Misgav Ladach Cesarean Section Research Articles

An evidence-based cesarean section suggested for universal use.

This article suggests a unified way to perform Cesarean sections. Even in the same departments, different modifications are in use. Therefore, one cannot rely on the early or late outcome of the procedure as long as all the surgical steps are not standardized. The Misgav Ladach (Stark) Cesarean Section presented here is an evidence-based operation. Its basic principles are a modified Joel-Cohen abdominal incision, one-layer continuous suturing of the uterus using a big needle, leaving peritoneum open, closing fascia continuously and a few Donati skin sutures. This method has been subjected to scores of comparative studies with other methods in use, proving its advantages over them concerning duration, blood loss, febrile morbidity, need for analgesics, and costs. It is suggested that this method should be used as the standardized universal method which will enable comparison between obstetricians and institutions, and offer the parturient the best possible outcome.

The extraperitoneal French AmbUlatory cesarean section technique leads to improved pain scores and a faster maternal autonomy compared with the intraperitoneal Misgav Ladach technique: A prospective randomized controlled trial.

To determine whether the French AmbUlatory Cesarean Section (FAUCS) technique reduces postoperative pain and promotes maternal autonomy compared with the Misgav Ladach cesarean section (MLCS) technique in elective conditions. One hundred pregnant women were randomly, but in a non-blinded manner, assigned to undergo FAUCS or MLCS. The primary outcome was a postoperative mean pain score (PMPS), and secondary outcomes were a combined pain/medication score, time to regain autonomy, surgical duration, calculated blood loss, surgical complications, and neonatal outcome. Women in the FAUCS group experienced less pain than those in the MLCS group (PMPS = 1.87 [1.04-2.41] vs. 2.93 [2.46-3.75], respectively; p < 0.001). Six hours after surgery, the combined pain/medication score for FAUCS patients was 33% lower than that for MLCS patients (p < 0.001). FAUCS patients more rapidly regained autonomy, with 94% reaching autonomy within 12 h vs. 4% of MLCS patients (p < 0.001). There were no differences in maternal surgical or neonatal complications between groups. Our results indicate that FAUCS can reduce postoperative pain and accelerate recovery, suggesting that this technique might be superior to MLCS and should be more widely used. One potentially key difference between FAUCS and MLCS is that MLCS includes 100 mcg spinal morphine anesthesia in addition to the same anesthesia used by FAUCS. Any interpretation of apparent differences must take the presence/absence of morphine into account.

Modified Stark's (Misgav Ladach) caesarean section: 15 – year experience of the own techniques of caesarean section

ObjectiveA 15-year-experience of the personal modification of Misgav Ladach (ML) caesarean section in relation to the Dörffler method. Study designA retrospective clinical randomized observational study included 822 transperitoneal cesarean sections: 557 were performed via modified ML (without bladder catheterization, small transverse fascial incision with muscular stretching and non-preparation of vesicouterine plica) vs. 265 Dörffler (Pfannenstiel – Kerr) method. ResultsPerioperative and postoperative complications were significantly more frequent in the Dörffler method (p < 0.0005) (perioperative hemorrhage, more frequent adhesions, plastic peritonitis in repeated caesarean sections, as well as two bladder lesions). Postoperative febrility, dehiscence and wound seroma were more frequent in the first study group (p < 0.0005). More frequent paralytic ileus, uroinfections and bladder atony, which we did not observe in our own technique (p < 0.0005). The use of antibiotics and analgesics was prolonged until the fifth postoperative day in the first group compared to the second group where it was reduced to only 10 % on the second day (p < 0.0005). Also, the incidence of anemia and the need for blood transfusions were higher in the first study group, as well as the need for revision behind caesarean section and two hysterectomies due to massive postoperative intraperitoneal and retroperitoneal bleeding (p < 0.0005). ConclusionOur fifteen-year study highlighted the importance of our own published modified ML caesarean section in minimizing technique of surgery and the reduction of perioperative morbidity and significantly faster recovery of operated patients in the current era of enormous caesarean section increase.

EP15.09: True umbilical cord hemangioma with significant hemodynamic alterations: case report

A 35-year-old women, G4P2, was referred to our clinic after abnormal findings in a routine prenatal check-up at 28 weeks of gestation. Ultrasound examination revealed a highly vascularised mass with arteriovenous malformations arising from the umbilical cord insertion and polyhydramnios. There was a mostly well-defined hyperechoic mass of heterogeneous structure with a diameter about 76x71mm. At that moment Doppler indices were normal. After 1 week ultrasound revealed a progressive expansion of the mass and a blood flow pattern similar to umbilical artery. 31 gestational age ultrasound showed for the first time moderate cardiomegaly, mild pericardial effusion and an altered E/A Ratio from 0,57. At that point the mass diameter was about 129x96mm. After reviewing all mentioned findings and clinical state of the fetus and the mother a programmed misgav ladach Caesarean section was performed yielding a preterm female weighing 1680g with warning signs of heart failure, cardiomegaly, IRDS, hepatomegaly and tricuspidal insufficiency. The placenta weighed 1187g with a 150x100x50mm tumour at the umbilical cord insertion. Histologically there were mainly thin-walled variable sized and dilated vascular channels without endothelian atypia or multilayering. These vessels are distributed in a myxoid matrix, characteristic of a true hemangioma of the umbilical cord. Mother and baby did well. The child did not require any further surgical interventions. True hemangiomas of the umbilical cord are extremely rare, after reviewing the literature less than 50 cases have been reported, they are strongly associated with fetal morbimortality, a causal relationship has not been definitely established. There is no apparent association between cord hemangiomas and maternal age, race or gravidity nor does one sex predominate.

Textbook of Caesarean Section. Edited by EricJauniaux and William A.Grobman. 224 pages. Oxford University Press. 2016. ISBN: 978-0-19-875856-3. 77€.

Cesarean section is the most commonly performed major operation around the world and it has become one of the first major surgical procedures performed independently by residents and trainees in Obstetrics and Gynecology. This first edition of a new textbook of cesarean section, aims to provide an overview of the topic, including history, the technical details of the procedure, and the different techniques currently used around the world. Global epidemiological perspective, complication rates, anesthetic and neonatal implications are also presented. Overall, the book provides a detailed description of the procedure which is easy to understand together with the illustrative pictures and photos. Throughout the book, a global perspective of the procedure is presented, and the last chapter is uniquely focused on this. The anatomy chapter has a pedagogical design with clinical relevance and informative images, even though it could have been more detailed. Every chapter ends with a summary of the key learning points, and the reference lists are up to date and relevant. However, not all epidemiological data is up to date, with some figures being older than 13 years. Some of the diagrams are unclear and, in a chart on cesarean rates in low income countries, the text is illegible. Searching YouTube gives more than 8000 results regarding cesarean section techniques, and the videos vary a lot in quality. The book's appurtenant video guides are strongly recommendable due to their high quality demonstration of the surgical procedure with superb narrative compared with other easily available resources. There are really good teaching aids comparing the Pfannenstiel and Misgav Ladach cesarean section, and describing the preparation of the patient and postnatal care. They are detailed, comprehensible and explain the procedure step by step. The price is $86 at amazon.com and 778 SEK at adlibris.com. The authors intend to use the profits from the sales in the United States and Europe to translate and disseminate the book in low income countries. In conclusion, this book is well-written, easy to read and provides a good overview of cesarean section epidemiology and technique, and with accompanying videos provides a valuable learning resource for trainees and residents in our specialty.

Prognosis of Misgav-Ladach Caesarean Sections in an African Environment: Case of the Banfora Regional Hospital in Burkina Faso about 110 Cases

Objective: To analyze the caesarean section prognosis aspects according to Misgav-Ladach versus classical technique in the regional hospital of Banfora. Materials and Methods: This is about a randomized clinical test of 2 groups carried in the regional hospital in Banfora on a two-month period from 1st October to 30 November 2015. In the first group, 66 patients had benefited from a caesarean section by the Misgav-Ladach technique. In the control group, 44 patients had benefited from a caesarean in the conventional technique. Were included in our sample all patients having benefited from a cesarean in the study site during the study period and who had consented to participate in the study. All patients were followed until the postpartum healing of the surgical wound. All prognostic elements have been compared. The results were analyzed with Epi Info 3.5.1 software and the significance level was set at 5%. Results: The indications for cesarean section were dominated by maternal causes in 70 cases (63.6%). The average duration of the surgical procedure was 27.98 mm for Misgav-Ladach technique versus 28.27 mm for the conventional technique (p = 0.49). The evaluation of blood loss by the change in hemoglobin pre- and post-operative did not find statistically significant differences between the two techniques (p = 0.6). The evaluation of the number of intraoperative suture used, was in favor of the technique of Misgav-Ladach (p = 0.007). The evolutionary trend in the intensity of postoperative pain was in favor of the technique of Misgav-Ladach. The average time of wound healing was 16.33 days for group 1 versus 21, 27 days for group 2 (p = 0.0001). Postoperative morbidity was greater with the conventional technique in comparison to Misgav-Ladach’s (p = 0.046). There was no statistically significant differences in length of hospital stay (p = 0.056). Conclusion: The Misgav-Ladach cesarean section reduces operative risk. The adoption and diffusion of this technique to the national level and its effective integration into training curriculas should contribute to reducing maternal morbidity and mortality of abdominal delivery.

Efficacy and tolerability of intravenous morphine patient-controlled analgesia (PCA) in women undergoing cesarean delivery.

The aim of the study was to evaluate analgesic efficacy and tolerability of patient-controlled analgesia (PCA) with intravenous morphine. Our observational study included 50 women who underwent a Misgav-Ladach or modified Misgav-Ladach cesarean section. Automated PCA infusion device (Medima S-PCA Syringe Pump, Medima, Krakow, Poland) was used for postoperative pain control. Time of morphine administration or initiation of intravenous patient-controlled analgesia (IV PCA) with morphine was recorded, as well as post-operative pain at rest assessed by a visual analogue scale (VAS). All patients were followed up for 24 hours after discharge from the operating room, taking into account patient records, worst pain score at rest, number of IV PCA attempts, and drug consumption. Median of total morphine doses used during the postoperative period was 42.9mg (IQR 35.6-48.5), with median infusion time of 687.0 min. (IQR 531.0-757.5). Pain severity and total drug consumption improved after the first 3 hours following cesarean delivery (p < 0.01). Mean number of PCA attempts per patient was 33 (IQR: 24-37), with median of 11 placebo attempts (IQR: 3-27). Patient-controlled analgesia with morphine is an efficient and acceptable analgesic method in women undergoing cesarean section.

Maternal and fetal effect of misgav ladach cesarean section in Nigerian Women: A randomized control study

Background:The poor utilisation of the Misgav-Ladach (ML) caesarean section method in our environment despite its proven advantage has been attributed to several factors including its non-evaluation. A well designed and conducted trial is needed to provide evidence to convince clinician of its advantage over Pfannenstiel based methods.Aim:To evaluate the outcome of ML based caesarean section among Nigerian women.Subjects and Methods:Randomised controlled open label study of 323 women undergoing primary caesarean section in Lagos Nigeria. The women were randomised to either ML method or Pfannenstiel based (PB) caesarean section technique using computer generated random numbers.Results:The mean duration of surgery (P < 0.001), time to first bowel motion (P = 0.01) and ambulation (P < 0.001) were significantly shorter in the ML group compared to PB group. Postoperative anaemia (P < 0.01), analgesic needs (P = 0.02), extra suture use, estimated blood loss (P < 0.01) and post-operative complications (P = 0.001) were significantly lower in the ML group compared to PB group. Though the mean hospital stay was shorter (5.8 days) in the ML group as against 6.0 days, the difference was not significant statistically (P = 0.17). Of the fetal outcome measures compared, it was only in the fetal extraction time that there was significant difference between the two groups (P = 0.001). The mean fetal extraction time was 162 sec in ML group compared to 273 sec in the PB group.Conclusions:This study confirmed the already established benefit of ML techniques in Nigerian women, as it relates to the postoperative outcomes, duration of surgery, and fetal extraction time. The technique is recommended to clinicians as its superior maternal and fetal outcome and cost saving advantage makes it appropriate for use in poor resource setting.

Tissue Elastography of Uterine Cervix for Prediction of a Successful Labor Induction: Preliminary Results

s S123 of an abnormal finding in the placental sonogram. Our ultrasound examination revealed a huge placental chorioangioma of an anterior placenta in an intact double-ovum twin pregnancy with normal developed fetuses. Imaging Findings or Procedure Details: Blood perfusion in the chorioangioma was checked and Doppler controls were performed (umbilical andmiddle cerebral artery). Pulsatility index (PI) and resistive index (RI) values were in normal limits. At 36 + 6 weeks gestation, a Misgav Ladach cesarean section was carried out. Two female infants were born weighing 2710 g, Apgar 8/9/10, pH 7.24, BE -5.2 and 2300g, Apgar 9/9/ 10, pH 7.23, BE -5.2, respectively. Histologically two placentas were described, 443 and 762 g, each with a three-vessel umbilical cord and small infarcts. The found hamartomous placental tumor, size 10,7 x 9.3 x 1.9, presented with innumerable blood vessels, lobulas, expanded villi, cystic spaces, dilated vascular channels and calcified areas in the proliferating trophoblastic epithelium. Conclusion: Such large clinically significant chorioangiomas occur very rarely (0.2-4:10,000 births). Often, they cause severe fetal complications, but not in this extraordinary case of a chorioangioma of the vascular type.

Short-term postnatal quality of life in women with previous Misgav Ladach caesarean section compared to Pfannenstiel–Dorffler caesarean section method

Objective. To examine whether short-term postnatal health-related quality of life differed among women after different methods of cesarean sections.Methods. One hundred forty-five women were evaluated with previous CS (85 by Misgav Ladach and 60 by Pfannenstiel–Dörffler). Short-time quality of life was measured using the Croatian version of Short Form Health Survey (SF – 36). Short-term postoperative recovery was assessed using two criteria: febrile morbidity and degree of pain. Incidence of peritoneal adhesions was assigned using Bristow scoring system.Results. Four weeks after delivery women with previous Misgav Ladach cesarean section significantly scored higher on the bodily pain (72.4 vs. 56.7, p < 0.05), social functioning (71.5 vs. 60.4, p < 0.05), and the vitality (61.7 vs. 50.3, p < 0.05) subscales. These differences disappeared in the second assessment (12-weeks postpartum) except in the bodily pain (74.7 vs. 61.2, p < 0.05) subscale. There was a significant trend toward a higher requirement for postoperative analgesics in the Pfannenstiel–Dörfler group (doses: 5.4 vs. 8.7, p < 0.05; hours: 17.9 vs. 23.3, p < 0.05), and they had a significantly higher rate of febrile morbidity than the Misgav Ladach group (5.7 vs. 9.4%, p < 0.05). Hospitalization time was reduced in the Misgav Ladach group (4.2 vs. 7.3, p < 0.05). The incidence of adhesions was significantly lower in patients who had undergone a previous operation using the original Misgav Ladach method (0.47 vs. 0.77, p < 0.05).Conclusion. Misgav Ladach cesarean section method might lead to better short-time quality of life resulting in reducing postoperative complications compared to Pfannenstiel–Dörfler cesarean section method.

Vaginal delivery after Misgav–Ladach cesarean section – Is the risk of uterine rupture acceptable?

Objective. To evaluate whether the single-layer closure as is a routine by the Misgav–Ladach method compared to the double-layer closure as used by the Dörfler cesarean method is associated with an increased risk of uterine rupture in the subsequent pregnancy and delivery.Methods. The analysis is retrospective and is based on medical documentation of the Clinic for Gynecology and Obstetrics, University Clinical Centre, Tuzla, Bosnia and Herzegovina. All patients with one previous cesarean section who attempted vaginal birth following cesarean section were managed from 1 January 2002 to 31 December 2008. Exclusion criteria included multiple gestation, greater than one previous cesarean section, previous incision other than low transverse, gestational age at delivery less than 37 weeks and induction of delivery. We identified 448 patients who met inclusion criteria.Results. We found that 303 patients had a single-layer closure (Misgav–Ladach) and 145 had a double-layer closure (Dörffler) of the previous uterine incision. There were 35 cases of uterine rupture. Of those patients with previous single-layer closure, 5.28% (16/303) had a uterine rupture compared to 13.11% (19/145) in the double-layer closure group (p < 0.05).Conclusion. We have not found that a Misgav–Ladach cesarean section method (single-layer uterine closure) might be more likely to result in uterine rupture in women who attempted a vaginal birth after a previous cesarean delivery. This cesarean section method should find its confirmation in everyday clinical practice.

Incidence of post-operative adhesions following Misgav Ladach caesarean section–A comparative study

Aim. To evaluate the incidence of peritoneal adhesions as a post-operative complication after caesarean section following the Misgav Ladach method and compare it with peritoneal adhesions following traditional caesarean section methods (Pfannenstiel-Dörffler, low midline laparotomy-Dörffler).Methods. The analysis is retrospective and is based on medical documentation of the Clinic for Gynecology and Obstetrics, University Clinical Centre, Tuzla, Bosnia and Herzegovina (data from 1 January 2001 to 31 December 2005). We analysed previous caesarean section dependent on caesarean section method (200 by Misgav Ladach method, 100 by Pfannenstiel-Dörffler method and 100 caesarean section by low midline laparotomy-Dörffler). Adhesion scores were assigned using a previously validated scoring system.Results. We found statistically significant difference (p < 0.05) in incidence of peritoneal adhesions in second and third caesarean section between Misgav Ladach method and the Pfannestiel-Dörffler and low midline laparotomy-Dörffler method. Difference in incidence of peritoneal adhesions between low midline laparotomy-Dörffler and Pfannenstiel-Dörffler method was not statistically different (p > 0.05). The mean pelvic adhesion score was statistically lower in Misgav Ladach group (0.43 ± 0.79) than the mean score in the Pfannestiel-Dörffler (0.71 ± 1.27) and low midline laparotomy-Dörffler groups (0.99 ± 1.49) (p < 0.05).Conclusions. Our study showed that Misgav Ladach method of caesarean section makes possible lower incidence of peritoneal adhesions as post-operative complication of previous caesarean section.

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years’ experience

Acta Obstetricia et Gynecologica ScandinavicaVolume 80, Issue 1 p. 91-91 Free Access Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years’ experience First published: 28 June 2008 https://doi.org/10.1111/j.1600-0412.2001.800119-2.pp.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Sir, I have read the letter from Varga and Bódis with interest, accounting for a comparative evaluation of the Misgav Ladach (M/L) cesarean section (CS), lower midline incision (LMI) and Pfannenstiel (PF) CS. They show results from two years, comparing 366 patients in a non-randomized study. Significant differences according to operation time, number of drains and duration of the hospital stay, were found, beneficial to the M/L method. Fewer patients were hospitalized for more than 5 days, and less hospital expenses were related to the M/L operations. Regional anesthesia was most frequently used and antibiotic therapy least frequently used in the M/L group. It is of great importance to discuss this new method of cesarean section, as it is now introduced in many countries and knowledge is gained. Furthermore, modifications of the method are discussed. In my opinion modifications of any surgical procedure should be evaluated in randomized studies to assess if improvements are made or not. The authors have in a commendable way followed the details of Stark’s original description of the method, with one small exception. Concerning the closure of the skin, Varga and Bódis use two Donati stitches, with knots tied caudally, instead of mattress sutures, in combination with small forceps pinching the skin edges together for approximately 10 min. This method has been described earlier and evaluated in our article (1) and communicated with Stark. Holmgren et al. (2) comment Ayres-de-Campos’ and Patricio’s modifications with 5–8 skin stitches (3), that good cosmetic results of 2–3 mattress sutures were found in 800 patients. However, alternative ways of closing the skin may be worth studying separately, while the use of forceps has not easily been accepted. Varga and Bódis raise another question in their letter. They have experience from more than 50 cases of CS after a previous laparotomy or CS. They suggest that M/L CS may be used in a subsequent operation, which is also my experience. In 17 operations following M/L CS they observed two minor omental herniations into the abdominal wall. We have the same experience in Uppsala, that a fixed omentum attached to the abdominal wall can cause difficulties, in repeat procedures. In a retrospective study from Uppsala University Hospital, we surveyed the reports of 50 repeat CS. The surgeon documented difficulties related to the opening of the abdomen, in 25% after a previous LMI, in 59% after one previous PF, in 74% after two earlier PF and in 43% after a M/L CS, respectively. Stark showed 6% intraabdominal adhesions in repeat operations after M/L CS and 29% after Pfannenstiel CS (4). Varga and co-workers are satisfied with M/L CS. The method was used in 92% of the CS the last year. More randomized studies are ongoing and will add to our knowledge of the M/L method. It will be interesting to follow the progression and development of the method. References 1 Darj E & Nordström M-L. The Misgav Ladach method for cesarean section compared to the Pfannenstiel method.Acta Obstet Gynecol Scand1999; 78: 37 – 41. 2 Holmgren G, Sjöholm L & Stark M. Reply from the authors to Ayres-de-Campos and Patricio.Acta Obstet Gynecol Scand2000; 79: 327. 3 Ayres-de-Campos D & Patricio B. Modification to the Misgav Ladach technique for cesarean section.Letter. Acta Obstet Gynecol Scand2000; 79: 326 – 327. 4 Stark Met al. Evaluation of combinations of procedures in cesarean section.Int J Gynaecol Obstet1995; 48: 273 – 276.DOI: 10.1016/0020-7292(94)02306-j Address for correspondence:Elisabeth Darj, M.D., Dr. Med. Sci. Department of Women’s and Children’s HealthSection of Obstetrics and GynecologyUniversity HospitalS-751 85 UppsalaSweden Volume80, Issue1January 2001Pages 91-91 ReferencesRelatedInformation

Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience

Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience

Reply to P. Vargas Letter to the Editor: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience (published in volume 80, 1)

Sir, Varga and Bódis’ experience with the Misgav Ladach technique for cesarean section (1) is certainly an interesting and extensive one. It is also curious to see how some aspects of surgical technique are so dependent on local policies. For instance, the number of drains left, presumably in the subaponeurotic space, in both lower midline and Pfannenstiel incisions (40 and 72%, respectively) seemed to us very high. While we are aware that it is common in some centers to drain this space when using the Pfannenstiel incision, in others this is seldomly performed with apparently very similar results! Another curious aspect of this paper is the reported mean operating times, namely for the Misgav Ladach technique. The Uppsala group (2), from whom the authors learned the technique, refer mean operating times of 12.5 minutes – roughly three times less! Of course, the present study included the surgeons’ initial learning period and many different people performed the operations, but even so, is this enough to justify the difference? Or could it not be that, as occurred elsewhere, slight technical modifications were used, once again dependent on local practices? One must not forget that a detailed description of the Misgav Ladach technique was only published recently (3) while its main principles (Joel Cohen abdominal opening, single layer closure of the uterus, and non-closure of the peritoneum) were described in 1995 (4). Consequently, a detailed description is probably warranted in studies evaluating this technique in different centers, as technical variations are very frequent. While it is certain that the development of modifications may weaken a technique, as they can create uncertainty when comparing results between publications, they may also be the way of arriving at the best technical solutions or of providing surgeons with different alternatives. In our experience, for instance, modifying the Misgav Ladach technique was the only way of putting it into practice, as our women were unwilling to accept the higher Joel Cohen abdominal incision, and many of the staff did not consider some of the steps evidence-based. The extraordinary practicality of the Misgav Ladach technique, whether modified or not, is self-evident to all those who perform it, and after being at ease with it, no one that I know of wants to return to previous methods. While the majority of papers evaluating this technique have reported encouraging results, study design can frequently be criticized, as it may be subject to bias, namely in selection of patients and publication of favorable results. For solid evidence of its more than probable benefits, large and well-conducted randomized controlled trials are needed, comparing it with what is probably still today the most widely used technique – the transverse lower uterine segment cesarean section described by Kerr, using the Pfannenstiel abdominal incision. This would certainly be, at this stage, the most important contribution towards the wider dissemination of the technique.

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years' experience

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years’ experience

Reply to: Comparative evaluation of the Misgav Ladach cesarean section with two traditional techniques. The first four years’ experience