Re: One layer uterine closure**let's talk incisions
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Sat Sep 2 09:11:48 2006
Regarding suturing muscle, Bernard is right.
On my standard C/S, I use a partial Maylard incision in which I do not
dissect the muscles off the fascia at all, leaving the attachments
(tendenious intersections, I believe).
I simply cut the muscles from medial to lateral for around 1/3 to 2/3 of
their width, avoiding the inferior epigastic vessels virtually always.
Then, I enter the peritoneum very high (you have to retract it
downwards, or caudally from under the muscle, especially if the patient
is advanced in dilatation, to avoid the bladder) and extend it
transversely.
The muscles are very pretty on the repeats, and it is so easy to do the
same thing again and not struggle. Occasionally, the muscle isn't
really back together as much on the repeats, and peritoneal entry is
even easier.
I don't suture the muscle, only the fascia, continuous non-locking 0
PDS.
I can make a 12 cm. skin incision for virtually all babies here, and
have plently of room, unless the patient is obese or it is a huge baby.
Then, I go to 14 cm. On a very small woman and a small baby, I
sometimes go 10 cm., but I have had a bit of skin dystocia with that.
This whole deal probably adds 5 to 10 minutes, and many would argue that
the Misgav/Israeli technique, or other techniques are quicker and
better.
In the end, the healthy young women on whom we do Cesareans do nicely as
long as our technique is good, IMHO.
Garry
At Sat, 2 Sep 2006, Bernard Cristalli wrote:
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>Bladder, as well as bowel is sutured with a single layer of continuous
>Vicryl-like suture.
>Even in transversal such as subcostal or Cherney type incisons the
>muscles are only approximated, not sutured. The fascia is sutured,
>posterior and anterior sheet, that's all.
>The uterus is a large muscle and you have to fix it and prevent it from
>bleeding: use large (deep) stitches seizing at the same time the muscle
>and the uterine fascia and it's enough.
>Bernard
>
>Dr Eberhard Lisse a écrit :
>> Bernard,
>>
>> I try to avoid lacerating the aorta or perforating the bowel, so I have
>> not much personal experience here, other than suturing the occasional
>> serosa defect with very thin vicryl. It is my understanding from our
>> surgeons however that one closes bowel in two layers. As one does with
>> the bladder.
>>
>> I don't think one can compare suturing a large muscle, which after all
>> does contract during breastfeeding (but then that's not en vogue much
>> over there :-)-O) with vessels.
>>
>> You are indeed right, the muscles heal nicely if yo split them
>> longitudinally, though, by the way, I *DO* adapt the muscles loosely,
>> since I have seen the odd obstruction from a loop slipping in behind the
>> fascia, but if you were to cut the muscles transversely, you surely
>> would suture them, now wouldn't you? Remember, origin/insertion?
>>
>> I have no answer as to why obstetricians are last, since this only seems
>> to be the case in France :-)-O.
>>
>> el
>>
>> on 9/2/06 11:50 AM Bernard Cristalli said the following:
>>
>>> El
>>> How come obstetricians always are the last ones?
>>> It's been a long time bowel and vascular anasomosis are done with one
>>> layer continuous absorbable sutures and obstetricians still wonder on
>>> interrupted double leyer closure, why not silk afer all?
>>> Do you think gut or arteries are of lesser importance than uterus? Isn't
>>> it more vital to close carefully the colon and/or the aorta than the
>>> uterus? Remember we don't even close the muscles in parietal transversal
>>> incisions and the muscles heal by themselves.
>>> One layer continuous suture./
>>> BC
>>>
>>> Dr Eberhard Lisse a écrit :
>>>
>>>> Bernard,
>>>>
>>>> There is no standard in Europe.
>>>>
>>>> In Europe there are at least 6 schools of thought that I know personally
>>>> of, French, UK, West and East German, Romanian and Russian. And I have
>>>> no clue what happens in Spain, Italy and other places.
>>>>
>>>> The rupture rates have nothing to do with other countries per se, but
>>>> perhaps with other techniques.
>>>>
>>>> I don't think 2 layers is worse than one, takes one minute longer, and
>>>> makes me feel better. I *HAVE* seen onlayer closure com eloose once with
>>>> catastrophic results.
>>>>
>>>> el
>>>>
>>>> on 9/2/06 7:23 AM Bernard Cristalli said the following:
>>>>
>>>>> One layer closure has been the standard of care here (France, and Europe
>>>>> I believe) for the last 40 years.
>>>>> I haven't seen our rupture rates at VBAC are higher than others, and we
>>>>> perform a lot of VBACs.
>>>>> BC
>>>>>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
