The Modified Misgav-Ladach versus the Pfannenstiel-Kerr Technique for Cesarean Section: A Randomized Trial

Abstract

Suturing the uterine wall after cesarean section, begun in the late 19th century, markedly lowered the mortality risk from operative delivery. Pfannenstiel, in 1897, proposed making a curved transverse suprapubic incision in the abdominal skin, and Kerr, in 1926, first described the transverse lower-segment incision accompanied by double-layer uterine wall sutures and peritoneal closure. In 1972, Joel-Cohen described a transverse skin incision made 5 cm above the pubic symphysis along with blunt dissection of the abdominal wall. Subsequently, single-layer suturing of the uterus and not closing the peritoneum were introduced. These innovations and subsequent changes are termed the modified Misgav-Ladach (MML) technique after the major hospital contributing to their development. The investigators planned a prospective, randomized study of 162 patients having transverse lower-uterine-segment cesarean section, 88 of them with the MML technique and 74 by the Pfannenstiel-Kerr method. After making a Pfannenstiel skin incision, the subcutaneous tissue is opened upward in the midline to reach the rectus sheath above the point of insertion of the pyramidalis muscles. The subcutaneous tissue is extended and the rectus muscles separated digitally. The parietal peritoneum is opened at the level of the upper intermuscular space, also digitally. A transverse lower-segment incision 2 to 3 cm in length then is made involving both the peritoneum and myometrium. After dissecting the remaining uterine fibers and opening the fetal membranes, the incision is extended laterally by blunt dissection, and the fetus and placenta are extracted. The uterine fundus may be removed from the abdominal cavity if necessary to aid suturing. The uterine incision is closed by one-layer suturing. The visceral and parietal peritoneum are not sutured. Finally, the rectus sheath is sutured, as is the subcutaneous tissue if it is deeper than 2 cm. There were no significant differences between the two surgical groups in maternal age or weight, gestational age, parity, previous cesarean section, frequency of a nonreassuring fetal sate, or maternal/fetal conditions that contraindicate vaginal delivery. No patient had intraoperative complications or postpartum endometritis, but one woman in the MML group who was taking heparin had serious postoperative bleeding. The MML technique took significantly less time than the Pfannenstiel-Kerr approach. Women in the MML group tended to have less febrile morbidity, but there were no important group differences in analgesic needs, return of bowel function, by the second day, or wound complications. These observations suggest that the MML technique will prove more cost-effective than earlier techniques of cesarean delivery, in part because of a shorter operating time and a lesser need for suture material. Using the more recently developed approach does not appear to compromise the immediate condition of the mother or infant.