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

METHODS:

• 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

RESULTS:

• 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

CONCLUSION:

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

Learn More – Primary Sources:

Uterine caesarean closure techniques affect ultrasound findings and maternal outcomes: a systematic review and meta-analysis.

Does Adding a 2nd Layer to Uterine Closure of a Cesarean Section Alter Outcomes?

INTRODUCTION: 

• There are randomized studies evaluating the addition of the second layer, but generally following locked suture technique  
• Bennich et al. (Ultrasound Obstet Gynecol, 2016) investigated the impact of adding a second layer to a single unlocked closure of a cesarean uterine incision on residual myometrial thickness (RMT) as a proxy for uterine rupture risk 

METHODS: 

• Randomized double-blind controlled trial (2008-2013) 
• Nulliparous women > 37 weeks scheduled for cesarean section  
• Women randomized to 
  •  Single-layer technique (continuous) 
  •  Double-layer technique 2nd layer (continuous – up to 3 separate sutures for hemostasis if needed)  
• At discharge 
  • Transabdominal ultrasound  
• At 5 months  
  • Saline contrast sonohysterography at a minimum of 5 months postpartum 
• Ultrasound examiners were blinded to closure technique 

RESULTS: 

• Single layer n= 35; double-layer n= 38 
• No difference in age, BMI or perioperative characteristics (e.g., duration of surgery) between groups  
• When comparing groups, there were no difference in the RMT whether at discharge (mean ± SD, 20.2 ± 8.0 mm vs 21.0 ± 9.7 mm) or after 5 months postpartum (5.7 ± 2.9 mm vs 5.7 ± 2.2 mm) 
  • RMT was approximately half that of the normal myometrium at both examinations 
• There were also no differences in gestational age at delivery, duration of surgery and perioperative blood loss 

CONCLUSION: 

• Double-layer closure of C-section incision does not increase RMT compared with single-layer closure when an unlocked technique is used 
• Some previous studies demonstrated a larger RMT with double-layer used locked first-layer 
• Authors suggest that unlocked technique for the first-layer is at least as good as double layer, and a first-layer locking technique may result in reduced RMT and possible increase risk for rupture 

Learn More – Primary Sources

Impact of adding a second layer to a single unlocked closure of a Cesarean uterine incision: randomized controlled trial 

Do Different Surgical C-Section Techniques Affect Outcomes?

PURPOSE:

This study by the Coronis Collaborative Group (Lancet, 2016) aimed to determine if there were differences in maternal morbidity depending on which of five surgical techniques for caesarean section a woman received.

METHODS:

Randomized Control Trial

RESULTS:

13,153 women were followed up with for a mean duration of 3.8 years after receiving a C-section through one of five surgical techniques. The five pairs of alternative surgical techniques surveyed were blunt vs. sharp abdominal entry; exteriorization of the uterus vs. intra-abdominal repair; single vs. double layer closure of the uterus; closure vs. non-closure of the peritoneum; and chromic catgut vs. polyglactin-910 sutures.

The study found no evidence to prefer one surgical technique over another based on the following outcomes

• Blunt vs sharp abdominal entry
  • Abdominal hernias: no difference (adjusted relative risk 0·66; 95% CI 0·39–1·11)
• Exteriorization vs abdominal repair
  • Infertility: no difference (adjusted relative risk 0·91, 0·71–1·18)
  • Ectopic pregnancy: no difference (adjusted relative risk 0·50, 0·15–1·66)
• Single vs double uterine closure
  • Maternal death: no difference (adjusted relative risk 0·78, 0·46–1·32)
  • Composite of pregnancy complications (adjusted relative risk 1·20, 0·75–1·90)
• Peritoneal closure vs non-closure
  • Pelvic adhesions (related complications such as infertility): no difference (adjusted relative risk 0·80, 0·61–1·06)
• Chromic catgut vs polyglactin-910 sutures
  • Adverse pregnancy outcomes in a subsequent pregnancy, such as uterine rupture: no difference (adjusted relative risk 3·05, 0·32–29·29).

CONCLUSIONS:

• Overall, severe adverse outcomes were uncommon in these settings
• Determination of technique will take in to account other factors including time and cost

Learn More – Primary Sources:

Caesarean section surgical techniques: 3 year follow-up of the CORONIS fractional, factorial, unmasked, randomised controlled trial

Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and meta-analysis