Joel-Cohen Incision Research Articles

Placenta accreta spectrum surgery with the Joel Cohen incision for abdominal access: a single-center experience.

Placenta accreta spectrum (PAS) is usually treated by hysterectomy performed through a midline incision. We hypothesize that PAS surgery can be performed through a Joel-Cohen incision with adequate sight and safety. The data on women having a hysterectomy due to PAS between 2013-2021 was collected retrospectively. Operation length, baby's pre-delivery general anesthesia exposure time, transfusion rates, complication rates, postoperative admission to the intensive care unit (ICU), postoperative hospital stay, and neonatal outcomes were collected. In addition, the data investigated whether the operation was performed under emergent conditions and in the early (2013-2016) or late (2017-2021) years. 161 patients met the inclusion criteria. The median gestational age at delivery was 34 weeks (27-39). The mean operation length was 150 minutes (75-420), and the anesthesia-to-delivery interval was 32 minutes (5-95). Twenty-three (14%) patients did not receive any blood product, 73 (45%) received less than three packs of erythrocyte, and only seven (4%) had a massive transfusion. Bladder injuries occurred in 24 (15%). Preoperative anemia, hypogastric artery ligation, transfusion, ICU admission, and maternal and neonatal complications were more frequent in emergent cases. Comparison between the early and late groups showed a decrease in the rate of anemia, maternal ICU admission, hypogastric artery ligation, and neonatal complications. In addition, infectious complications were relatively rare in all groups. The Joel-Cohen incision and bladder dissection before the baby's delivery reduce transfusion rates and avoid midline incision, which is prone to complications and unpleasant cosmetic appearance while performing a hysterectomy for PAS surgery.

Postoperative pain after cesarean section: an audit of practice after implementation of the PROSPECT recommendations

Cesarean section (CS) is the most frequently performed surgical intervention worldwide. Post- cesarean pain is often underestimated and undertreated and can impair rapid maternal recovery, mother and child bonding and breastfeeding. Recently, PROSPECT recommendations on postoperative pain for CS were published and they include systematic paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), intravenous dexamethasone, neuraxial morphine/dia- morphine or an abdominal wall block or wound infiltration, abdominal wall binders, non-closure of the peritoneum and a Joel-Cohen incision. Opioids are administered as rescue. In UZ Leuven, these PROSPECT recommendations were implemented at the end of 2020. To evaluate the efficacy of these PROSPECT recommendations, a prospective audit was performed from January 1 st , 2021 till April 30 th , 2021. All patients with a CS were prospectively followed for correct implementation of the pain protocol and for pain scores in rest and at mobilization. Rescue opioid consumption as well as patient satisfaction were recorded. 185 consecutive patients that had undergone a CS were included in the audit. In 55 patients the pain protocol was not followed mostly due to no or reduced administration of NSAIDs. Patient satisfaction was high, especially in patients in which the protocol was followed. Pain scores at rest and at mobilization were low and the percentage of patients having pain scores above 30 mm VAS remained low. Rescue opioid consumption was low. We conclude that the implementation of the PROSPECT based pain protocol after CS was effective in controlling pain, reducing opioid consumption and resulted in high patient satisfaction especially if the protocol was correctly followed. Omission of NSAIDs is occurring relatively frequent, but mostly because of valid medical reasons to omit NSAIDs.

Evidence-Based Cesarean Section for Universal Use in China: The “Stark (Misgav Ladach) Method”

Abstract There are many ways to perform cesarean section, with many methods developing from local traditions. Following a 3-year study process, a modified, evidence-based method has been developed, which is now in use in many countries. The abdomen incision is based on the Joel-Cohen incision, the peritoneum is opened by repeated stretching, and the uterus is opened transversely after pushing the bladder down. After delivery the uterus is sutured with one layer using a large needle, and the abdomen is closed with only two layers, fascia and skin. This method was subject to scores of studies, with all upholding its superiority over traditional methods. As a result, the “Stark (Misgav Ladach) method” is recommended to become a standard procedure across China.

CLINICO-MORPHOLOGICAL FEATURES OF RE-CESAREAN SECTION

A high number of repeat cesarean sections increases a risk of excessive bleeding, uterine atony, hysterectomy.The aim of study was to evaluate the efficacy of medical and technical methods (argon plasma coagulation, tranexamic acid, carbetocin) to prevent complications following repeat cesarean section and to improve the myometrial wound healing, to establish morphological features of uterine scar tissue in case of using argon plasma coagulation of myometrium in the area of the suture during the previous operation.Materials and methods Prospective cohort study of 87 patients who had undergone repeat cesarean section. I group included 42 women who had repeat cesarean section using argon plasma coagulation. Ten minutes before the operation, 1,0 g of tranexamic acid was injected intravenously. 100 mcg carbetocin was administered intravenously after cutting the umbilical cord. ІІ group comprised 45 women who had traditional cesarean section using Stark’s technique and Joel-Cohen incision. Pathomorphological study of scarred lower uterine segment myometrium was performed. Immunohistochemical staining against CD3, CD34, CD68, vimentin, α-SMA was performed.Results are presented as Mean±SD.Results. Total operative time was significantly shorter in the І group (37,7±2,4 minutes) compared to ІІ (47,4±1,6 minutes) (р<0,05). Volume of blood loss in the І group was 476,7±37,4 ml, and in the ІІ — 549,7±35,7 ml (p<0.05). Patients of the І group needed analgesic for 18-24 hours, the ІІ group — 36-72 hours after operation. The width of the uterine cavity in group І was 9,7±0,39 mm, in group ІІ — 14,8±0,52 mm (р<0,05). One patient of group І and 9 patients of group ІІ had signs of uterine subinvolution. Length of hospital stay after surgery in group I was 4,7±0,12 days, in ІІ — 6,8±0,24 days. The ultrasound thickness of myometrium in group I and group II is an average of 8,72±0,54 mm and 6,75±0,69 mm, respectively. Pathomorphological data of scarred lower uterine segment myometrium showed that in group I regenerative processes have more favorable course, a tendency to restore the structure of myometrium, while in group II there were processes of disturbed regeneration with the replacement of smooth muscle tissue varying maturity of connective tissue, moderate inflammatory process.Conclusion. So, the use of tranexamic acid, carbetocin and argon plasma coagulation is effective in reducing perioperative blood loss, total operative time, dosage of uterotonic and analgesic medications and postoperative hospital stay in patients giving birth by repeat cesarean section. According to the pathomorphological study, argon plasma coagulation of myometrium in the area of suture increases the value of the reparative processes and promotes the formation of a morphologically complete scar, with the predominance of smooth muscle cells over connective tissue.

Clinico-morphological features of the postoperative period and healing process of the uterine scar tissue after re-cesarean section

A high number of repeat cesarean sections increases a risk of excessive bleeding, uterine atony, hysterectomy. The aim of study was to evaluate the efficacy of medical and technical methods (argon plasma coagulation, tranexamic acid, carbetocin) to prevent complications following repeat cesarean section and to improve the myometrial wound healing, to establish morphological features of uterine scar tissue in case of using argon plasma coagulation of myometrium in the area of the suture during the previous operation. Prospective cohort study of 77 patients who had undergone repeat cesarean section. I group included 37 women who had repeat cesarean section using argon plasma coagulation. Ten minutes before the operation, 15 mg/kg of tranexamic acid was injected intravenously. 100 mcg carbetocin was administered intravenously after cutting the umbilical cord. ІІ group comprised 40 women who had traditional cesarean section using Stark's technique and Joel-Cohen incision. Pathomorphological study of scarred lower uterine segment myometrium was performed. Immunohistochemical staining against CD3, CD34, CD68, vimentin, α-SMA was performed. Results are presented as Mean±SD. Total operative time was significantly shorter in the І group (37,0±2,1 minutes) compared to ІІ (46,1±1,8 minutes) (р<0,05). Volume of blood loss in the І group was 465,7±37,5 ml, and in the ІІ — 547, 7±34,6 ml (p<0.05). Patients of the І group needed analgesic for 18-24 hours, the ІІ group — 36-48 hours after operation. The width of the uterine cavity in group І was 9,8±0,37 mm, in group ІІ — 14,6±0,54 mm (р<0,05). One patient of group І and 9 patients of group ІІ had signs of uterine subinvolution. Length of hospital stay after surgery in group I was 4,7±0,12 days, in ІІ — 6,6±0,28 days. The ultrasound thickness of myometrium in group I and group II is an average of 9,32±0,64 mm and 6,24±0,59 mm, respectively. Pathomorphological data of scarred lower uterine segment myometrium showed that in group I regenerative processes have more favorable course, a tendency to restore the structure of myometrium, while in group II there were processes of disturbed regeneration with the replacement of smooth muscle tissue varying maturity of connective tissue, moderate inflammatory process. So, the use of tranexamic acid, carbetocin and argon plasma coagulation is effective in reducing perioperative blood loss, total operative time, dosage of uterotonic and analgesic medications and postoperative hospital stay in patients giving birth by repeat cesarean section. According to the pathomorphological study, argon plasma coagulation of myometrium in the area of suture increases the value of the reparative processes and promotes the formation of a morphologically complete scar, with the predominance of smooth muscle cells over connective tissue.

Caesarean section: could different transverse abdominal incision techniques influence postpartum pain and subsequent quality of life? A systematic review.

The choice of the type of abdominal incision performed in caesarean delivery is made chiefly on the basis of the individual surgeon’s experience and preference. A general consensus on the most appropriate surgical technique has not yet been reached. The aim of this systematic review of the literature is to compare the two most commonly used transverse abdominal incisions for caesarean delivery, the Pfannenstiel incision and the modified Joel-Cohen incision, in terms of acute and chronic post-surgical pain and their subsequent influence in terms of quality of life. Electronic database searches formed the basis of the literature search and the following databases were searched in the time frame between January 1997 and December 2013: MEDLINE, EMBASE Sciencedirect and the Cochrane Library. Key search terms included: “acute pain”, “chronic pain”, “Pfannenstiel incision”, “Misgav-Ladach”, “Joel Cohen incision”, in combination with “Caesarean Section”, “abdominal incision”, “numbness”, “neuropathic pain” and “nerve entrapment”. Data on 4771 patients who underwent caesarean section (CS) was collected with regards to the relation between surgical techniques and postoperative outcomes defined as acute or chronic pain and future pregnancy desire. The Misgav-Ladach incision was associated with a significant advantage in terms of reduction of post-surgical acute and chronic pain. It was indicated as the optimal technique in view of its characteristic of reducing lower pelvic discomfort and pain, thus improving quality of life and future fertility desire. Further studies which are not subject to important bias like pre-existing chronic pain, non-standardized analgesia administration, variable length of skin incision and previous abdominal surgery are required.

Abdominal surgical incisions for caesarean section.

Caesarean section is the commonest major operation performed on women worldwide. Operative techniques, including abdominal incisions, vary. Some of these techniques have been evaluated through randomised trials. To determine the benefits and risks of alternative methods of abdominal surgical incisions for caesarean section. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2013). Randomised controlled trials of intention to perform caesarean section using different abdominal incisions. We extracted data from the sources, checked them for accuracy and analysed the data. Four studies (666 women) were included in this review.Two studies (411 women) compared the Joel-Cohen incision with the Pfannenstiel incision. Overall, there was a 65% reduction in reported postoperative febrile morbidity (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.14 to 0.87) with the Joel-Cohen incision. One of the trials reported reduced postoperative analgesic requirements (RR 0.55, 95% CI 0.40 to 0.76); operating time (mean difference (MD) -11.40, 95% CI -16.55 to -6.25 minutes); delivery time (MD -1.90, 95% CI -2.53 to -1.27 minutes); total dose of analgesia in the first 24 hours (MD -0.89, 95% CI -1.19 to -0.59); estimated blood loss (MD -58.00, 95% CI -108.51 to -7.49 mL); postoperative hospital stay for the mother (MD -1.50, 95% CI -2.16 to -0.84 days); and increased time to the first dose of analgesia (MD 0.80, 95% CI 0.12 to 1.48 hours) compared with the Pfannenstiel group. No other significant differences were found in either trial.Two studies compared muscle cutting incisions with Pfannenstiel incision. One study (68 women) comparing Mouchel incision with Pfannenstiel incision did not contribute data to this review. The other study (97 women) comparing the Maylard muscle-cutting incision with the Pfannenstiel incision, reported no difference in febrile morbidity (RR 1.26, 95% CI 0.08 to 19.50); need for blood transfusion (RR 0.42, 95% CI 0.02 to 9.98); wound infection (RR 1.26, 95% CI 0.27 to 5.91); physical tests on muscle strength at three months postoperative and postoperative hospital stay (MD 0.40 days, 95% CI -0.34 to 1.14). The Joel-Cohen incision has advantages compared with the Pfannenstiel incision. These are: less fever, pain and analgesic requirements; less blood loss; shorter duration of surgery and hospital stay. These advantages for the mother could be extrapolated to savings for the health system. However, these trials do not provide information on severe or long-term morbidity and mortality.

A randomized comparative study on modified Joel-Cohen incision versus Pfannenstiel incision for cesarean section

Pfanennstiel incision is the most commonly used incision for cesarean section, but may not be the best. This study compared the modified Joel-Cohen incision with the Pfannenstiel incision to evaluate whether techniques to open the abdomen might influence operative time, and maternal and neonatal outcomes. In a randomized comparative trial, 302 women with gestational age >34 weeks, requiring cesarean section, were randomly assigned to either modified Joel-Cohen incision or Pfannenstiel incision for entry into the peritoneal cavity. The primary outcome measure was total time required for performing operation and secondary outcome measures were baby extraction time, number of haemostatic procedures used in the abdominal wall, postoperative morbidity, postoperative hospital stay and neonatal outcome. Mean total operative time was significantly less in the modified Joel-Cohen group as compared to the Pfannenstiel group (29.81 vs 32.67 min, p<0.0001, 95%CI=2.253 to 3.467). Time taken to deliver the baby and haemostatic procedures required during operation were also significantly less in the modified Joel-Cohen group as compared to the Pfannenstiel group. Requirement of strong analgesics was higher in the Pfannenstiel group (53.64% vs 21.85%, p<0.0001). There was no statically significant difference in the incidence of postoperative wound complications but postoperative stay in hospital was significantly less in the modified Joel-Cohen group (p=0.002). Neonatal outcomes were similar in both groups. The modified Joel-Cohen incision for entry into peritoneal cavity during cesarean section is associated with reduced mean total operative and baby extraction times with less postoperative pain and shorter hospital stay, which may be beneficial and cost effective.

Caesarean deliveries by Pfannenstiel versus Joel-Cohen incision: A randomised controlled trial

This study was designed to compare the Pfannenstiel versus Joel-Cohen incisions during caesarean deliveries. Women undergoing caesarean deliveries (n=153) were randomly assigned to the conventional Pfannenstiel or the Joel-Cohen incision. The outcome measures included postoperative pain, requirement for analgesics, operative time and other postoperative data. Maternal age, parity, gestational age and indications for caesarean delivery were similar across groups. Total operative time, postoperative recovery duration, time to get out of bed, to walk straight without support, to detect audible intestinal sounds and to pass gases or stools were shorter in the Joel-Cohen group. Postoperative haematocrit decreases and estimated intraoperative blood loss were similar between the two techniques. Moderate and severe pain at 6, 12 and 18 hours postoperatively was less frequent after the Joel-Cohen technique. Joel-Cohen incision in the non-scarred abdomen may provide a faster technique for caesarean section with less postoperative pain and probably early postoperative recovery in our circumstances.

Spontaneous prelabor uterine rupture in a primigravida: a case report and review of the literature

A rare case of prelabor uterine rupture in a primigravida was reported. A woman with a history of uterine perforation during hysteroscopy became pregnant after donor oocyte in vitro fertilization. To provide more insight into the possible risk factors for prelabor uterine rupture in primigravidae, a literature review was performed.

Caesarean Section Incision In Abdomen Revisited

Introduction: Caesarean section is one of the oldest operations performed from around sixteen century. Different method of uterine incision studied extensively but there are very limited studies on abdominal incision. Types of incisions: Vertical, Pfannenstiel, Maylard etc. The Joel-Cohen incision has advantages compared to the Pfannenstiel incision. Closure: Closure of the subcutaneous fat may reduce wound complications but it is unclear to what extent these differences affect the well-being and satisfaction of the women concerned. No adequate study available about the advantage and disadvantage of material used in skin closure. Conclusion: It is a fascinating fact that although caesarean section is one of the oldest surgeries in mankind there is no unanimous agreement about different techniques among experts in abdominal incision and closure.

Maternal infection rates after cesarean delivery by Pfannenstiel or Joel–Cohen incision: A multicenter surveillance study

Objective Our purpose was to evaluate maternal nosocomial infection rates according to the incision technique used for caesarean delivery, in a routine surveillance study. Study design This was a prospective study of 5123 cesarean deliveries (43.2% Joel–Cohen, 56.8% Pfannenstiel incisions) in 35 maternity units (Mater Sud Est network). Data on routine surveillance variables, operative duration, and three additional variables (manual removal of the placenta, uterine exteriorization, and/or cleaning of the parieto-colic gutter) were collected. Multiple logistic regression analysis was used to identify independent risk factors for infection. Results The overall nosocomial infection and endometritis rates were higher for the Joel–Cohen than Pfannenstiel incision (4.5% vs. 3.3%, 0.8% vs. 0.3%, respectively). The higher rate of nosocomial infections with the Joel–Cohen incision was due to a greater proportion of patients presenting risk factors (i.e., emergency delivery, primary cesarean, blood loss ≥800 mL, no manual removal of the placenta and no uterine exteriorization). However, the Joel–Cohen technique was an independent risk factor for endometritis. Conclusion The Joel–Cohen technique is faster than the Pfannenstiel technique but is associated with a higher incidence of endometritis.

Long-term outcomes of two different surgical techniques for cesarean

Objective To assess the rate of adhesions and other long-term outcomes of two cesarean delivery techniques. Methods A total of 600 women were randomly assigned to either a standard (Pfannenstiel–Kerr) or modified (Joel-Cohen–Stark) technique for first-time cesarean delivery. A total of 124 women were assessed at repeat cesarean delivery. The primary outcome measure was the presence of adhesions. Results At repeat cesarean delivery, anesthesia-to-delivery time, total duration of surgery, change in hemoglobin level, time to mobilization and oral intake, and postoperative hospital stay were significantly less with the modified technique. Adhesions were found in 7 (11.3%) and 22 (35.5%) of the cases using the modified and standard techniques, respectively ( P = 0.0026; relative risk 3.14 [95% CI, 1.45–6.82]). Conclusion A modified cesarean delivery technique, including Joel-Cohen incision, exteriorized full thickness suturing of the uterine incision, and non-closure of the peritoneum may reduce long-term morbidities of the procedure.

Comparison between the use of the Joel-Cohen incision and its modification during Stark's cesarean section

Objective. A comparative evaluation between the Joel-Cohen incision and its modification for the Stark's cesarean section (CS).Materials and methods. In a retrospective study, 477 women who underwent a Stark's CS were evaluated: 204 with the Joel-Cohen incision (JC) and 273 with a modified Joel-Cohen incision (MJC). All patients were checked for the following parameters: febrile morbidity, the need for painkillers, duration of hospital stay, and ultrasound examination for blood collection (BC) on the third postoperative day. The collections, when diagnosed were divided into three groups: (1) in the abdominal wall, (2) in the pouch of Douglas, and (3) in the lower uterine segment (LUS). Those included in the study were low-risk primiparae at term, presenting for CS for breech presentation, macrosomia, and on demand, and who had combined spinal–epidural anesthesia. Statistical evaluation was performed using SAS/V12 software.Results. There were no statistical differences between the two groups with regard to febrile morbidity, duration of need for painkillers, and hospital stay. Statistically more blood collections were found in the MJC incision group (5.4% in the abdominal wall, 12.4% in the pouch of Douglas, and 11.7% in the LUS) than in the classical JC incision group (3.9% in the abdominal wall, 10.2% in the pouch of Douglas, and 8.8% in the LUS), however without any clinical significance.Conclusions. The routine use of the classical JC incision during the Stark's CS seems to be more rational, and causes fewer blood collections.

Joel-Cohen or Pfannenstiel Incision at Cesarean Delivery: Does it Make a Difference?

This study attempted to show whether the technique used to open the abdomen at cesarean delivery affects operating time and maternal and neonatal outcomes. Consecutive women having cesarean section at 32 weeks' or more gestational age were randomly assigned to have either a Pfannenstiel incision (about 2 cm above the pubic symphysis with its mid-portion within the shaved area of the pubis) or a Joel-Cohen incision (about 3 cm below the line joining the anterior superior iliac spines and approximately 17 cm long). The latter is part of the Misgav Ladach method of cesarean section. Women having two or more previous sections or a previous longitudinal incision were excluded. All participants were older than 18 years of age and had a singleton pregnancy. The Pfannenstiel incision was used in 158 patients and the Joel-Cohen incision in 152. Total operating time was similar in the two groups, approximating just over 30 minutes. Extraction times from skin incision to clamping of the cord were shorter in the Joel-Cohen group (190 vs. 240 seconds). This difference persisted after adjusting for general anesthesia, surgery by a junior surgeon, and previous section delivery. There were no group differences in intraoperative or postoperative complications, Apgar scores, or admission to neonatal intensive care. Neurodevelopmental assessments at age 6 months showed no incision-related differences. This study does not warrant recommending a Joel-Cohen incision rather than a Pfannenstiel incision for cesarean section, even though the fetus is delivered somewhat more rapidly.

Joel-Cohen or Pfannenstiel incision at cesarean delivery: does it make a difference?

Objective. To evaluate whether the technique to open the abdomen might influence the operative time and the maternal and neonatal outcome. Methods. All consecutive women who underwent a cesarean section at a gestational age greater than or equal to 32 weeks were randomly allocated to have either the Joel-Cohen or the Pfannenstiel incision. Exclusion criteria were two or more previous cesarean sections and previous longitudinal abdominal incision. During the study period 366 patients underwent a cesarean delivery. Of these patients, 56 did not meet the inclusion criteria. The remaining patients were allocated to the Joel-Cohen (n= 152) group and to the Pfannenstiel (n= 158) group. Extraction time was defined as the time interval from skin incision to the clamping of the umbilical cord. Results. The total operative time was similar in both groups [Joel-Cohen 32 min (12–60) vs. Pfannenstiel 33 min (18–70)]. The extraction time was shorter in the Joel-Cohen group than in the Pfannenstiel group [190 s (60–600) vs. 240 s (50–600), p= 0.05]. This remained statistically significant after adjustment for confounding variables (Hazard = 1.26, p= 0.05). No difference was found between groups in terms of intraoperative and postoperative complications. No difference was found in the neonatal neurodevelopmental assessment at 6 months of age in relation to the abdominal incision performed. Conclusion. The Joel-Cohen method of opening the abdomen at cesarean delivery is faster then the Pfannenstiel technique at delivering the fetus. However, considering the absence of benefits to the mother and the fetus there is no clear indication for performing a Joel-Cohen incision.

Can Joel-Cohen incision and single layer reconstruction reduce cesarean section morbidity?

Objective: To compare an innovative cesarean section based on Joel-Cohen incision with the traditional Pfannenstiel technique in terms of operative data and post-operative recovery. Method: Out of 158 randomized patients, 83 patients underwent the innovative cesarean section (Joel-Cohen incision, one-layer locked uterine suture, no peritoneization) and 75 the traditional operative approach (Pfannenstiel incision, double layer closure of the uterus, visceral and parietal peritoneization). Operative data and post-operative morbidity were compared; sample size was calculated to detect a 13% difference in the occurrence of post-operative fever with a statistical power of 80%. Result: Post-operative fever was not different in the two groups. Total operating time was shorter with the innovative technique: 31.6 ±1.38 min vs. 44.4±1.44 ( P=0.0001) and fewer sutures were used: 3.6±0.13 vs. 6±0.13 ( P=0.001). Patients operated by the new technique began moving sooner and intestinal function restarted earlier. Conclusion: The proposed technique made for shorter operating times and faster recovery but no decrease in puerperal morbidity.

A Randomized Clinical Trial of Two Surgical Techniques for Cesarean Section

The Joel-Cohen incision followed by nonclosure of pelvic and parietal peritoneum has been advocated as an alternative method to the Pfannenstiel incision with peritonealization at cesarean section. A randomized trial was designed to compare intra- and postoperative morbidity between the two techniques. Women to undergo a cesarean section were randomly allocated to have either the Joel-Cohen incision with the parietal and pelvic peritoneum left open (group 1) or to have the Pfannenstiel incision with both peritoneal layers sutured (group 2). The myometrium was closed with 1-0 polyglactin 910 suture using a continuous single-layer nonlocking technique. Patients in group 2 had the peritoneum approximated with 2-0 polyglactin 910 suture. The fascia was sutured with continuous 1-0 polyglactin 910 suture in all cases. Opening time was defined as the interval from skin incision to the opening of the uterine cavity. Febrile morbidity was defined as a temperature > or =38 degrees C on two occasions 4 hours (hr) apart excluding the first postoperative day. Endometritis was defined as postpartum temperature > or =38 degrees C on two occasions 4 hr apart, with uterine tenderness and/or foul-smelling lochia. One hundred forty-nine and 150 patients were allocated to group 1 and to group 2, respectively. A shorter median (range) opening time [4 min (2-21) vs. 6 min (2-19), respectively, p < 0.01] and a shorter median (range) operative time [30 min (10-65) vs. 40 min (20-110), respectively, p < 0.01] were observed in group 1. No difference was found in terms of intraoperative complications, proportion of patients who required transfusion, endometritis, sepsis, febrile morbidity, and urinary tract infections. A higher rate of wound infections was found in group 2 than in group 1 [14 of 150 (9.3%) vs. 2 of 149 (1.3%), respectively, p < 0.01]. The Joel-Cohen incision without peritonealization resulted in a shorter opening and total operative time than the Pfannenstiel laparotomy with peritonealization. This was accomplished with a reduction of wound infections.

The Misgav Ladach method for cesarean section, method description

A method description is given for the Misgav Ladach method for cesarean section. This is based on the Joel-Cohen incision originally introduced for hysterectomy. The incision is a straight transverse incision somewhat higher than the Pfannenstiel incision. The subcutaneous tissue is left undisturbed apart from the midline. The rectus sheath is separated along its fibres. The rectus muscles are separated by pulling. The peritoneum is opened by stretching with index fingers. The uterus is opened with an index finger and the hole enlarged between the index finger of one hand and the thumb on the other. The uterus is closed with a one-layer continuous locking stitch. The visceral and parietal peritoneal layers are left open. The rectus muscle is not stitched. The rectus sheath is stitched with a continuous non-locking stitch. The skin is closed with two or three mattress sutures. The space in between is apposed with non-traumatic forceps for 5 minutes. The basic philosophy is to work in harmony with the body's anatomy and physiology and not against them. The method is restrictive in the use of sharp instruments, preferring manual manipulation. The method gives quicker recovery, less use of post-operative antibiotics, antifebrile medicines and analgesics. There is a shorter anesthetic and shorter working time for the operative team. It is suitable for both emergency and planned operations.