • Odibo A.O.
        • Fogertey P.
        • Roehl K.
        • Stamilio D.
        • Macones G.A.
        Utility of the bladder flap at cesarean delivery: a randomized controlled trial.
        Obstet Gynecol. 2012; 119: 815-821
      4. Randomizer: Web-based patient randomization service for multi-center clinical trials. Available at: http://www.randomizer.at/index.php. Accessed June 15, 2011.