Grand Rounds

Double or Single Layer Closure for Best Cesarean-Section Outcomes?

BACKGROUND AND PURPOSE:

Niche on ultrasound describes a triangular anechoic area at the site of a previous cesarean section
- Seen with saline or gel contrast hysterosonography
- Residual myometrium thickness (RMT) at apex of niche is thin
Possible that RMT thickness related to closure technique
Stegwee et al. (BJOG, 2017) examined whether uterine closure technique after cesarean section has an impact on maternal and ultrasound outcomes

Systematic review and meta-analysis
Literature search of randomized controlled trials (RCTs) or prospective cohort studies that evaluated uterine closure techniques and reported on ultrasound findings, perioperative or long-term outcomes
The following techniques were included in the analyses
- Single- versus double-layer closure
- Locked versus unlocked suturing
- Inclusion versus exclusion of the decidua
Outcomes
- Ultrasound findings post cesarean section
- Intra-operative and short-term post-operative findings
- Gynecologic symptoms
- Reproductive outcomes

Meta analyses performed using twenty studies
Data was analyzed from 15,053 women
RMT decreased by 1.26 mm after single- vs double-layer closure (95% CI -1.93 to -0.58; P=0.0003)
- More pronounced with locked sutures
Healing ratio (RMT/adjacent myometrium thickness) was decreased with single-layer closure (Weighted mean difference -7.74%, 95% CI -13.31 to -2.17)
- More pronounced with locked sutures
Niche more common when the decidua was excluded (RR 1.71, 95% CI 1.11-2.62)
Dysmenorrhea occurred more often in the single-layer group (RR 1.23, 95% CI 1.01-1.48)
Incidence of uterine rupture was similar (RR 1.91, 95% CI 0.63-5.74) between groups

Double-layer unlocked sutures were preferable to single-layer locked sutures regarding RMT, healing ratio and dysmenorrhea
Niche prevalence increased with excluded decidua

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