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Re: tecnica-cesareanaFrom: João Batista Marinho de Castro Lima (jbmclima@uol.com.br)Sun, 23 Jul 2000 16:40:58 -0300
Tem muita coisa apublicada. Inclusive uma revisão sistemática da literatura sobre o assunto, ou seja, evidência científica de nível 1a segundo Sackett et al. Vai aí para você. João Batista Belo Horizonte - MG
>----- Original Message -----
> Realizando cesareanas a mais de 20 anos, sempre peritonizei peritone
>> ----- Original Message ----- Peritoneal non-closure at caesarean section Peritoneal non-closure at caesarean section Wilkinson CS, Enkin MW A substantive amendment to this systematic review was last made on 17 September 1997. Cochrane reviews are regularly checked and updated if necessary. Background: It has been suggested that the peritoneal suture might be omitted during caesarean section without adverse effects. 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 intra-operative and immediate postoperative outcomes. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register. Selection criteria: Controlled trials comparing leaving the visceral and/or parietal peritoneum unsutured at caesarean section with a technique which involves suturing the peritoneum in women undergoing elective or emergency caesarean section. Data collection and analysis: Trial quality was assessed and data were extracted by two reviewers. Main results: Four trials involving 1194 women were included. Non-closure of the peritoneum saved operating time (weighted mean difference of -6.12 minutes, 95% confidence interval -8.00 to -4.27) with no significant differences in postoperative morbidity, analgesic requirements and length of hospital stay. There was a consistent, although nonsignificant, trend for improved immediate postoperative outcome if the peritoneum was not closed. Reviewers' conclusions: There seems to be no significant difference in short term morbidity from non-closure of the peritoneum at caesarean section. Background Closure of the peritoneum at laparotomy has been a part of standard surgical practice. Cited reasons for closure include restoration of anatomy and reapproximation of tissues, reduction of infection by re-establishing an anatomical barrier, reduction of wound dehiscence and minimisation of adhesions (Duffy 1994). However, these advantages have never been scientifically verified, particularly in regard to caesarean section. In vivo experiments using dogs (Parulkar 1986) and rats (Kapur 1979; Kyzer 1986) have shown no difference in wound strength whether the peritoneum is closed or not, and have suggested that peritoneal adhesions may be more extensive when the peritoneum is closed, presumably as a result of the foreign body reaction from the suture material. Randomised controlled trials in general surgery of peritoneal closure or non-closure with vertical abdominal incisions (Ellis 1977; Gilbert 1987; Hugh 1990) has shown no significant short term differences in postoperative complications or pain scores. In operative gynaecology, controlled trials of peritoneal non-closure in vaginal hysterectomy (Lipscomb 1996), abdominal and radical hysterectomy (Than 1994) and lymphadenectomy (Kananali 1996) have demonstrated no difference, or an improvement in short term postoperative morbidity if the peritoneum is not closed. In the trial of peritoneal non-closure when lymphadenectomy was practiced, peritoneal non-closure significantly reduced adhesion formation. The parietal peritoneum is often sutured at caesarean section. That this suture might be omitted without adverse effect, and with saving of operating time, is a reasonable hypothesis in view of this information. Objectives To determine whether dispensing with closure of the peritoneum at caesarean section will affect the duration of operation and the short term short term postoperative course. Criteria for considering studies for this review Types of studies All controlled trials comparing leaving the peritoneum unsutured at caesarean section with the conventional approach of suturing the peritoneum. Types of participants Women undergoing caesarean section. Types of intervention The peritoneum, either visceral, or parietal, or both visceral and parietal were left unsutured for the experimental group, and were sutured with a continuous suture in the control group. Types of outcome measures Operating time, measures of maternal morbidity. Search strategy for identification of studies See: Collaborative Review Group search strategy This review has drawn on the search strategy developed for the Pregnancy and Childbirth Group as a whole. Relevant trials were identified in the Group's Specialised Register of Controlled Trials. See Review Group's details for more information. Methods of the review Data on trial methodology and results were abstracted from published trials by the reviewers. Assessment of quality of each study was performed by the reviewers, and studies were excluded when appropriate before analysis of results or incorporation into meta-analysis to minimise chances of selection bias. Authors of published abstracts or unpublished data were approached by one of the reviewers for further details of the study methodology and results, so that their data could be included where appropriate. Description of studies The largest included study (Nagele 1996) compares closure to non-closure of both visceral and parietal peritoneum in 549 women. Allocation was by days of the week of delivery, with resultant potential for bias and difficulty of concealment of treatment allocation. The next largest included study (Irion 1996) examined 280 women. The quality of this trial was superior to the others, with random allocation by sequentially numbered sealed envelopes. As with Nagele's study, this compared closure to non-closure of both visceral and parietal peritoneum. The third largest included study (Pietrantoni 1991) of 248 women used the last digit of the hospital number for allocation. Only the parietal peritoneum was left unsutured in the experimental group. This method of allocation also has potential for bias and difficulty in concealment of treatment. The smallest included study (Hull 1991) of 117 women also used allocation based on the last digit of the medical record number. Only the visceral peritoneum was left unsutured in the experimental group. Methodological quality One of the trials (Irion 1996) was a well conducted randomised controlled trial with good concealment of treatment allocation. The methodologies of the remaining trials were weak, allocation being 'quasi-randomised' rather than randomised. Results Dispensing with peritoneal closure saved between 4 and 8 minutes of operating time, and of course, the cost of the suture. No significant differences in postoperative morbidity or length of hospital stay were found. Indeed there is a consistent although nonsignificant trend for improved immediate postoperative outcome if the peritoneum is not closed. Summary of analyses MetaView: Tables and Figures Discussion Currently available evidence raises questions concerning the use of peritoneal closure as conventional practice in routine caesarean section. There seems to be no significant difference in short term morbidity from non-closure of the peritoneum at caesarean section compared to routine closure. Indeed there is a consistent although nonsignificant trend for improved immediate postoperative outcome if the peritoneum is not closed. This possible difference in morbidity may be small, but as caesarean section is so commonly performed, any small improvement in morbidity may have important population and cost benefits. The question of long term benefits or hazards of leaving the peritoneum unsutured in wound closure has not been addressed in the trials performed to date. Reviewers' conclusions Implications for practice The data are insufficient to warrant a change in practice. What evidence is available suggests that leaving the peritoneum unsutured is not likely to be hazardous in the short term, and may be of benefit, but the longer term effects remain unknown. Implications for research The advantages in terms of shorter operating time obtained by leaving the peritoneum unsutured warrant further trials to determine whether or not non-closure of the peritoneum confers any advantages in terms of postoperative morbidity. The absence of information on long term benefits or complications on non-closure of the peritoneum at caesarean section is a serious deficit in this research literature. Further randomised controlled trials should be conducted, particularly with the view of establishing a cohort of randomised participants for longer term follow-up with regard to future adhesions and operative complications. Acknowledgements None. Characteristics of included studies Table: Characteristics of included studies Characteristics of excluded studies Study : Ohel 1996 This was a well conducted randomised controlled trial examining the use of closure or non-closure of peritoneum at Caesarean section along with the use of a double or single layer uterine closure. Unfortunately, it was not possible to separate the effect of double or single layer uterine closure from the closure or non-closure of peritoneum on operation time and morbidity, because of the methodology used. Study : Stark 1995 Retrospective analysis of two different operating techniques by two groups of surgeons, using different techniques of uterine and peritoneal closure. There was significant reduction in febrile morbidity and adhesions in repeat sections when the peritoneum was not closed, without differences in haematocrit or haemoglobin changes. Although analysis of the two groups showed no differences in age, gestation, gravidity, parity, previous Caesarean section or rupture of membranes, this was not a randomised controlled trial, and is thus excluded. The direction of effect is consistent with the included studies. References References to studies included in this review Hull 1991 {published data only} Hull D, Varner M. Closure of the peritoneal membranes at the time of cesarean section - a prospective randomized study. Proceedings of the 10th Annual Meeting of Society of Perinatal Obstetricians; 1990; Houston, Texas, U.S.A. 1990:119. Hull DB, Varner MW. A randomized study of closure of the peritoneum at Cesarean delivery. Obstet Gynecol 1991;77:818-821. Irion 1996 {published data only} Irion O, Luzuy F, Beguin F. Non closure of the visceral and parietal peritoneum at cesarean section: a randomised controlled trial. Br J Obstet Gynaecol 1996;103:690-694. Luzuy F, Irion O, Beguin F. A randomized study of closure of the peritoneum at Cesarean delivery. Am J Obstet Gynecol 1994;170:341. Nagele 1996 {published data only} Nagele F, Karas H, Spitzer D, Staudach A, Karasegh S, Beck A, Husslein P. Closure or non closure of the visceral peritoneum at caesarean delivery. Am J Obstet caesarean delivery. Am J Obstet Gynecol 1996;174:1366-1370. Pietrantoni 1991 {published data only} Pietrantoni M, Parsons MT, Collins E, Knuppel RA, O'Brien WF, Spellacy WN. Evaluation of peritoneal closure at cesarean section. Proceedings of the 10th Annual Meeting of Society of Perinatal Obstetricians; 1990 Houston, Texas, U.S.A. 1990:118. Pietrantoni M, Parsons MT, O'Brien WF, Collins E, Knuppel RA, Spellacy WN. Peritoneal closure or non-closure at Cesarean. Obstet Gynecol 1991;77:293-296. * indicates the major publication for the study References to studies excluded from this review Ohel 1996 Ohel G, Younis JS, Lang N, Levit A. Double layer closure of uterine incision with visceral and parietal peritoneal closure: Are they obligatory steps of routine cesarean sections? J Mat Fet Med 1996;5:366-369. Stark 1995 Stark M, Chavin Y, Kupferstzain C, Guedj P, Finkel AR. Evaluation of combination of procedures in caesarean section. Int J Obstet Gynecol 1995;48(3):273-276. References to studies awaiting assessment Hojberg 1997 Hojberg K E, Aagard J, Laursen H, Diab L Secher N J. Pain measurement and assessment after closure versus non closure of the peritoneum parietale after low segment cesarean section. A randomised study. Acta Obstet Gynecol Scand 1996;75:93. Jacobson 1992 Jacobson JD, Gregerson GN, Valenzeula GJ. Does non closure of bledder flap at caesarean section decrease fluid collection and infectious morbidity? Am J Obstet Gynecol 1992;166(1 Pt 3):409. Svigos 1990 Svigos J. Unpublished controlled trial of peritoneal closure or non closure at caesarean section. Women's and Children's Hospital - Adelaide. South Australia. (data requested). Additional references Duffy 1994 Duffy DM, diZerega GS. Is peritoneal closure necessary? Obstet Gynecol Surv 1994;49(12):817-22. Ellis 1977 Ellis H, Heddle R. Does the peritoneum need to be closed at laparotomy? Br J Surg 1977;64(10):733-736. Gilbert 1987 Gilbert JM, Ellis H, Foweraker S. Peritoneal closure after lateral paramedian incision. Br J Surg 1987;74(2):113-115. Hugh 1990 Hugh TB, Nankivell C, Meagher AP. Is closure of the peritoneal layer necessary in the repair of midline surgical abdominal wounds? World J Surg 1990;14(2):231-233. Kananali 1996 Kananali S, Erthen O, Kucikozkan T. Pelvic and peritoneal closure and non closure at lymphadenectomy in ovarian cancer: effects on morbidity and adhesion formation. Eur J Surg Oncol 1996;22(3):282-285. Kapur 1979 Kapur ML, Daneshwar A, Chopra P. Evaluation of peritoneal closure at laparotomy. Am J Surg 1979;137(5):650-652. Kyzer 1986 Kyzer S, Bayer I, Turani H, et al. The influence of peritoneal closure on the formation of intraperitoneal adhesions: an experimental study. Int J Tissue React 1986;8(5):355-359. Lipscomb 1996 Lipscomb GH, Ling FW, Stovall TG. Peritoneal closure at vaginal hysterectomy: a reassessment. Obstet Gynecol 1996;87(1):40-43. Parulkar 1986 Parulkar BG, Supe AN, Vora IM et al. Effect of experimental non closure of peritoneum on development of suture line adhesions and wound strength in dogs. Ind J Gastroenterol 1986;5(4):251-253. Than 1994 Than GN, Arany AA, Schunk E et al. Closure and non closure Than GN, Arany AA, Schunk E et al. Closure and non closure after abdominal hysterectomies and Wertheim-Meigs radical abdominal hysterectomies. Acta Chirg Hung 1994;34(1-2):79-86. Previously published versions Enkin 1995 Enkin MW. Non-closure of peritoneum at Caesarean section. [revised 01 October 1993] In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration, Issue 2, 1995. Oxford: Update Software. Coversheet Title Peritoneal non-closure at caesarean section Reviewer(s) Wilkinson CS, Enkin MW Date of most recent amendment : 25 October 1999 Date of most recent substantive amendment : 17 September 1997 This review should be cited as : Wilkinson CS, Enkin MW. Peritoneal non-closure at caesarean section (Cochrane Review). In: The Cochrane Library, Issue 2, 2000. Oxford: Update Software. Contact address : Dr Chris S Wilkinson Staff Specialist - Obstetrics and Feto Maternal Medicine Department of Perinatal Medicine/University Department of Obstetrics & Gynaecology Women's and Children's Hospital 72 King William Road North Adelaide South Australia AUSTRALIA 5006 Telephone: +61 8 8204 7633 Facsimile: +61 8 8204 7654 E-mail: cwilkins@medicine.adelaide.edu.au For information on the editorial group see: Cochrane Pregnancy and Childbirth Group Extramural sources of support to the review No sources of support supplied Intramural sources of support to the review Women's and Children's Hospital, North Adelaide, South Australia AUSTRALIA Keywords PERITONEUM / surgery; CESAREAN-SECTION / methods; SUTURE-TECHNIQUES; PREGNANCY; HUMAN; FEMALE; COMPARATIVE-STUDY; TIME-FACTORS; POSTOPERATIVE-COMPLICATIONS; FEVER / etiology; ENDOMETRITIS / etiology; SURGICAL-WOUND-INFECTION; LENGTH-OF-STAY; CLINICAL-TRIALS CRG Code: HM-PREG Cochrane Library number: CD000163 ----- END OF DOCUMENT -----
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