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Meta-Analysis
. 2014 Aug 11;2014(8):CD000163.
doi: 10.1002/14651858.CD000163.pub2.

Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes

Anthony A Bamigboye  1 , G Justus Hofmeyr
Affiliations
Meta-Analysis

Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes

Anthony A Bamigboye et al. Cochrane Database Syst Rev. .

Abstract

Background: Caesarean section is a very common surgical procedure worldwide. Suturing the peritoneal layers at caesarean section may or may not confer benefit, hence the need to evaluate whether this step should be omitted or routinely performed.

Objectives: The objective of this review was to assess the effects of non-closure as an alternative to closure of the peritoneum at caesarean section on intraoperative and immediate- and long-term postoperative outcomes.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 November 2013).

Selection criteria: Randomised controlled trials comparing leaving the visceral or parietal peritoneum, or both, unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked it for accuracy.

Main results: A total of 29 trials were included in this review and 21 trials (17,276 women) provided data that could be included in an analysis. The quality of the trials was variable. 1. Non-closure of visceral and parietal peritoneum versus closure of both parietal layersSixteen trials involving 15,480 women, were included and analysed, when both parietal peritoneum was left unclosed versus when both peritoneal surfaces were closed. Postoperative adhesion formation was assessed in only four trials with 282 women, and no difference was found between groups (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.76 to 1.29). There was significant reduction in the operative time (mean difference (MD) -5.81 minutes, 95% CI -7.68 to -3.93). The duration of hospital stay in a total of 13 trials involving 14,906 women, was also reduced (MD -0.26, 95% CI -0.47 to -0.05) days. In a trial involving 112 women, reduced chronic pelvic pain was found in the peritoneal non-closure group. 2. Non-closure of visceral peritoneum only versus closure of both peritoneal surfacesThree trials involving 889 women were analysed. There was an increase in adhesion formation (two trials involving 157 women, RR 2.49, 95% CI 1.49 to 4.16) which was limited to one trial with high risk of bias.There was reduction in operative time, postoperative days in hospital and wound infection. There was no significant reduction in postoperative pyrexia. 3. Non-closure of parietal peritoneum only versus closure of both peritoneal layersThe two identified trials involved 573 women. Neither study reported on postoperative adhesion formation. There was reduction in operative time and postoperative pain with no difference in the incidence of postoperative pyrexia, endometritis, postoperative duration of hospital stay and wound infection. In only one study, postoperative day one wound pain assessed by the numerical rating scale, (MD -1.60, 95% CI -1.97 to -1.23) and chronic abdominal pain d by the visual analogue score (MD -1.10, 95% CI -1.39 to -0.81) was reduced in the non-closure group. 4. Non-closure versus closure of visceral peritoneum when parietal peritoneum is closed.There was reduction in all the major urinary symptoms of frequency, urgency and stress incontinence when the visceral peritoneum is left unsutured.

Authors' conclusions: There was a reduction in operative time across all the subgroups. There was also a reduction in the period of hospitalisation post-caesarean section except in the subgroup where parietal peritoneum only was not sutured where there was no difference in the period of hospitalisation. The evidence on adhesion formation was limited and inconsistent. There is currently insufficient evidence of benefit to justify the additional time and use of suture material necessary for peritoneal closure. More robust evidence on long-term pain, adhesion formation and infertility is needed.

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Conflict of interest statement

None known.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
Funnel plot of comparison: 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, outcome: 1.2 Wound infection.
4
4
Funnel plot of comparison: 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, outcome: 1.6 Infectious morbidity.
5
5
Funnel plot of comparison: 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, outcome: 1.8 Operating time (minutes).
6
6
Funnel plot of comparison: 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, outcome: 1.9 Postoperative days in hospital.
1.1
1.1. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 1 Postoperative adhesions.
1.2
1.2. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 2 Wound infection.
1.3
1.3. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 3 Uterine dehiscence.
1.4
1.4. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 4 Numbers of narcotic analgesics required.
1.5
1.5. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 5 Additional analgesia after 24‐48 hours.
1.6
1.6. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 6 Infectious morbidity.
1.7
1.7. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 7 Endometritis.
1.8
1.8. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 8 Operating time (minutes).
1.9
1.9. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 9 Postoperative days in hospital.
1.10
1.10. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 10 Chronic pelvic pain.
1.11
1.11. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 11 Pain at 6 weeks postpartum.
1.12
1.12. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 12 Secondary infertility.
1.13
1.13. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 13 Blood transfusion > 1 unit (not prespecified outcome).
1.14
1.14. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 14 Maternal death (not prespecified outcome).
1.15
1.15. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 15 Intervention for postpartum haemorrhage (not prespecified outcome).
1.16
1.16. Analysis
Comparison 1 Non‐closure of both parietal and visceral peritoneum versus closure of both peritoneal layers, Outcome 16 Readmission to hospital within 6 weeks (not prespecified outcome).
2.1
2.1. Analysis
Comparison 2 Non‐closure of visceral peritoneum only versus closure of both peritoneal layers, Outcome 1 Adhesion formation.
2.2
2.2. Analysis
Comparison 2 Non‐closure of visceral peritoneum only versus closure of both peritoneal layers, Outcome 2 Wound infection.
2.3
2.3. Analysis
Comparison 2 Non‐closure of visceral peritoneum only versus closure of both peritoneal layers, Outcome 3 Postoperative fever.
2.4
2.4. Analysis
Comparison 2 Non‐closure of visceral peritoneum only versus closure of both peritoneal layers, Outcome 4 Endometritis.
2.5
2.5. Analysis
Comparison 2 Non‐closure of visceral peritoneum only versus closure of both peritoneal layers, Outcome 5 Operating time (minutes).
2.6
2.6. Analysis
Comparison 2 Non‐closure of visceral peritoneum only versus closure of both peritoneal layers, Outcome 6 Postoperative days in hospital.
3.1
3.1. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 1 Wound infection.
3.2
3.2. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 2 Postoperative pain.
3.3
3.3. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 3 Postoperative fever.
3.4
3.4. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 4 Endometritis.
3.5
3.5. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 5 Operating time (minutes).
3.6
3.6. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 6 Postoperative days in hospital.
3.7
3.7. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 7 Mobilisation time in hours (not prespecified outcome).
3.8
3.8. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 8 Time to oral intake in hours (not prespecified outcome).
3.9
3.9. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 9 Drop in haemoglobin g/dL (not prespecified outcome).
3.10
3.10. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 10 Blood loss (not prespecified outcome).
3.11
3.11. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 11 Time to flatus (not prespecified outcome).
3.12
3.12. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 12 Wound pain, day 1 (visual analogue score).
3.13
3.13. Analysis
Comparison 3 Non‐closure of parietal peritoneum only versus closure of both peritoneal layers, Outcome 13 Persistent abdominal pain after 8 months (numerical rating scale).
4.1
4.1. Analysis
Comparison 4 Non closure versus closure of visceral peritoneum when parietal peritoneum is closed, Outcome 1 Urinary frequency at 8 weeks.
4.2
4.2. Analysis
Comparison 4 Non closure versus closure of visceral peritoneum when parietal peritoneum is closed, Outcome 2 Urgency of urination.
4.3
4.3. Analysis
Comparison 4 Non closure versus closure of visceral peritoneum when parietal peritoneum is closed, Outcome 3 Stress incontinence.
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Update of

References

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Ayres‐de‐Campos 2000 {published data only}
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