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Comment and Controversy

1- or 2-layer closures for cesarean section?

October 2004 · Vol. 16, No. 10
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I read with interest the July article on minimally invasive cesarean by Drs. Marco A. Pelosi II and Marco A. Pelosi III (“Minimally invasive cesarean: Improving an innovative technique”).

Although I found many weaknesses within the article and several statements of fact that are, at best, borderline, 2 items in particular concern me.

First, recent studies have shown that patients who undergo single-layer closure of the uterus following a cesarean are twice as likely to dehisce and/or rupture during a subsequent pregnancy or vaginal birth after cesarean than those who have had double-layer closure.

Second, many general surgeons believe the parietal peritoneum should always be closed in any patient expected to need a second abdominal procedure. Otherwise, adhesions are much more extensive—especially when they involve the recti muscles.

Jonathan A. Fisch, MD
Indianapolis, Ind

Drs. Pelosi and Pelosi respond:

Since its inception, the cesarean operation has been standardized in precise steps, each with its own alleged purpose. But this time-honored approach is based more on anecdotal impressions than scientific evidence.

Regarding single- versus double-layer uterine closure, a review of the literature supports the former’s effectiveness and safety. It is important to remember that the reduction in uterine size after delivery is not due to necrosis or degeneration of uterine cellular components, but to reduction of fluid and protein content and simultaneous shrinking in uterine cell size. Ultrasound and computed tomography of the involuting puerperal uterus reveal that most of the decrease in uterine size occurs during the first 7 days (42% reduction).1,2

These findings indicate that the hysterotomy incision suture line (regardless of suture material or surgical closure technique) loosens in less than 7 days. They also indicate that the suture line’s primary function is to provide early hemostasis and prevent uterine contents from escaping into the abdominal cavity. An excellent review was published in this journal by Bivins and Gallup.3

As for peritoneal nonclosure at cesarean, the evidence supporting it is overwhelming. While we do not routinely close the vesico-uterine fold and parietal peritoneum, we clearly stated in the article that we strongly recommend peritoneal closure in cases in which 1 or both rectus muscles have been transected. Otherwise, thick fibromuscular adhesions may develop between the lower anterior surface of the uterus and the undersurface of the rectus muscles.4

For more information, we recommend the Cochrane review of peritoneal nonclosure at cesarean section and the recent review by Tulandi et al.5,6


1. Lavery JP, Shaw LA. Sonography of the puerperal uterus. J Ultrasound Med. 1989;8:481-483.

2. Twickler DM, Setiawan AT, Harrell RS, et al. CT appearance of the pelvis after cesarean section. Am J Radiol. 1991;156:523-526.

3. Bivins HA, Gallup DG. C/S closure techniques: Which work best? OBG Management. April 2000;14:98-99.

4. Pelosi MA, III, Pelosi MA, II. Peritoneum closure at cesarean section. Am J Obstet Gynecol. 2004;191:382.-

5. Bamigboye AA, Hofmeyer GJ. Closure versus non-closure of the peritoneum at cesarean section. Cochrane Database Syst Rev (England). 2003;(4):pCD000163.-

6. Tulandi T, Al-Jaroudi D. Nonclosure of peritoneum: a reappraisal. Am J Obstet Gynecol. 2003;189:609-612.

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