Cesarean section (CS) is the most common intraperitoneal surgical procedure in obstetric and gynecologic practice. The most common method during the late 20th century was the Pfannenstiel-Kerr (PK) method, which uses a curved transverse suprapubic incision in the abdominal skin, a transverse lower uterine segment incision, including a double-layer uterine suture, and peritoneal closure. In the 1970s, the Joel-Cohen technique was developed to cause the least damage to tissues, avoid superfluous steps, and make the intervention the simplest possible. This technique was adopted at the Misgav-Ladach hospital in Jerusalem and underwent further changes to become the modified Misgav-Ladach (MML) technique, which was believed to make the procedure more acceptable to clinicians and patients. This 9-year prospective study was performed to compare the MML with the classic PK technique for intraoperative and short-term postoperative outcomes.
Women undergoing an elective or emergent CS were selected for either the MML or PK technique according to surgeons’ preferences; patients were not randomized. All CSs were performed under general anesthesia. Intravenous analgesics were administered to all patients on postoperative day 1 (POD 1), and anticoagulant therapy was administered to all patients for 10 days after the CS. Main outcome measures were the duration of surgery, analgesic requirements, febrile morbidity, postoperative antibiotic use, postpartum endometriosis, wound complications, and hospitalization time. Wound complications were evaluated on POD 3. The outcomes for the techniques were compared using the χ2 test for proportions and Student t test for continuous variables. In a secondary analysis, outcomes were compared between women who delivered in 2003–2004, the first 2 years of the study, and women who delivered in 2010–2011, the last 2 years, when the MML technique had become the method of choice for all primary CSs. In the PK procedure, the uterine incision was closed in 2 layers (endometrium and myometrium separated) with a continuous suture. Visceral and parietal peritoneum was closed with a continuous suture and the rectus muscles with 3 to 5 interrupted approximating sutures. The transversely incised fascia was closed with a continuous suture, and the subcutis was sutured in interrupted stitches. For the MML procedure, the uterine incision was closed in 1 layer with continuous suture reapproximating the full thickness of the myometrium, with additional hemostatic stitches if required. The suture was usually unlocked. The skin was closed with widely spaced sutures. Postpartum care for both procedures were similar with intravenous hydration on the day of the surgery, catheter removal on POD 1 or 2, drinking 12 to 24 hours postoperatively, and regular diet from POD 2 or 3. Stitches were removed on POD 7.
A total of 4336 women underwent the MML technique, and 608 underwent the PK technique. The obstetric characteristics and indications for CS did not differ significantly between the 2 groups. Compared with the PK technique, the MML technique was associated with a shorter operative time (13.4 ± 7.4 vs 19.1 ± 6.8 minutes), less surgical material (3.5 ± 2.5 vs 7.9 ± 2.1), lower requirements for postoperative analgesics (5.01 ± 4.7 vs 8.9 ± 1.4 doses), and lower rates of febrile morbidity (1.27% vs 6.6%) and wound infections (1.64% vs 4.9%). By the end of the study period, nearly all CSs were performed using the MML technique. Analysis of outcomes comparing 2003–2004 with 2010–2011 showed shorter operative times (17.9 ± 1.3 vs 14.2 ± 6.3 minutes), less surgical material (6.3 ± 4.7 vs 3.7 ± 2.1), lower requirements for postoperative analgesics (9.1 ± 4.7 vs 6.6 ± 2.2 doses), and lower rates of febrile morbidity (5.4% vs 1.2%), wound infections (6.8% vs 1.6%), and dehiscence (3.1% vs 1.4%) in 2010–2011.
Because of the many technical differences between these 2 methods, the differences in outcomes may be secondary to specific steps of the procedures instead of the overall technique. The MML technique seems to be the least traumatic surgical procedure. Controversy still exists over the impact of the single- versus double-layer closure of the uterus on the risk of uterine rupture at the next pregnancy and on the choice between parietal and visceral closure of the peritoneum. The results suggest that the MML technique might lead to better short-term postoperative outcomes, especially in reduction of pain and postoperative complications compared with the PK technique.