Modification of cesarean section operative technique by Vejnovi

Vejnovi modification of cesarean section represents an improvement of previous operative

techniques. Vejnovi introduced a new perspective on cesarean section as an imitation of vaginal
delivery. This point of view induced changes in each step of the operation (opening of the anterior
abdominal wall, opening of the uterus, delivering the baby and placenta, revision of the uterine
cavity and dilation of the cervix, uterus suturing, closing of the anterior abdominal wall), which
reduced the traumatization of the tissue, and supported healing and physiological postpartum
processes.
According to that, three basic principles of Vejnovi modification were defined:
1. Minimal tissue trauma 2. Minimal operation time 3. Imitation of vaginal delivery.
The principle of imitation of vaginal delivery involves the creation of a new birth canal,
which is tailored for an individual fetus. It means that the opening of the abdominal wall and the
uterus should be the smallest possible for the baby to pass through, using the same mechanism as in
vaginal delivery. In this way, pressure is achieved on the head and chest of a newborn, which helps
to squeeze out fetal lung fluid, thus providing better transition to air breathing.
The most significant contribution of the modified technique is a new way of uterus suturing.
It is also based on the principle of imitation of natural processes, especially of the uterus involution
after delivery. According to Vejnovi modification, uterus suturing is performed in four steps. By a
particular order of placing the stitches and tightening the knots, the length of the uterus incision
already intraoperatively gets twice shorter. Centripetally directed vectors of the force within the
scar, contribute to its further reduction in the postoperative period and preserving the thickness of
the uterine wall. Everything above-mentioned provides faster and better healing of the uterus and
reduces the risk of acute complications (bleeding and infection), as well as chronic complications of
caesarean section in future pregnancies (rupture of the uterus and placenta accreta) which may
cause much greater morbidity and potentially fatal consequences.
It has been scientifically confirmed that this modified technique leads to a significant
reduction in blood loss, the length of the operation and stay in hospital, as well to the reduction in
suture material consumption and use of instruments. Likewise, patients operated with Vejnovi
modification experienced less postoperative pain, used fewer painkillers, and had less surgical
wounds complications.
A retrospective study showed that among the 15.000 patients operated only by using
Vejnovi modification, there was no case of placenta accreta, which is considered to be the most
serious complication of cesarean section.
This operative technique was presented in over fifteen health centers in the world. In several
clinics in Europe (Serbia, Germany, Austria, Hungary, Romania), Vejnovi modification is adopted
and applied regularly.
In 2017, the Ministry of Health of the Republic of Serbia approved the implementation of
the Modification of cesarean section operative technique by Vejnovi as scientifically proven
and tested new health technology.
In order to provide a precise explanation of the modified technique and a better quality of
education for surgeons, 3D animation of modified uterus suturing by Vejnovi was made and this
educational course was organized.
 Modified Vejnovic technique

Tihomir Vejnovic – Serban Dan Costa – Atanas Ignatov - Aleksandra Vejnovic

Tihomir Vejnovic was born in Apatin on 22nd November 1958. He graduated from University
of Novi Sad, Faculty of Medicine in 1984. and two years after got employed at the Clinic of
Gynaecology and Obstetrics in Novi Sad. Meanwhile and during military service he used to work in a
Military Hospital at general surgery department and teach anatomy at the Faculty of Medicine. In 1997
he became head of the second biggest Delivery department in Serbia with approximately 6500
deliveries per year. Since he started his education and clinical work at the Clinic, pronounced changes
in obstetrical practice happened. During his residency most of the breech presenting fetuses and
multiple pregnancies were delivered vaginaly using Bracht maneuver, internal podalic version etc.
Afterwards, as caesarean section became safer to perform, many manual skills in vaginal delivery were
progressively replaced by caesarean section (Table 1). The rate of caesarean section sharply started to
increase.

Table 1 – Obstetrical operations rates in period 1990-2015 expressed as percentages of vaginal

deliveries (episiotomy, vacuum extraction, breech delivery) and total number of deliveries (caesarean
section) respectively (1)
1990 1995 2000 2005 2010 2015
Episiotomy 60.5% 64.5% 36.3% 41.8% 44.2% 37.1%
Vacuum extraction 2.4% 2.5% 1.3% 0.7% 0.8% 0.9%
Breech delivery 84.9% 55.9% 31.0% 22.1% 27.5% 9.1%
Caesarean section 11.7% 12.2% 20.8% 25.5% 29.0% 30.5%

Tihomir Vejnovic belonged to both obstetrical eras, so he became skilled in wide spectrum of
obstetrical procedures, knowing surgical principles and anatomy by heart. Working in referent center
for Obstetrics made him competent for the management of various kinds of complications. All this
helped him to learn, respect and understand nature of vaginal delivery.
Since his early career he was receptive and open-minded for new solutions which could reduce
maternal and neonatal morbidity. Together with Prof. Dr. Aleksic he replaced lower midline
laparotomy with suprapubic laparotomy in caesarean section at Novi Sad clinic (Figure 1).
%

90
80
70
60
50
40
30
20
10
0
'93 '94 '95 '96 '97 '98 '99
Lap.medianainferior 56,05 47,98 54,19 47,13 33,41 22,49 14,89
Lap.sec.Pfannenstiel 43,95 52,02 45,81 52,87 66,59 77,51 85,11

Figure 1. Percentage of lower midline laparotomy and Pfannenstiel laparotomy at the Clinic of
Gynaecology and Obstetrics Novi Sad
 All these circumstances of his professional life were triggers to investigate in details existing
techniques of laparotomy and caesarean section, among which Joel Cohen and Misgav Ladach, and
initiated idea of the new modification of caesarean section.
Vejnovic modification of caesarean section technique was developed in 2000. It includes
changes in each step of the operation. More important, it introduced new logic of the operation –
immitating the mechanisms of vaginal delivery, using same factors of delivery, but making new,
virtual birth canal in the abdominal wall. During the years of testing, observing and comparing,
important details of the technique were distinguished and their clinical effects were hypothesized or
proven.
Basic principles of Vejnovic modification are:
1. Minimal traumatisation of the mother and the fetus
2. Maximal shortening of the operative time
3. Immitation of the vaginal delivery (nature).

Description of the operative technique:

Every operation begins with adequate preparation of the patient and operative field, thorough
surgical hand washing and disinfection. Caesarean section has to be considered major surgical
operation, because the complications are major and sudden. Caesarean section is operation with time
limit. This is why operator should always access to the patient with respect and care, and be
concentrated no matter if it is elective operation or urgent caesarean section in the middle of the night.
’’Think of caesarean section as it is an apnea diving. Do not start if you did not take deep
breath and focused your mind.’’
Laparotomy
Skin incision
’’By the incision of the skin and uterus you are tailoring the destiny of your operation’’
There is a simple rule to determine right place to make incision on the skin. Operation should
begin at the site of a natural fold of the skin that can be vizualized by wrinkling the abdominal skin
downwards (Figure 2).

Figure 2. Skin incision site. Natural fold of the skin (scheme left, live right)

This place corresponds to the insertion of underlying pyramid muscles, which makes other
steps of the laparotomy easier to perform. In small percentage of the patients where natural fold cannot
be vizualized, incision should be made 3-4 cm above the upper rim of pubic symphysis.
Incision should be straight transverse and initially not longer than 10-12 cm, because this is the
average range of occipitofrontal diameter of fetal head. It is an illusion that big incision will make
extraction easier and vice versa.

’’You can always make small incision bigger, but cannot ever make big scar smaller.’’
Fascia and muscles
Further steps of laparotomy represent modification of Joel-Cohen technique. As described in
the original technique first cut goes through the skin and the very superficial subcutaneous tissues. The
subcutaneous tissue is then transversely cut down to the fascia (rectus muscle sheath) only in the
midline with a width of 3-4 cm (2). Modification of laparotomy is reflected in further steps
which reduce the trauma to the tissue. Rectus muscle sheath is cut transversely with scalpel in the same
length of 3-4cm, till separation of two rectus muscle occurs. With Kocher grasper upper edge of the
sheath is pulled up (Figure 3).

Figure 3. Laparotomy modification – incision of a. skin b. subcutaneus tissue c. fascia

One index finger is used to break transversalis fascia and parietal peritoneum bluntly. Just then,
two rectus muscles are separated by synchronized pulling with one, two and three fingers gradually.
Important thing is that fingers have to be placed beneath the parietal peritoneum and pull muscles
together with transversalis fascia and parietal peritoneum. This is due to protection of deep epigastric
vessels and prevention of the hematoma.

Hysterotomy
Opening of the uterus is one of the most important steps in the operation. The incision of 1-2cm
is done paracentric (2cm closer to the operator) in isthmicocervical segment above the vesicouterine
fold, with scalpel till the decidual layer is reached (Figure 4a). Anatomical forceps is then used to open
the uterine cavity through this incision (Figure 4b) and guide scissors with the blunted ends to further
cut uterine wall in transverse direction (Figure 4c,d). The length of this incision is prefered to be
minimum 5 cm (Figure 4e).
 Figure 4. Hysterotomy and first adaptation of the incision

Uterine wall is lifted by tip of the forceps from inside the uterine cavity in order to avoid injury
of the umbilical cord, or tiny parts of the fetus.You should think of this risk, which is not greater than
usual. However, do not let it become fear, because there is an exclusive advantage of this kind of
opening. By cutting myometrium with scissors, all smooth muscle fibers are cut and retracted at the
same moment. The result are straight and regular edges which ensure better adaptation when suturing
the uterus afterwards.
After opening the uterus with scissors, size of the incision should be adapted digitally to the size of
fetal head using thumb and index finger (Figure 4f).
There is an important rule concerning the place of uterus incision according to the cervical dilatation:
1. When you perform elective cesarean section, make incision 1 cm above the vesicouterine fold
in isthmicocervical segment of the uterus.
2. When you perform cesarean section in patient who is in labor, again make incision above the
vesicouterine fold which is lifted up as many centimeters above the place where it would be in
elective surgery as cervical ostium is dilated. If dilatation is greater than 5 cm, do not make
incision higher than 5 cm, because it will be corporeal incision.
If you do not follow this rule there is increased risk of making incision too low, in cervical
segment, which is associated with higher incidence of wound dehiscence, unintended extension of the
incision and excessive bleeding.

Extraction of the fetus

Extraction of the fetus is the main reason to perform cesarean section. However, it is the most
difficult step to explain. Here are some instruction we find useful.
When you are preparing for the caesarean section, approach with clear goal and positive energy –
successful extraction of the fetus. After hysterotomy and first adaptation of the uterine opening, hand
of the operator is inserted into uterine cavity, in front of the fetal presenting part. Presenting part is
then luxated i.e. lifted to the new birth pathway. At the same time fetal head should be orientated so
that occiput takes anterior position and small fontanella become leading point. This is done by flexing
and rotating it with the hand of the operator as it would happen by the mechanism of the vaginal
delivery (Figure 5).

Figure 5. Immitating the mechanism of vaginal delivery; a. luxation of the fetal head b. shifting
the edges over fetal head c. fetal head deflexion d. external rotation

When fetal head is fixed in the opening of the uterus, parallelly with fundal pressure, operator should
shift the edges of the uterus over the fetal head, like putting on the turtleneck sweater, till the fetal head
comes out of the uterus. Specially important is the upper edge of the uterine incision to be shifted.
Opening of the uterus should be just as big as baby to be able to deliver. Remember that fetus should
be pushed out of the uterus and not pulled out. The reason again lays in natural process – during
extraction baby’s head and chest are compressed which helps secretion and pulmonary fluid to be
squeezed out and prevents respiratory distress (Figure 6). This principle is abandoned only in the case
when there are signs of severe fetal suffering or prematurity, because in these cases the point is to
avoid the trauma of passage through the birth canal.
If new birth canal is not big enough at first adaptation, both incision of the skin and uterus can be
stretched out in craniocaudal direction using both hands.
Breech presenting fetuses are extracted with usual maneuvers, and extreme prematures you should try
to extract ’’en caul’’ i.e. in intact membranes to protect them from trauma. All maneuvers with fetus
have to be gentle and physiological.
Figure 6. Extraction of the fetus; a. optimal size of the new birth canal b. external rotation of the fetus
c. amniotic fluid squeezed out of the fetal orificies d. drainage position of the newborn after extraction.

If you have difficulties to extract the fetus, consider doing internal version, extraction for legs,
prolonging the incision, T-incision etc. If fetus was in good condition, you have 15 minutes to do
extraction. However, time runs in unsuccessful attempts. Do not let your vanity be more important than
safety of your patients – do not hesitate to timely call more experienced colleague for help. When
newborn is delivered and no need for resuscitation, delayed cord clamping 30-60s is advisable.

Delivery of placenta
As in vaginal delivery, placenta needs some time to detach. When newborn is delivered and the cord is
clamped, uterotonic is to be administred (Oxytocin 5 IU i.v. bolus + Oxytocin 10 IU in Sol. NaCl 0,9%
a 500ml). Gentle traction for the umbilical cord and fundal pressure will lead to detachment and
spontaneus evacuation of the placenta and all the membranes (Figure 7).

Figure 7. Delivery of placenta; a. umbilical cord traction and fundal pressure b. removal of the
amniotic membranes from internal uterine ostium.

After this, uterine cavity should gently be revised with two fingers to check if there is any residual
tissue. There is no need to rush, and make unnecessary trauma to the sensitive decidual layer using
gauzes and similar procedures. Very important thing to do is to remove membranes that are covering
internal uterine ostium, because they are the most common cause of haematometra after cesarean
section. Main goal of doing cervical dilatation afterwards is not primaraly dilatation of cervical canal,
but in fact checking if there are any remaining membranes that could obstruct elimination of lochia.
Uterus suture
After extracting the newborn, suturing the uterus is crucial step in caesarean section. This is because it
is important not only for current pregnancy but for the following pregnancies as well. From our point
of view, the way of closing the uterus directly influences the healing process, and incidence of the
acute and chronic complications. This is why the biggest value of Vejnovic modification represents the
modification of suturing the uterus.
Two main points of modified suturing are:
1. reconstruction– making smaller scar and preserving thickness of the uterine wall
2. support of the involution of the uterus.
’’Uterus is sutured in four steps using two threads and without penetrating the decidual layer.’’
Keep in mind that all the way of suturing you have to avoid penetrating the decidual layer. Suturing
of the uterus have to be supraendometrial! This is very important because of the cases of iatrogenic
endometriosis. However, what is even more important is that suture with penetration is everting suture
which compromises healing (Figure 8). For correct healing of the uterus you need inverting suture!

Figure 8. Uterus suturing with and without penetrating decidual layer.

All layers have to be adapted precisely in order to preserve thickness and the structure of the
uterine wall. To obtain this, use tip of the needle to unroll the lower edge of incision which is rolled up
by retraction of the muscle fibers (Figure 9).

Figure 9. Adaptation of the myometrial layers using needle.

Sequence of the suturing movements will be presented through the set of drawings (Figure 10-13).
In majority of the cases, there is no need to take uterus out of the abdomen or to grasp edges of the
incision with any instrument. After birth of placenta immediately start to suture uterus.
In surgery it is mandatory to have good vizualization of the operative field. Never use sharp
instruments blindly!

Step one
First stitch is set 1-2 cm medialy to the right edge of the incision, where you can see and control the
movements of the needle. Free end of the thread should stay around 20 cm long for further actions
(Figure 10, row 1-2). Use thread as an instrument to pull the uterus and vizualize the correct point for
second stitch (Figure 10, row 3). Second stitch is then placed 1-2 cm laterally to the edge of the
incision i.e. in healthy tissue of the uterus. After this, the first knot is tied (always use first double and
then single right and left knot to get secured knot, Figure 10, row 3-4). With this first knot you will
close the edge of the incision, and there will not be left any defect, which could cause bleeding and
hematomas. However, you should always palpate the edges from inside the uterine cavity to check if
there is any defect. Sometimes deeper layers of myometrium tend to extend more than superficial
layers which cannot be seen by inspection. If you detect defect, you can close it using the same thread
without interrupting the suture and without using extra suture material.
When you tie first knot it should stay fixed in the point which corresponds to the first stitch. Continue
suturing by making three continuous locking sutures (Figure 10, row 5-6). Assistant should keep thread
under tension all the time. Final part of the first step is tying two ends of the thread into second knot
(Figure 10, row 7-8). Notice that thread will fall diagonally over the incision and supress it towards the
uterine cavity i.e. the sutured incision will be in the same level with surrounding tissue, and not above
it. Another important thing is that second knot will reduce the lenght of the incision by compressing
the myometrium.

Figure 10. Uterus suturing – step one.

Step two
Second step is identical to the first step, but performed as an object in the mirror (Figure 11).

Figure 11. Uterus suturing – step two.

Step three
Third step consists of suturing the central part of the incision. One or two continuous locking suture are
made from each side till you reach the center of the incision, then you tie a knot (Figure 12).

Figure 12. Uterus suturing – step three

Step four
Final step represents intraoperative reduction of the length of the incision. This is done by tying thread
from each edge to the central thread and form the knots as shown in the Figure 13.
In this way myometrium is compressed and vectors of the forces that act between the knots are
directed towards the center of the incision.

Figure 13. Uterus suturing – step four

There are two positive effects. First, compression of the myometrium, that we call myotamponade
(Figure 14), closes the blood vessels in vascular stratum of myometrium and provides adequate
hemostasis without need for extra hemostatic sutures. The second effect is support of the involutive
process of the uterus in puerperium by pulling the healing part of the uterus towards center unlike
stretching it when you suture uterus from one edge of incision to the other.

To summarize: uterus is sutured using two threads in four steps. Each step leads to certain reduction of
the incision length which will result in twice shorter incision intraoperatively and support the
involution in puerperium (Figure 15). All sutures have to be extraendometrial.
After the uterus is closed, you should perform toilette of the abdominal cavity and check the
hemostasis.
* For uterus suture we usually choose Vicryl Plus 2 (90cm, 1/2c, taperpoint 48mm).
 Figure 14. Myotamponade effect

Figure 15. Uterus suture; a. four steps of suturing b. intraoperative reduction of the incision length
Fascia suture
The same way you started suturing the uterus, place the Z-stitch in the right corner of the fascia. Fascia
is further closed using continuous suture all the way to the other corner. You do not need to grasp the
corner with any instrument. Use your needle as an instrument to show underlying structures (Figure
16).

Figure 16. Fascia suture; a. Z-stitch in the corner b. locking in the middle c. needle used as an
instrument
If the patient is obese, it is recommended to lock ones or twice the suture in the middle and continue
without locking to the left corner. In skinny patients, knot that is tied in left corner, specially if it is
bulky can provoke discomfort and chronic pain. To avoid that, in this group of the patients, when you
reach the left corner, you should always continue suturing back two to three stitches toward the center
and then tie the knot.
* For fascia suture we usually choose Vicryl Plus 1 (90cm 1/2c taperpoint 40mm) or Vicryl Plus 2 in obese
patients and relaparotomies.

Parietal peritoneum and subcutaneous tissue require no suturing. In fact subcutaneous tissue if it is
treated unnecessarily usually causes complications.
’’Offended tissue is lit.’’
Skin suture
Let the elegancy of all previous steps be reflected on the skin. Skin suture is the final step of the
operation. However, it should be done equally meticulously and precisely, because it is the only visible
proof for the patient based on which she will built impression about whole operation.
’’Sign your operation calligraphicaly.’’
Buried continuous intradermal suture is the suture of first choice, when there is no contraindication to
use it. First and last stitch are placed around 1,5-2 cm from the corresponding corner of the skin
incision. This is meaningful solution that reduces complication of the operative wound to the minimum
by leaving natural drainage space from both sides of the skin incision (Figure 17).
* For uterus suture we usually choose Vicryl rapide 2-0 (75cm, 1/2c, taperpoint 31mm).

Figure 17. Skin suture; a. starting 1,5-2cm from the corner b. continuous intradermal suture c. blood
drains from the corners

In 2008 the results of first retrospective-prospective study were published. This was the first
time the new modification was introduced to the Serbian scientific public, comparing it to
Pfannenstiel-Kerr caesarean section technique. Results of almost 2000 patients showed that Vejnovic
modification last three times shorter (average operating time is 12 minutes). Not only time, it also
saves blood (30,9% less bloodloss), suture material (two times less consumption of suture material)
and hospitalization costs (two times shorter stay) (3).
Grahovac et al. investigated wound complications (redness, swelling, pain in the wound,
presence of haematoma (on skin and subcutaneous region), serous discharge and dehiscence) in
different techniques of caesarean section and found significantly less in Vejnovic modification. They
also noticed that the length of the incision was significantly shorter in Vejnovic technique (4).
Postoperative pain also was compared to the Pfannenstiel-Kerr technique and objectivized less
pain in patients operated by Vejnovic modified technique as well as less consumption of analgesics
postoperatively (5).
Tihomir Vejnovic published monography about cesarean section in 2010 (6) and in 2011
Caesarean Section – Modification Vejnovic was entered into the record of works of authorship by
Department for Intellectual Property of Republic of Serbia.
However, crucial role for further acceptance of the modification Tihomir Vejnovic owes to
professor Egon Diczfalusy and his close collaborators professor Guiseppe Benagiano and Serban Dan
Costa who encouraged him and gave thoughtful advice. After organizing successful live-surgery
course in Magdeburg, which aimed to critically and impartially evaluate technique with colleagues
from abroad, description of technique was published in English in Geburtshilfe und Frauenheilkunde.
Vejnovic modified technique was presented in Montenegro, Hungary, Romania, Germany,
Sweden, Austria, France and USA. In several obstetric centers it is performed regularly (Arad, Oradea,
Timisoara, Bucharest, Szeged, Magdeburg), thanks to colleagues from Arad and Oradea who made
receptive atmosphere presenting their experience with modification Vejnovic in several publications
(7,8) and every conference.
Articles in Geburtshilfe und Frauenheilkunde Journal (9) and Jatros (10) announced new
hypothesis that operative technique of caesarean section can influence the incidence of complications
in future pregnancies, as all the serious complications such as uterine rupture and placenta accreta
occur at the site of the uterine scar.
This initiated new projects, which indicate that uterine scar after modification Vejnovic suturing
measured with ultrasound is thicker and shorter than in other techniques (unpublished data).
Histological structure of the uterine scar is investigated in another project.
Preliminary results of retrospective study showed that there were no cases of placenta increta/percreta
among the patients who were delivered only using Vejnovi modified technique in previous
pregnancies, and that incidence of placenta percreta cases at Novi Sad clinic where Vejnovic
modification is predominant technique is lower than ACOG reported (1/533 deliveries) (11,12), which
could be a significant result and confirm the hypothesis.
In order to facilitate training of young obstetricians in using Vejnovic modification 3D
animation was developed (13) and it is now available for trainees.
This textbook was another very important possibility to explain the phylosophy and practical
aspects of our technique and make it more accesible to our Romanian colleagues. For that opportunity
and support, I would like to express my gratitude to the editor and all his collaborators.
Reference
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Clinic of Gynaecology and Obstetrics, Clinical Center of Vojvodina; 2015.
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just Cohen? Acta Obstet Gynecol Scand. 2015 Feb;94(2):224-5. doi: 10.1111/aogs.12552.
Epub 2014 Dec 30.
3. Vejnovi TR. [Cesarean delivery--Vejnovi modification]. Srp Arh Celok Lek. 2008 May;136
Suppl 2:109-15. Serbian.
4. Vejnovic T, Grahovac M, Veselovski A, Koledin S. Surgical wounds complications in two
different techniques of a cesarian section. HealthMed. 2011 Dec;5(6):1754-61
5. urev N. [Postoperative pain in different techniques of caesarean section. Master thesis].
Novi Sad: Faculty of Medicine; 2013. Serbian.
6. Vejnovi T. [Caesarean section]. Beograd: Section for Gynaecology and Obstetrics of Serbian
Medical Association; 2010. Serbian.
7. Furau C, Furau G, Dascau V, Ciobanu G, Onel C, Stanescu C. Improvements in cesarean
section techniques: Arad's obstetrics department experience on adapting the Vejnovic cesarean
section technique. Maedica (Buchar). 2013 Sep; 8(3): 256–60.
8. Chitulea P, Paina G, Gherai R. Vejnovic procedure for caesarian section. Poster session
presented at: 7th Diczfalusy award lecture symposium on reproductive health; 2013 Sep 27-28;
Belgrade, Serbia.
9. Vejnovi TR, Costa SD, Ignatov A. New technique for caesarean section. Geburtshilfe
Frauenheilkd. 2012 Sep;72(9):840-5.
10. Vejnovi T, Vejnovi A. New technique in obstetrics: Vejnovi modification of caesarean
section. Is there an impact on the frequency of placenta increta/percreta? Jatros. Medizin fr die
Frau 3/16. p.26-9. Available from:
http://ch.universimed.com/files/grafik/Zeitungen_2016/Frau_1603/e-papers/index.html#26/z
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11. Stojilkovic T, Vejnovic A, Ilic , Vejnovic T. Prenatal ultrasound diagnosis of invasive
placentation in patients with placenta praevia at Clinic of gynaecology and obstetrics in Novi
Sad. Poster session presented at: From periconception to early infancy. 1st World congress on
maternal fetal neonatal medicine; 2017 Apr 24-26; London, Great Britain.
12. Placenta accreta. Committee Opinion No. 529. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2012;120:207–11.
13. Obradovi R, Vejnovi T, Kekeljevi I, Vejnovi A, Višnjevac N, Rakovi M et al. Pre
production for development of educational 3D animation according to Vejnovic modification
of the cesarean section technique. 5th International Scientific Conference on Geometry and
Graphics, moNGeometrija; 2016.
840 GebFra Science

New Technique for Caesarean Section

Die Entwicklung einer modifizierten Technik für eine Sectio caesarea

Authors T. R. Vejnović 1, S. D. Costa 2, A. Ignatov 1

1
Affiliations Geburtshilfe und perinatologische Abteilung, Universitätsklinikum Novi Sad, Serbien
2
Universitätsfrauenklinik Magdeburg, Magdeburg, Deutschland

Key words Abstract
l
" Caesarean section
! !
l
" section modification
Caesarean section is one of the most common op-
l
" Vejnović method
erations worldwide and more than 30 % of proce-
Schlüsselwörter dures in perinatal centres in Germany are caesar-
l
" Sectio caesarea ean sections. In the last few years the technique
l
" Sectio‑Modifikation
used for caesarean sections has been simplified,
l
" Vejnović‑Methode
resulting in a lower postoperative morbidity. But
persistent problems associated with all caesarean
section techniques include high intraoperative
loss of blood, the risk of injury to the child during
uterotomy and postoperative wound dehiscence
of the uterine scar. We present here a modifica-
tion of the most common Misgav-Ladach method.
The initial skin incision is done along the natural
skin folds and is extended intraoperatively de-
pending on the circumference of the babyʼs head.
After blunt expansion of the uterine incision us-
ing an anatomical forceps, the distal uterine wall
is pushed behind the babyʼs head. The babyʼs head
is rotated into the occipito-anterior or posterior
position and delivery occurs through the applica-
tion of gentle pressure on the uterine fundus. Clo-
sure of the uterotomy is done using 2 continuous
sutures, which are then knotted together result-
ing in a short double-layer closure. The two ends
of the skin suture are left open to allow for natural
received 26. 12. 2011 drainage. Our experience at the University Gynae-
revised 1. 8. 2012 cological Hospitals in Novi Sad and Magdeburg
accepted 1. 8. 2012
has shown that this modification is associated
Bibliography with shorter operating times, minimal blood loss
DOI http://dx.doi.org/ and shorter in-hospital stay of patients as well as
10.1055/s-0032-1315347 high rates of patient satisfaction.
Geburtsh Frauenheilk 2012; 72:
840–845 © Georg Thieme
Verlag KG Stuttgart · New York ·
ISSN 0016‑5751 Introduction
! by caesarean section [2–4].
Correspondence
Dr. Atanas Ignatov Caesarean section is one of the most commonly
Universitätsfrauenklinik performed operations for women all over the
Magdeburg world. Until the middle of the last century caesar-
Gerhart-Hauptmann Straße 135
39108 Magdeburg ean section rates in Europe rarely exceeded 3–5 %
atanas.ignatov@med.ovgu.de [1]. Currently around every 3rd baby (31.3% on
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Zusammenfassung
Die Sectio caesarea ist weltweit eine der am häu-
figsten durchgeführten Operationen, und ihr An-
teil in Perinatalzentren in Deutschland beträgt
über 30 %. In den letzten Jahren wurde die Tech-
nik der Sectio caesarea vereinfacht, was zu einer
niedrigeren postoperativen Morbidität führte.
Weiterhin bestehende Probleme aller Sectio-
Techniken sind hohe intraoperative Blutverluste,
die Gefahr der Verletzung des Kindes bei der Ute-
rotomie und die spätere Nahtdehiszenz im Be-
reich der Uterotomienarbe. Wir stellen eine Mo-
difikation der am häufigsten durchgeführten Me-
thode nach Misgav-Ladach vor. Die Hautinzision
wird in den Hautlinien durchgeführt und intra-
operativ entsprechend der kindlichen Kopfgröße
erweitert. Nach stumpfer Uterotomie wird der
distale Uterotomierand über den führenden Teil
des Neugeborenen geschoben und dieser durch
leichten Druck geboren. Der Verschluss der Utero-
tomie erfolgt durch 2 fortlaufende Nähte, derer
Verknotung zu einem kurzen, doppelschichtigen
Verschluss führt. Bei der Hautnaht werden die
beiden Enden offen, im Sinne einer natürlichen
Drainage belassen. Die Erfahrungen an den Uni-
versitäts-Frauenkliniken Novi Sad und Magde-
burg zeigen eine deutliche Verkürzung der Opera-
tionszeit mit geringem Blutverlust und verkürz-
tem stationären Aufenthalt, kombiniert mit einer
hohen Zufriedenheit der Patientinnen.
average) born in German hospitals is delivered
The increase in the numbers of caesarean sections
performed has been ascribed to the increased
range of indications, increased numbers of pre-
term deliveries and increased legal disputes. The
most important indications for caesarean section

Vejnović TR et al. New Technique for … Geburtsh Frauenheilk 2012; 72: 840–845

include breech presentation, protracted birth including failure to
progress in labour, incipient intrauterine hypoxia and previous
C‑section [5–8]. In the past few years it appears that the rate of
elective C-sections has also risen, but no reliable figures are avail-
able on this point. It is also assumed that improvements in C-sec-
tion techniques resulting in decreased maternal and foetal mor-
bidity and mortality have also contributed to a more general use
of this method of delivery [9, 10]. Over the past few decades the
“classic” Pfannenstiel technique has been replaced, first by the
Joel-Cohen method and then by the “gentle” Misgav-Ladach
technique [11–13]. The changes in operative techniques have
resulted in shorter operating times, less loss of blood, reduced
tissue trauma and a greater patient satisfaction [14–16].
Other modifications to the C-section method were developed at
the beginning of 2000 at the University of Novi Sad (Serbia) and
have been retrospectively compared with the classic C-section
technique [17]. A Doerfler C-section was done in 600 patients
[18] and 5648 patients were operated using the newly modified
method. A comparison with the classic caesarean section method
showed that the modified technique reduced blood loss (342 vs.
495 ml) and postoperative pain and shortened the time required
for surgery (average time: 12 vs. 40 min). The in-hospital stay
was also significantly shorter (3.3 vs. 6.7 days) [17]. Overall, in-
traoperative and postoperative morbidity were significantly re-
duced with the modified technique.
We describe this technique in detail below and present the first
data of a prospective comparative study comparing the “classic”
C-section method and the modified technique.
Patients and Methods
! um and the musculature are sutured with continuous or inter-
Study design
The prospective study was carried out between 1 May 2008 and 1
March 2009 in the Department for Gynaecology and Obstetrics of
the Clinical Centre Vojvodina in Novi Sad, Serbia. Inclusion crite-
ria were primiparity and planned elective C-section together
with informed consent signed by the patient. Patients were ran-
domised into one of two groups by computer randomisation. A
total of 122 patients were investigated in the study; the new
C‑section method was used in 72 patients (59.1 %) (Group A)
while the classic Doerfler C-section method was used in 50 pa-
tients (40.9 %) (Group B). Exclusion criteria were emergency
C‑section for various reasons, refusal of patient consent to take
part in the study and incomplete follow-up data.
The surgeon was only informed a short time prior to the opera-
tion which technique would be used. On the day of discharge
patients were informed which arm of the study they had been
randomised to. Operations were performed under local or spinal
anaesthesia. The time required for surgery, duration of inpatient
stay and blood loss were recorded for comparison. The operating
time was measured from starting the skin incision at the start of
the operation to completion of skin suturing at the end of the op-
eration. Blood loss was measured using a suction device which
suctioned only blood and not amniotic fluid. Blood loss was also
measured indirectly through the determination of preoperative
and postoperative Hb levels. A total of 10 surgeons were involved
in the study, half of them operated the women using the classic
method and the other half used the modified technique. All sur-
geons had performed at least 30 C-sections using their chosen
method prior to taking part in the study. The number of patients
of each group operated on by each surgeon was relatively bal-
Vejnović TR et al. New Technique for …
Original Article 841
anced and evenly distributed. Each surgeon operated on at least
10 patients.
Postoperative clinical follow-up was done at regular intervals;
laboratory tests were done as needed. Postoperatively, scar
length, local reddening, swelling, seroma or haematoma forma-
tion and pain in the area around the scar were evaluated. Patient
satisfaction was also investigated.
Comparison of Classic Caesarean Section
with New Operative Technique
!
Description of the classic operative technique
The skin incision in the classic C-section technique is done as a
horizontal Pfannenstiel incision 2 cm above the pubic symphysis;
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subcutaneous adipose tissue and the abdominal fascia are also
sharply dissected using a scalpel and the aponeurosis of the
transverse abdominal muscles is detached from the straight ab-
dominal muscles. The rectus abdominis muscles are then pushed
apart. This is followed by cranio-caudal incision of the peritone-
um. The peritoneum is severed from the front uterine wall and
pushed away caudally. In the classic C-section method the uterine
wall is completely dissected using a scalpel, and the incision is
then extended manually in a slight horizontal curve. The child is
delivered manually after opening the amniotic sac. After deter-
mining the neonatal pH-value, the placenta is removed by hand.
Curettage of the uterus is done if there is any suspicion that rem-
nants of the placenta have been retained. Depending on the ex-
tent of cervical dilation, manual cervical dilatation or dilatation
using Hegar pins is done to a width of around 3 cm. The uterus
is closed using continuous or interrupted sutures. The peritone-
rupted sutures. The fascia is closed as usual with a continuous
suture. Finally the skin incision is closed with intracutaneous
continuous sutures.
Description of the new operative technique
Opening the abdomen (abdominotomy)
The site for the skin incision is selected by gently pressing the ab-
dominal wall caudally. The incision is then done along the skin
fold created by this gentle pressure (l " Fig. 1 a) at approximately
5 cm above the pubic symphysis. The initial length of the incision
is approx. 6–7 cm. Later during the operation the incision is
adapted to the circumference of the babyʼs head (fronto-occipital
diameter) or the breech presentation. This can be achieved with-
out difficulty if the skin is incised precisely along the skin fold.
The abdominal fascia are then sharply severed with a scalpel
above the pyramidalis muscles (l " Fig. 1 b). The abdomen is
opened at the linea alba through traction on and dissection of
the fascia and access is subsequently enlarged through vertical
and transversal traction and blunt dissection.
Uterotomy
After incising (approx. 2 cm) the uterine serosa 2 cm above the
uterovesical fold, gentle pressure is used to introduce a long ana-
tomical forceps into the uterine cavity at the level of the isthmic
cervical segment at an oblique angle of approx. 30° past the foetal
head or breech presentation (l " Fig. 1 c). Using scissors positioned
between the two arms of the forceps, the uterine wall is incised
along a length of 5 to 6 cm and bluntly expanded manually.
Geburtsh Frauenheilk 2012; 72: 840–845
842 GebFra Science
Delivery of the baby
The lower pole of the presenting part of the foetus is visible in the
uterine opening and is rotated into position. In the second phase
the presenting part is “born” by pushing the upper (“front”) and
lower (“back”) uterine wound using the fingers of the left hand
cranially over the foetal presentation (l " Fig. 1 d). The “birth” is
assisted by pressure exerted on the uterine fundus. The uteroto-
my and the skin incision can be bluntly extended (digital ma-
noeuvre) to adapt the incision to the circumference of the foetal
head. The right hand of the surgeon or assistant is used to “press
the baby out” of the uterus by pressing on the uterine fundus. No
wound retractors (i.e. no Fritsch or Roux retractors) are required
during delivery of the baby as skin elasticity is sufficient.
After delivery of the baby and clamping of the cord, a piece of the
umbilical cord between two clamps is removed to determine the
neonatal pH-value, and the placenta is removed using cord trac-
tion (traction using the remaining Pean clamp) and pressure on
the fundus. If the placenta is complete, digital exploration of the
uterine cavity is sufficient. If there is a suspicion that part of the
placenta has been retained, curettage of the uterine cavity is
done using a large blunt curette. Depending on the extent of cer-
vical dilation, manual cervical dilatation or dilatation using Hegar
pins is done to a width of around 3 cm.
Uterine sutures
The uterine wall is closed using 2 sutures starting from the mid-
dle of the uterotomy (l " Fig. 2). The 1st suture is placed 3–4 cm
medially from the anatomical corner of the wound. Traction on
the suture thread is used to properly approximate the corner of
the wound and the wound is closed using one or two transfixing
sutures. The same thread is then used to create 2–4 continuous
sutures and the ends of the suture threads are knotted and left
long (l" Fig. 2 a). Using a second suture thread the contralateral
side is closed analogously (l " Fig. 2 b). The middle of the uterus
incision which is still open is then completely closed using one
of the two threads to create a continuous line of sutures
Vejnović TR et al. New Technique for … Geburtsh Frauenheilk 2012; 72: 840–845
Fig. 1 a to d Skin incision, uterotomy and delivery
of the baby.
a The skin incision is done along the skin folds and
b the fascia are dissected above pyramidalis
muscles.
c The uterotomy is done using blunt forceps
and scissors.
d The baby is “born” by expanding the uterine
wound using the fingertips to cranially push the
edges of the wound (arrows pointing cranially) over
the babyʼs head like a collar and exerting pressure
on the uterine fundus (from [12]). The pressure on
the fundus moves the babyʼs head in a caudal direc-
tion (s. arrows).
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" Fig. 2 c). The wound is then shortened further by alternately
(l
knotting the two ends of the suture threads, burying the suture
(l
" Fig. 2 d).
Closure of the peritoneum and the fascia
After inspecting both adnexa, the peritoneum is placed on the
front wall of the uterus. The peritoneum is not sutured. The fascia
is closed as usual using a continuous suture.
Skin suture
The skin is closed using intracutaneous continuous sutures start-
ing and ending approx. 2 cm medial to the corners of the wound
" Abb. 3). This modification permits natural drainage of wound
(l
secretions and blood. After disinfection, a large compress is
placed on the wound. Although the subcutaneous adipose tissue
will be free of blood at the end of the operation the compress will
typically be soaked with blood after 2–3 hours and have to be re-
placed. Stitches are removed between the 8th and the 10th post-
operative day.
Instruments required
A not unimportant aspect of this modified C-section technique is
the low number of instruments required, which results in a con-
siderable reduction of costs. The following instruments are re-
quired: scalpel, Kocher forceps, 2 Pean clamps, a long anatomical
forceps, long straight scissors, needle holder. Depending on the
indication, obstetrical Hegar pins for cervical dilatation and a
large blunt curette for curettage of the uterine cavity may be
used. Both C-section techniques are described in l " Table 1.
Pain score
The patientʼs subjective pain sensation was assessed using the
visual analogue pain scale. Pain intensity was recorded daily by
the patient, with 0 representing no pain and 9 standing for worst
possible pain. The pain intensity was recorded using a score: 0 no
 Original Article 843

Fig. 2 a to d Uterine suture technique. The uterus

is closed by 2 sutures starting from either end of the
wound.
a The first suture stitch is placed slightly medially
from the anatomical corner of the wound. The
same suture thread is used to make 2–4 more con-
tinuous sutures and the ends of the suture thread
are knotted.
b Analogously a second suture thread is used to
close the uterine wall starting from the other side.
c Both sutures are knotted in the middle and
d subsequently the suture is buried by knotting the
suture threads (from [12]).

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Fig. 3 a and b Skin suture.
a The skin is closed using a continuous suture but
both ends are left open for approx. 2 cm.
b Schematic representation of the skin incision
(from [12]).

Table 1 Differences between the classic and modified the procedure.

Procedure Vejnovic modification Classic caesarean section

Skin incision Joel-Cohen Pfannenstiel
Incision of subcutaneous tissue in the middle along a length of 3 cm along the full length
Incision of the fascia in the middle with minimal severing of the musculature along the full length with severing of the musculature
Opening of the peritoneum in the middle, blunt dissection, along the full length, sharp, bladder is pushed to one side
with minimal severing of the musculature
Uterotomy superficial incision of the uterine serosa (scalpel), incision through all layers of the uterus using a scalpel,
blunt introduction of forceps, horizontal expansion manual horizontal expansion
of incision using scissors
Placenta extraction cord traction manual extraction
Uterine suture buried, short suture continuous, long suture
Peritoneal suture none continuous
Myosuture none interrupted sutures
Subcutaneous tissue none interrupted sutures
Skin suture intracutaneous, continuous, open at either end intracutaneous, continuous

pain; 1–3 slight pain; 4–6 moderate to severe pain; 7–9 very
severe pain.
Statistical evaluation
Data were obtained from questionnaires completed by the pa-
tients and from medical records (operation protocol, postopera-
tive follow-up etc.). The data was then encoded and sent to a spe-
cially developed online database. The algorithm was subse-
quently additionally verified and validated (logic control). Basic
descriptive methods were used for statistical analysis of the data.
Absolute and relative figures, mean, standard deviation and
ranges were calculated.
Statistical calculations were done using SPSS 18 (SPSS, Chicago,
IL, USA). The correlation between C-section technique and clinical

Vejnović TR et al. New Technique for … Geburtsh Frauenheilk 2012; 72: 840–845
844 GebFra Science

parameters was analysed using χ2 test and Fisherʼs exact test. and only 34 of 50 patients (68 %) in Group B reported that they
Independent samples were analysed using the non-parametric were very satisfied with the C-section scar and this difference
Mann-Whitney U-test. Values < 0.05 were considered statistically was statistically significant (p < 0.001).
significant.

Results
! The operative technique presented here represents a further de-
The mean age was statistically similar in both groups: 29.6 years
for Group A and 28.7 for Group B (l " Table 2). There were no sta-
tistically significant differences between the two groups with
regard to body mass index (BMI) or co-morbidities (e.g. diabetes
mellitus, preoperative anaemia, etc.). A comparison with the clas-
sic C-section method showed that with the modified C-section
technique the inpatient stay, particularly the postoperative in-
Discussion
!
velopment of the so-called “gentle” Misgav-Ladach C-section
technique, which is already very popular all over the world as
the optimal method for caesarean section [13]. Use of the modi-
fied method was introduced in the University Gynaecological
Clinic of Novi Sad in Serbia in 2000 and it has been used there
ever since [17]. Since 3 years it has also been used very success-
fully in the University Gynaecological Clinic Magdeburg. The aim

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hospital stay, could be distinctly reduced (l " Table 2). The com- of the modifications was to reduce tissue trauma and minimise
parison shows a clear decrease in blood loss (p = 0.013) and a re- perioperative morbidity. These basic aims of the modified meth-
duction in operating times (p < 0.001). The mean loss of blood od are already discernable when performing the skin incision. In
was 471 ml in Group A and 561 ml in Group B (l " Table 2). The the horizontal Pfannenstiel incision and the Misgav-Ladach
mean operating time in Group A was 10 min less than the mean C‑section the skin is incised 2 cm above the pubic symphysis or
operating time for Group B (20.6 vs. 30.7 min). 2 cm below the linea interspinalis [11, 13]. The incision is done
In addition, other outcomes such as scar length, skin reddening, using a scalpel along a length of 10–15 cm. In the Vejnovic mod-
formation of seroma and haematoma and administration of anti- ification, the skin is incised along the skin folds which initially
biotics were analysed in relation to the chosen surgical tech- results in a relatively small incision. The incision is later bluntly
nique. The patients operated on using the modified technique re- expanded depending on the circumference of the babyʼs head
ported significantly less pain in the first 4 days postoperatively and is thus adapted to fit the circumstances. This creates a scar
(l" Table 3, p < 0.001). The average length of the scar in Group A with an optimal length and generally with a very good cosmesis
was shorter (12.6 cm) compared to the length of the scar in the because it is not very visible in the skin folds.
control group (14.1 cm). Fewer incidences of reddening and The fascia are initially incised and the incision is then expanded
swelling were noted in Group A compared to patients in Group manually (bluntly). Caudally they are no longer severed from the
B (l" Table 3). There were no differences between groups with pyramidalis muscles. The fascia incision can also be adapted to
regard to seroma and haematoma formation, skin dehiscence, in- the circumference of the babyʼs head during delivery of the baby.
flammation or fever. A total 68 of 72 patients (94.4 %) in Group A In contrast to classic methods and analogously to the Misgav-
Ladach technique the peritoneum is opened bluntly and horizon-
tally [11–13]. This helps prevent injury to the bladder and the
vasculature and excessive bleeding.
Table 2 Patient age, in-hospital stay, duration of surgery and blood loss in
both study groups.
The most important modifications are related to the uterotomy
and its closure. With this uterotomy technique, after incising the
Group A Group B uterine serosa with a scalpel, long anatomical forceps are intro-
Parameter n = 72 n = 50 p-value duced through the uterus wall into the uterine cavity. By intro-
Age (years) 29.6 28.7 0.350 ducing the forceps obliquely past the babyʼs head, it is possible
Inpatient stay (days) 5.56 6.08 0.018 to avoid injuries to the babyʼs skin. In the classic C-section the
Duration of surgery (minutes) 20.6 30.7 < 0.001 uterine wall is completely incised, which can occasionally (e.g. if
Blood loss (ml) 471 561 0.013
the amnion has already ruptured and the amniotic fluid is no lon-
ger present or if there is increased bleeding because the placenta
is on the anterior uterine wall) result in cuts to the babyʼs skin. In
the Vejnovic modification the uterotomy is incised using scissors
Table 3 Complications in both study groups.
between the arms of the forceps and is then extended bluntly.
Group A Group B The uterotomy is “adapted” to the circumference of the babyʼs
Parameter n = 72 n = 50 p-value head when the head is delivered. The vertical cut using scissors
Pain (subjective) Score Score < 0.001 through all the uterine wall layers results in a better adaptation
" 1st postoperative day 2.89 4.1 of the two wound edges of the uterotomy, which may otherwise
" 2nd postoperative day 2.22 2.96 not always occur if they are simply bluntly “torn apart”. Closure
" 3rd postoperative day 0.71 1.18 of the uterine wall is done in a single layer as with the Misgav-
" 4th postoperative day 0.06 0.3
Ladach method, but there are a few differences. Thus, the uterine
Length of scar (skin) 12.6 cm 14.1 cm < 0.001
suture is started approx. 3 cm from both corners of the wound
Fever 2.8 % 4% 1.000
and suturing is then continued laterally. Traction on the suture
Wound healing
" Reddening 13.9 % 32 % 0.029 thread gives an optimal view of the wound edges. Knotting the
" Swelling 2.8 % 14 % 0.048 different suture threads together reduces the size of the uteroto-
" Dehiscence 1.4 % 0 1.000 my to around 50 % and buries the suture. This helps avoid addi-
" Seroma 0% 2% 0.854 tional secondary sutures to treat bleeding from the uterine wall.
" Haematoma 4.2 % 8% 0.617 The resulting scar is short with a relatively thick myometrium

Vejnović TR et al. New Technique for … Geburtsh Frauenheilk 2012; 72: 840–845

and very stable. This is done with the aim of decreasing the inci-
dence of uterine rupture and suture dehiscence and minimising
placental disorders in subsequent pregnancies. While complete
uterine rupture after a classic or Misgav-Ladach C-section is rare
(0.7 % after one and 0.9 % after repeated C-section deliveries, cf.
[19, 20]), the length of the uterotomy scar, measured ultrasono-
graphically after a C-section, appears to correlate with suture de-
hiscence during birth. It has been shown that suture dehiscence
or uterine rupture occurs in 5.3 % of cases with smaller scars com-
pared to 42.9 % with large scars [21]. Whether this suture tech-
nique could be an important factor in preventing uterine rupture
in subsequent pregnancies will only be clear with longer follow-
up times. As more than 7000 C-sections have been carried out
using the new technique at the University Gynaecological Clinics
of Novi Sad and Magdeburg, the data obtained could offer a good
basis to answer such questions.
In contrast to other C-section techniques, in the modified C-sec-
tion technique presented here the fascia and skin incisions are
adapted to the size of the babyʼs head or breech position by man-
ually pushing back the anterior and posterior uterine walls. The
baby is literally “born” through pressure exerted on the uterine
fundus. It is conceivable that this compression pressure could
help expel amniotic fluid from the lungs as occurs in vaginal
births. Only a prospective study in a defined patient collective
could show whether there are fewer respiratory adjustment dis-
orders with the method described here compared to classic cae-
sarean sections.
The fascia is closed using a continuous suture as is done in other
C-section techniques. The two ends of the skin suture are left
2 cm open. This modification creates “natural drainage” and
helps prevent haematomas and seromas. The cosmesis with this
method is very good as the initially open edges of the wound
close within a few hours and no fluid-filled cavities remain sub-
cutaneously.
Conclusion
! 15 Hofmeyer GJ, Novikova N, Mathai M et al. Techniques for caesarean sec-
C-sections are the most common obstetrical operations. In Ger-
many around one third or all children are now delivered by cae-
sarean section. This amounts to approximately 200 000 C-sec-
tions annually. The “gentle” Misgav-Ladach C-section technique
is currently the standard procedure used in Germany. The modi-
fication of the caesarean section technique described here
changes the position and length of the skin incision, avoids injury
to the baby by the blunt introduction of forceps into the uterus
and involves a different type of closure of the uterine wall. This
new type of closure should help reduce complications in subse-
quent pregnancies. The first promising results are expected from
prospective studies in a defined patient collective.
Vejnović TR et al. New Technique for …
Original Article 845
Conflict of Interest
!
The authors declared they have no financial ties to any company
relevant for this paper.
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sarean hysterotomy scar at transvaginal ultrasonography in nonpreg-
nant women. Obstet Gynecol 2011; 117: 525–532
Deutschsprachige Zusatzinformationen online abrufbar unter:
www.thieme-connect.de/ejournals/toc/gebfra.
Geburtsh Frauenheilk 2012; 72: 840–845
 MEDIZIN FÜR DIE FRAU REFERAT

New technique in obstetrics: Vejnovi modification of caesarean section

Is there an impact on the frequency

of placenta increta/percreta?
Since the first caesarean section was performed, the aim is to decrease
mortality and morbidity of both mother and fetus. In the last century
maternal mortality related to caesarean section in developed countries
was reduced to minimum. As the procedure became safer, its rate started

© ZELJKO
to grow exponentially. New problems emerged – conditions that can be
fatal. Are we facing the boomerang effect? What can we do? T. R. Vejnovi, Novi Sad

Caesarean section is one of the most nentially, reaching the point where in scribed for the first time in detail the
common surgical procedures perfor- some hospitals more babies are born Misgav-Ladach technique, paying a
med in women. There is a long his- by caesarean section than by vaginal lot of attention on the uterus incision
tory since the first section was car- delivery.2 Everyday obstetric practice and the way of widening it.5
ried out. In the last century maternal with the patients who experienced
mortality related to caesarean section caesarean section revealed new health Correct closure of the uterus avoids
in developed countries was reduced to problems. This led to numerous stu- further problems
minimum. Still the incidence of severe dies. They showed that trends of pe-
maternal morbidity in caesarean sec- rinatal pathology have changed. Some However, the repair of the uterus
tion is at least two-fold higher com- serious conditions such as rupture of is the most important step of cae-
pared to vaginal delivery.1 New in- the uterus and abnormal placental at- sarean section. Main complications
ventions and improvements of the tachment are recognized as emerging in post-caesarean pregnancies men-
operative technique were made in or- threats that increase the risk of ma- tioned earlier occur at the site of the
der to help further decreasing mater- ternal death. Thus, the need for mo- uterine scar. The assumed reason for
nal morbidities, but also to achieve dification of existing techniques and this is that in the existing techniques
some economic advantages by redu- finding new surgical solutions conti- of uterine closure (single or double la-
cing operation time, blood loss and nues. The technique of Joel-Cohen3 yer, from one angle of the incision to
amount of suture material. As cae- contributed a lot to the laparotomy the opposite) correct approximation
sarean section became a safer proce- as an initial step of every caesarean of the cut margins, that is, decidua
dure, its rate started to grow expo- section.4 In 1994, Michael Stark de- to decidua, myometrium to myome-
trium, serosa to serosa, is not gua-
KeyPoints ranteed. This is due to the high in-
tersurgeon variability.6 Almost every
t
5IF
SFQBJS
PG
UIF
VUFSVT
JT
UIF
NPTU
JNQPSUBOU
TUFQ
PG
DBFTBSFBO
TFDUJPO surgeon uses a slightly different inter-
pretation of the original description of
t

5FDIOJRVF
PG
UIF
VUFSVT
SFQBJS
QSFEJTQPTFT
UIF
PDDVSSFODF
BOE
UZQF
PG
DPNQMJDBUJPO the technique because not every detail
can be explained in words. Although
t

$BFTBSFBO
TFDUJPO
TIPVME
CF
UIF
JNJUBUJPO
PG
UIF
WBHJOBM
EFMJWFSZ
BOE
TZODISPOJ[FE

the principle of making uterine sutures
XJUI
UIF
QIZTJPMPHJDBM
DIBOHFT
JO
QVFSQFSJVN
so that they penetrate the full thick-
t

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BMM
EFUBJMT
PG
UIF
DBFTBSFBO
TFDUJPO
UFDIOJRVF
TIPVME
TFDVSF
UIF
QFS- ness of the myometrium without pe-
GPSNBODF
BT
PSJHJOBMMZ
DPODFQUFE netrating the decidua is well known
and strongly recommended, many sur-
t

5IFSF
JT
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FWJEFODF
UIBU
UIF
VTF
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7FKOPWJ technique for caesarean section geons still suture the uterine wall
SFEVDFT
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UZQJDBM
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JO
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through all the layers.7 This can cause
eversion of the cut margins, iatrogenic

JATROS I Seite 24 Medizin für die Frau 3/16

REFERAT
adenomyosis and compromise the hea-
ling process. This can lead to thinning
of the scarred uterine wall and create
locus minoris resistantiae for uterine
rupture and even more serious con-
ditions like scar pregnancies and pla-
centa increta/percreta.
The closure of the uterus is one of the
most important parts of the Vejnovi
modification. It is assumed that the
technique of the uterus repair predis-
poses the occurrence and type of com-
plications. New problems induced new
requests and ideas – to leave a smal-
ler scar and to preserve thickness and
the structure of the uterine wall.6, 8, 9
Following these ideas, the Vejnovi
modification of the caesarean section
was created. It was performed for the
first time at the Clinic of Obstetrics
and Gynaecology in Novi Sad in the
year 2000. After a comparative pro-
spective study was done, the descrip-
tion of the technique was published
first in Serbian (2008) and then in En-
glish (2012).8, 10 This technique in-
cludes innovations in each step of the
operation. However, the technique of
the uterus repair carries the greatest
value and clinical impact of Vejnovi
modification. Main principle of the
Vejnovi modification is that perfor-
ming the caesarean section should be
the imitation of the vaginal delivery –
its factors and mechanisms. However,
it also has to be synchronized with the
physiological changes in puerperium.
Uterus repair – Vejnoviđ modification
Uterus repair by Vejnovi modifica-
tion consists of four steps. (Fig. 1-5)
The uterine wall is closed using two
sutures starting from the angles of the
uterine incision. All sutures are made
through the full thickness of the my-
ometrium without penetrating the de-
cidua. (Fig. 1)
'JH

Medizin für die Frau 3/16
MEDIZIN FÜR DIE FRAU
Step 1: (Fig. 2)
UÊÊ-Ì>À̈˜}Ê«œÃˆÌˆœ˜ÊœvÊ̅iʈ˜ˆÌˆ>ÊÃ̈ÌV…Ê
is approximately 2cm medially from
the angle of the incision and 1cm cra-
nially from the cut margin. Both sides
of the thread are then pulled together
in the same direction (towards opera-
tor) and kept tightened. Second stitch
is placed into the intact part of the
uterine wall, approximately 2cm la-
terally from the first stitch and about
0.5cm (up to 1cm) from the angle of
the incision. The angle of the wound
is thus secured using Z-shaped suture.
UÊÊ/…iÊÃ>“iÊ̅Ài>`ʈÃÊ̅i˜ÊÕÃi`Ê̜ÊVÀi>ÌiÊ
3 running-locked sutures (each 1-2cm
medially from the last one and around 'JH

1cm cranially from the cut margin).
UÊÊ/ÜœÊ i˜`ÃÊ œvÊ Ì…iÊ ÃÕÌÕÀiÊ Ì…Ài>`Ê >ÀiÊ Step 2: (Fig. 3)
tied into knot and left long. Dis- UÊÊ1Ș}Ê̅iÊÃiVœ˜`ÊÃÕÌÕÀiÊ̅Ài>`]Ê̅iÊ
tance between the initial suture and contralateral side is closed analo-
3rd running-locked suture is appro- gously as in step 1.
ximately 4cm before tightening the
knot. After tightening the knot the
distance is halved.
'JH

Step 3: (Fig. 4)
UÊÊ/…iÊVi˜ÌÀ>Ê«>ÀÌʜvÊ̅iÊÕÌiÀÕÃʈ˜VˆÃˆœ˜Ê
which is still open is completely clo-
sed using both suture threads to create
a continuous line of running-locked
sutures and then two threads are tied
into knot in the middle of the incision.
'JH

Seite 25 I JATROS
 MEDIZIN FÜR DIE FRAU
Step 4: (Fig. 5)
UÊÊ/…iÀiÊ>ÀiÊvœÕÀÊ̅Ài>`Êi˜`ÃÊqÊÌܜʜvÊ
them are in the middle and end with
a needle, one free end originates from
left side knot and another free end
originates from the right knot.
UÊÊ/…iÊܜ՘`ʈÃÊ̅i˜ÊÀi`ÕVi`ÊvÕÀ̅iÀÊLÞÊ
tying the knot with thread ends from
the middle and thread ends from the
each side of the incision.11
UÊÊ/…iÊÕÌiÀˆ˜iʈ˜VˆÃˆœ˜Ê>ÌÊ̅iÊÃÌ>ÀÌÊÜ>ÃÊ
approximately 10 cm long. After the
suturing the length of the uterine inci-
sion is reduced to approximately 5cm.
'JH

This way of suturing the uterus and
compression of the uterine incision has
two hypothetical advantages. The first
is the so called myotamponade effect.
The myometrium is compressed and
potential bleeding that can occur af-
ter running-locked sutures are made is
stopped with no need for extra sutures.
Secondly, the vectors of the forces that
act among the knots are directed to the
center of the incision, which helps the
physiological process of the uterus in-
volution.
The thickness of the wall is maintained
if not temporarily increased, and the de-
cidual layer is inverted towards the ca-
vum of the uterus so that regeneration
of the endometrium will have continuity
without sinking into myometrial layer.
Less complications compared to the
common technique
At the Clinic of Obstetrics and Gynae-
cology in Novi Sad a retrospective/pro-
JATROS I Seite 26
spective study was done. It involved
1886 subjects delivered between 2000
and 2006 by caesarean section with
Vejnovi modification, and a control
group of 100 patients delivered from
1991 to 2006 by “common” opera-
tive technique (s.c. Doerfler, abdomi-
nal opening by Pfannenstiel, trans-
versal incision of the lower uterine
segment, double layer uterine clo-
sure, peritonization using continu-
ous sutures to repair the abdomen).
The outcomes of the two techniques
were compared. The results showed
that the modified technique was twice
shorter that the “common” tech-
nique, two times less suture mate-
rial was used, hospital stay was shor-
ter, with lower blood loss for 30.9%,
and there were less complications,
which was all of statistical signifi-
cance (p < 0.01).8
This technique was presented in Mon-
tenegro, Hungary, Romania, Ger-
many, Sweden, Austria (Wien 2012),
France and USA. In several obste-
tric centers it is performed regularly
(Arad, Oradea, Timisoara, Szeged,
Magdeburg). In 2011, caesarean sec-
tion-modification Vejnovi was pro-
tected as an intellectual property by
Institute for Intellectual Property of
Republic of Serbia.
Until 2016 around 10,000 (more than
5,000 operated by Prof. Vejnovi) cae-
sarean sections with Vejnovi modifi-
cation were performed in Novi Sad.
New problems call for
more research
Recently, an increasing number of pe-
ripartum hysterectomies has been no-
ticed. Xiao-Yu Pan et al reported that
from 2004 to 2014 the incidence of
hysterectomies after caesarean sec-
tion increased by 100% (0.8/1000
– 1.5/1000). Also they showed that
the main indication for the peripar-
tum hysterectomy changed from ute-
rus atony to placental complication.
From 2004 to 2010, placenta increta/
percreta made up 20% of all indica-
tions for hysterectomy; this number
increased up to 77,8% in the years
2011 to 2014.12
The same trend is seen at the Clinic of
Obstetrics and Gynaecology in Novi
REFERAT
Sad, where the incidence of peripar-
tum hysterectomies in 2007 was 4
and reached 11 in 2015. (Fig. 6)
This is why new projects have been
started and new parameters were
included in the evaluation of the
Vejnovi modification of the cae-
sarean section.
The hypothesis of this research is
that the operative technique has an
impact on the frequency of placenta
increta/percreta. Preliminary results
showed that there were no cases of
placenta increta/percreta among the
patients who were delivered only
using Vejnovi modified technique in
previous pregnancies (overall number
15,000 patients), and the reported in-
cidence of placenta increta/percreta is
1/533 deliveries for the period 1982–
2002,13 which could be a significant
result.
Another prospective study was star-
ted in which repeated ultrasound ex-
aminations are done after a caesarean
section. The length of the uterine scar
and the thickness of the uterine wall
are followed and compared to the
outcomes of other techniques.
In order to get insight in the struc-
ture of the uterine scar, a pilot study
of sampling the skin and uterine
scar intraoperatively is also in pro-
gress, looking for decidual foci and
excavations in the myometrium. All
these studies should provide evi-
dence-based conclusions and check
if the hypothesis is correct.
Imperative for obtaining relevant
data and conclusions is to standar-
dize the technique14 and reduce inter-
surgeon variability. With this aim the
development of educational 3D ani-
mations according to Vejnovi mo-
dification of the caesarean section
technique is initiated and its pre pro-
duction phase is finished. This project
should help trainees to better under-
stand all details of the technique and
perform it in the same way as origi-
nally concepted.
Under such conditions only, trustwor-
thy multicentric studies can be per-
formed and lead to conclusions that
represent reality. The aim is to help
our patients and make caesarean sec-
tion a safer procedure. Q
Medizin für die Frau 3/16
REFERAT MEDIZIN FÜR DIE FRAU

Literature: 12 Pan XY et al: A marked increase in ob-


stetric hysterectomy for placenta ac-
1 Villar J et al: Maternal and neonatal in- creta. Chin Med J 2015; 128: 2189-93
dividual risks and benefits associated 
with caesarean delivery: multicentre 13 American College of Obstetricians and
prospective study. BMJ 2007; 335: 1025 Gynecologists: Placenta accreta. Com-
8 mittee Opinion No. 529. Obstet Gyne-
2 Furau C et al: Improvements in cesarean col 2012; 120: 207–11
section techniques: Arad's obstetrics de-
6 14 Stark
partment experience on adapting the M et al: The importance of ana-
Vejnoviđ cesarean section technique. lyzing and standardizing surgical me-
Maedica (Buchar) 2013; 8: 256–60  thods. Journal of Minimally Invasive
Gynecology 2009; 16: 122–5
3 Olofsson P: Opening of the abdomen
ad modum Joel Cohen, Joel-Cohen, Joel 
Joel-Cohen, or just Cohen? Nordic Fe-
deration of Societies of Obstetrics and 
Gynecology. Acta Obstet Gynecol Scand 









2015; 94: 224-5
Fig. 6:
)ZTUFSFDUPNJFT
QFS
ZFBS
BU
$MJOJD
PG
(ZOBFDPMPHZ
BOE
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/PWJ
4BE
4 Abalos E: Surgical techniques for cae-
sarean section: RHL commentary (last
8 Vejnoviđ TR: Cesarean delivery – Vejnoviđ modification.
revised: 1 May 2009). The WHO Reproductive Health
Library; Geneva: World Health Organization. [Article in Serbian] Srp Arh Celok Lek 2008;136 Suppl
2: 109-15
5 Holmgren G et al: The Misgav Ladach method for ce-
9 Turan C et al: Purse-string double-layer closure: a no-
sarean section: method description. Acta Obstet Gy-
vel technique for repairing the uterine incision during Authors:
necol Scand 1999; 78: 615–21
cesarean section. J Obstet Gynaecol Res 2015; 41: 565- Prof. Tihomir R. Vejnovi
6 Babu KM, Magon N: Uterine closure in cesarean 74 E-Mail: vejnovict@gmail.com
delivery: a new technique. N Am J Med Sci 2012; 4: Dr. Aleksandra T. Vejnovi
10 Vejnoviđ TR et al: New technique for caesarean sec-
358–61 Department of Gynecology and Obstetrics,
tion. Geburtsh Frauenheilk 2012; 72: 840–5
7 Cunningham Clinical Centre Novi Sad, Faculty of Medicine,
FG, editor. Cesarean delivery and peripar-
11 Vejnoviđ T: Carski rez – Vejnoviđeva modifikacija, Srp- University of Novi Sad/Serbia
tum hysterectomy. In: Williams obstetrics. 22nd ed:
596-8 ski Arh Celok Lek 2008, 136: 109-15 Q12

Medizin für die Frau 3/16 Seite 27 I JATROS

Surgical wounds complications in two different techniques of a cesarian
section
AUTHOR(S)
Vejnovic, T.; Grahovac, M.; Veselovski, A.; Koledin, S.

PUB. DATE
December 2011

SOURCE
HealthMed;2011, Vol. 5 Issue 6, p1754

SOURCE TYPE
Academic Journal

DOC. TYPE
Article

ABSTRACT
Introduction: There are different techniques in applying a caesarean section. They differ in the type of incision and
opening the abdominal wall, and also on the way of opening and sewing up the uterus. The aim of this work is to
compare the complications of the surgical wound between two caesarean section techniques -- Pfannenstiel
laparatomy and Joel-Cohen laparotomy with Vejnovic's modification. Material and methods: A prospective
randomized study has been undertaken at the Gynaecology and Obstetrics Clinic of the Clinical Centre of Vojvodina
in Novi Sad. Out of (n=122) patients who were delivered by caesarean section (n=50) of them were from group B and
their deliveries were performed by Pfannenstiel incision of the abdominal wall, while (n=72) of the patients were from
group A and were delivered by Joel -- Cohen incision with Vejnovic modification. All the patients were postoperatively
examined clinically on a daily basis, while laboratory and biochemical analyses were aimed according to the clinical
indications or due to complications. While dressing the wounds, they were inspected for any irregularities such as
redness, swelling, pain in the wound, presence of haematoma (on skin and subcutaneous region), serous discharge
and dehiscence. Also, the length of the skin incision was measured. The incidence and gradation of infection in the
surgical wound during the hospital stay was in harmony with the protocol of the wound infection classification
according to CDC (Centre for Disease Control). Results: Our analysis shows that there is a statistically important
difference in the length of the skin incision between the patients from the two groups p<0.001, postoperative wound
redness p=0.029 (p<0.05) and wound swelling p=0.048 (p<0.05), subjective satisfaction with how their wound looked
p<0.001 between the patients from the two groups. There is a statistically important difference in the average pain
estimate of the wound between the patients from the two groups from the first 24 hours until the fourth postoperative
day p<0.001 and in the length of hospitalisation p=0.018 (p<0.05), postoperative stay p=0,016 (p<0,05),
administering antibiotics p<0,001, length of time spent in surgery p<0,001 and blood loss during surgery p=0,013.
Conclusion: Based on the results of this research, the advantages of the surgical technique applied on patients from
group A (Joel -- Cohen laparotomy, Vejnovic modification, and the one applied on patients from group B (Pfannenstiel
laparotomy), considering the reduced incidence of complications of the surgical wound are significant. The
contemporary surgical technique should utilize almost all of the elements of the minimum invasive surgery during the
caesarean section. This way the overall engagement of mechanisms that take part in the physiological process of
healing the surgical wound is reduced.
 Postoperative pain after different types of Cesarean section
Master thesis, Novi Sad 2013.

Authors: urev Nemanja, Vejnovi Tihomir

Affiliation: Faculty of Medicine, University of Novi Sad

ABSTRACT
INTRODUCTION: Pain is a type of sensation. It registers and identifies the nature of various
injuries incurred on the surface of the body and inside the body. Pain is the result of complex
interaction of peripheral and central factors (nociception) that leads to an unpleasant emotional
experience (grief) which threats the integrity of the organism. This research was conducted in
order to assess the intensity of pain after cesarean section in the early postoperative period,
influence of surgical technique on postoperative pain intensity , and to determine the influence of
non-surgical factors on the intensity of postoperative pain.

MATERIALS AND METHODS: A prospective study included 95 patients, delivered by

elective, emergency, or Caesarean section in labor, where 47 of them were operated by Joel
Cohen Vejnovi modification techniques, while 48 of them were operated by Pfannenstiel
techniques. To assess the intensity of postoperative pain we used one-dimensional scales to
assess pain and the need for analgesics.

RESULTS: In this study, we demonstrated that postoperative pain was most intense on the first
day after surgery (NUM = 4.88, VAS = 4.04) and the weakest intensity was during the third
postoperative day (NUM = 2.98, VAS = 2.38 ). The Joel-Cohen modification Vejnovi
technique, compared with the conventional Pfannenstiel technique, demonstrated that
postoperative pain (measured by numerical scale) was weaker during the first (p <0.04), the
second (p <0.02), and the third postoperative day (p <0.03), the postoperative pain measured by
the VAS scale was weaker during the third postoperative day (p <0.01) and the lower demand for
analgesics during the third postoperative day (p <0.001). Although the result was not significant,
we also concluded that there is a moderate correlation between patients education and the
experience of pain. Patients with higher educational status were perceiving pain in a greater
extent.(p <0,06).

CONCLUSION: Analyzing the results of this study we concluded that the intensity of pain
caused by surgical trauma in the early postoperative period is the most intense on the first day
after surgery, while the lowest is on the third postoperative day. Our results also show that
postoperative pain is less severe, and the demand for analgesics were lower in patients who were
operated by Joel Cohen Vejnovi modification technique which significantly affects patient
satisfaction and cost-effectiveness of this technique. The impact of other non-surgical factors
(age and education level) on postoperative pain was not significant.

Keywords: postoperative pain, pain scales, cesarean section, operative techniques



    

 
 

  
  
 
  


 


   
 "

PRE PRODUCTION FOR DEVELOPMENT OF EDUCATIONAL 3D

ANIMATION ACCORDING TO VEJNOVIC MODIFICATION OF THE
CESAREAN SECTION TECHNIQUE

 
X{>€ ‚ƒ &„|†X> †&|&‡ˆ |†‰&Q‡†€ ‚ƒ ‚‰† X\ˆ ‚‰† X\ˆ &Š{‹>† ‚ƒ &Q‹†X
PhD., Full Professor, obrad_r@uns.ac.rs
 
X{>€ ‚ƒ &\††|&ˆ |†‰&Q‡†€ ‚ƒ ‚‰† X\ˆ ‚‰† X\ˆ &Š{‹>† ‚ƒ &Q‹†X
PhD., Full Professor, vejnovict@gmail.com
Igor Kekelje 
Faculty of Technical Sciences, University of Novi Sad, Novi Sad, Republic of Serbia
„ ˆ ‡‡†‡€X|€ˆ †@‚QŒ&Œ&>&‰†Ž@X†>‚
Aleksandra  
X{>€ ‚ƒ &\††|&ˆ |†‰&Q‡†€ ‚ƒ ‚‰† X\ˆ ‚‰† X\ˆ &Š{‹>† ‚ƒ &Q‹†X
MD., Teaching Associate, aleksandra_vejnovic@yahoo.com
Nemanja Višnjevac
X{>€ ‚ƒ &\††|&ˆ |†‰&Q‡†€ ‚ƒ ‚‰† X\ˆ ‚‰† X\ˆ &Š{‹>† ‚ƒ &Q‹†X
MD., Assistant, nvisnjevac@gmail.com
 
X{>€ ‚ƒ &„|†X> †&|&‡ˆ |†‰&Q‡†€ ‚ƒ ‚‰† X\ˆ ‚‰† X\ˆ &Š{‹>† ‚ƒ &Q‹†X
PhD., Assistant Professor, rakovicm@uns.ac.rs
  
X{>€ ‚ƒ &\††|&ˆ |†‰&Q‡†€ ‚ƒ ‚‰† X\ˆ ‚‰† X\ˆ &Š{‹>† ‚ƒ &Q‹†X
MD., Assistant, milatstevan@gmail.com

ABSTRACT
Computer Graphics can be used for educational, interdisciplinary presentations and for
visualization purposes, as it represents an ideal means to teach any discipline that could benefit
from the visual presentation. Everyone needs visualization because it is the most natural way in
which people view the world, hence the well-known saying that “a picture is worth a thousand
words". Visualization represents an excellent choice for presentation in studying and teaching, as
well as in information transfer. Engineering Animation is used as a presentation technique. It can be
an important link between an idea and its realization like building a model/object.
In this paper, we will show all the necessary techniques used in the process of creating 3D
Computer Animation which are prepared to assist in the education and virtual training of Medical
Doctors. We are in charge of the development of 3D Computer Animation according to professor
Vejnovic’s modification of the cesarean section technique. The process of creating 3D animation
will be shown using a couple of examples. Also, the procedure and the list of steps that need to be
followed in this specific case to create a 3D animation for educational purposes will be shown.

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1. INTRODUCTION
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ŠQ&‡&Q‰X€†‚| †| €„& X€†‚|X> †> &@†‡€Q œž
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’†€„ †|‚Q ‚Š>†X€†‚|‡ [8].
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Q‚’\&\ ‡&|& „& Š‚‡†€†‚| ‚ƒ €„& X&QX †| ‡{„ X ‡†€{X€†‚| ’‚{>\ ‹& ‹X\ X|\ ’‚{>\ˆ €„&Q&ƒ‚Q&ˆ Q&‡{>€ †| X ‹X\
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ŠQ&‡&|€&\ †| €„†‡ ŠXŠ&Q
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‹‡€&€Q†‡ †| ‚‰† X\ˆ &Q‹†X „X€ ’X‡ €„& {|\&Q>†|@ †\&X ƒ‚Q ƒ‚Q†|@ ‚{Q €&X ‚‹†|†|@ €„& &–Š&Q€†‡e ‚ƒ
\‚€‚Q‡ - @|X&‚>‚@†‡€‡ X|\ ŠQ‚ƒ&‡‡†‚|X>‡ ’„‚ \&X> ’†€„ ‚Š{€&Q ‰†‡{X>†•X€†‚| [š]ˆ &‡Š&†X>> ‚Š{€&Q
@QXŠ„†‡. „& {>€†X€& @‚X> ‚ƒ €„†‡ ŠQ‚&€ †‡ €‚ Q&X€& X  ‚Š{€&Q X|†X€†‚| †| ’„†„ €„& \&‡Q†‹&\ ŠQ‚&\{Q&
‚ƒ Q&ŠX†Q†|@ {€&Q{‡ ’†>> ‹& X|†X€&\ ›†€„ ‡€‚Q‹‚XQ\ˆ €„& ŠQ&-ŠQ‚\{€†‚| ŠQ‚&\{Q& †‡ ‚Š>&€&\ ƒ‚Q Q&X€†|@
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2. STORYBOARD OF VEJNOVIC MODIFICATION OF THE CESAREAN SECTION

TECHNIQUE
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Figure. ~ †Q‡€ ‡€&Š ‚ƒ €„& Q&ŠX†Q ‚ƒ €„& {€&Q{‡

„&Q& XQ& ƒ‚{Q ‚>{|‡ œ~ˆ ^ˆ  X|\ šž X|\ €„Q&& Q‚’‡ œˆ B X|\ ž ‚| &X„ †@{Q& ‡„‚’| †| €„†‡ €&–€ „X€
&X|‡ &X„ ƒ†@{Q& †‡ ‚Š‚‡&\ ‚ƒ X–†{ €’&>‰& Š†€{Q&‡ ~ˆˆ šˆ ~ˆ ˆ šˆ X|\ ~ˆ ˆ š

‚Q\†|@ €‚ &|‚‰† ‚\†ƒ†X€†‚| ‚ƒ X&‡XQ&X| ‡&€†‚|ˆ €„&Q& XQ& ƒ‚{Q ‡€&Š‡ †| >‚‡†|@ €„& {€&Q{‡ †|†‡†‚| ›&
’†>> ŠQ&‡&|€ X>> €„& ‡€&Š‡ €„Q‚{@„ &>&‰&| ƒ†@{Q&‡

I| †@{Q& ~ ’& X| ‡&& €„& ƒ‚>>‚’†|@ \&€X†>‡

†€{Q& A1 ‡„‚’‡ €„X€ ƒ†Q‡€ ‡€&Š ‚ƒ Q&ŠX†Q ‚ƒ €„& {€&Q{‡ †‡ ‡€XQ€†|@

A2 A {€&Q{‡ †|†‡†‚| †‡ Q&ŠQ&‡&|€&\ ’†€„ X| ‚Š&|†|@ ’„†„ †‡ XŠŠQ‚–†X€&> ~}  >‚|@ ‚Š ‰†&’ †‡ ŠQ&‡&|€&\“

A3-4 &&\>& X|\ ‡{Q@†X> €„Q&X\ XQ& ŠQ&‡&|€&\“ ƒ‚Q ‹&€€&Q ‰†‡†‹†>†€ ‚ƒ €„& \QX’†|@ˆ €„& |eedle „‚>\&Q †‡ |‚€
\QX’|

B1 €XQ€†|@ Š‚‡†€†‚| ‚ƒ €„& †|†€†X> ‡€†€„ †‡ XŠŠQ‚–†X€&> ^ &\†X>> ƒQ‚ €„& X|@>& ‚ƒ €„& †|†‡†‚| X|\ ~
QX|†X>> ƒQ‚ €„& {€€†|@ ‡{QƒX& ‚ƒ €„& {€&Q{‡

B2  |&&\>& X|\ X €„Q&X\ Š&|&€QX€†|@ €„Q‚{@„ €„& X|€&Q†‚Q {€&Q†|& ’X>>

B3 Q‚‡‡-‡&€†‚| ‚ƒ €„& X|€&Q†‚Q {€&Q†|& ’X>> †‡ ‡„‚’| Q‚|€ ‰†&’ †‡ ŠQ&‡&|€&\ „& {€&Q†|& ’X>> ‚|‡†‡€‡ ‚ƒ
€„Q&& >X&Q‡ perimetrium œ‚{€&Q >X&Qžˆ myometrium œ†\\>& >X&Qžˆ X|\ endometrium œ†||&Q >X&Qž | 
endometrium †‡ €„& ‹‚€€‚ >X&Q X|\ †‡ ŠX†|€&\ †| ‹>{& Myometrium †‡ XŠŠQ‚–†X€&> ™}¢ ‚ƒ €„& €‚€X> €„†Œ|&‡‡
‚ƒ €„& {€&Q{‡ X|\ †‡ ŠX†|€&\ †| Q&\

B4 „& &|€†Q& Q‚‡‡-‡&€†‚| †‡ ‡„‚’| †| @Q& &–&Š€ €„& ŠXQ€ ‚ƒ myometrium €„X€ †‡ ‚l‚{red Q&\ „†‡ Q&\ ŠXQ€ ‚ƒ
myometrium †‡ €„& ŠXQ€ €„Q‚{@„ ’„†„ ’& ’†‡„ œ†|€&|\ž €‚ @‚ ‚{€ ’†€„ €„& |&&\>& ƒQ‚ €„& †|€&Q‡&€†‚| „&
r&X‡‚|‡ ƒ‚Q €„†‡ X€€†€{\& XQ& ‚ƒ &\†X> |X€{Q&.
C1 eedle @‚&‡ ‚{€ ƒQ‚ €„& Q†@„€ ŠXQ€ œŠ‚‡†€†‚| X€ €„& Š†€{Q&ž ‚ƒ €„& †|€&Q‡&€†‚|

C2 eedle @‚&‡ €‚ €„& >&ƒ€ ŠXQ€ ‚ƒ €„& †|€&Q‡&€†‚| &&\>& Š‚†|€ ŠX‡‡&‡ ‹ €„& ‚{€&Q >X&Q œperimetriumž ‚ƒ €„&
>&ƒ€ Q‚‡‡ ‡&€†‚|

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C3 „& ‹‚\ ‚ƒ €„& |&&\>& Š{‡„&‡ \‚’|’XQ\‡ œ{|€’†‡€†|@ž endometrium ’„†„ †‡ Q‚>>&\ {Šˆ {|€†> €„& Š‚†|€ ‚ƒ
€„& |&&\>& €XŒ&‡ Š>X& †| €„& >&‰&> ‚ƒ myometrium €„X€ ‚QQ&‡Š‚|\‡ €‚ €„& ‚ŠŠ‚‡†€& ‡†\& ‚ƒ €„& {€&Q†|& ’X>>. „&
‡&@&|€ ‚| €„& >&ƒ€ Q‚‡‡ ‡&€†‚| ’„&Q& ’& ’X|€ €„& Š‚†|€ ‚ƒ €„& |&&\>& €‚ Š&|&€QX€& †|€‚ €„& >&ƒ€ ‡&€†‚| †‡
‚>‚{red red.

C4 „& |&&\>& †‡ ‚QQ&€> XŠŠ‚†|€&\.

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Figure. 2: Q&X€†|@ †|†€†X> ‡{€{Q&

A1 „& |&&\>& ‚QQ&€> Š&|&€QX€&‡ myometrium X|\ perimetrium ‚| €„& Q‚‡‡ ‡&€†‚| œ€„& Š‚†|€‡ ‚ƒ |&&\>&
Š&|&€QX€†‚| ‡„‚{>\ ‹& X€ €„& ‡X& \&Š€„ †| myometrium X|\ ‡X& \†‡€X|& X€ €„& perimetrium ‡{QƒX&ž

A2 Š‚Q€X|€ |‚€&     

  
  ENDOMETRIUM!

A3: ƒ €„& |&&\>& ŠX‡‡&‡ €„Q‚{@„ €„& endometrium €„&| †|†‡†‚| ‡†€& @&€‡ &‰&Q€&\ œendometrium †‡ \†Q&€&\ €‚ €„&
‚{€&Q >X&Q‡ ‚ƒ €„& {€&Q†|& ’X>>ž | €„X€ X‡&ˆ €„& ‡{€{Q&\ ‡&@&|€ ‹&‚&‡ €„†||&Q ‚ŠXQ&\ €‚ €„& ‡{QQ‚{|\†|@
’X>> ‚ƒ €„& {€&Q{‡ „& Š†€{Q& ‚| €„& Q†@„€ ‚ƒ  ‡„‚’‡ €„& ŠQ‚Š&Q ‡{€{Q&. | €„X€ X‡&ˆ €„& ‡{€{Q&\ ‡&@&|€
‹&‚&‡ €„†Œ&Q ‚Q &”{X> ‚ŠXQ&\ €‚ €„& ‡{QQ‚{|\†|@ {€&Q{‡ ’X>> €„†Œ|&‡‡ Š‚€„&€†X>> €„†‡ X| Q&\{& €„&
Q†‡Œ ‚ƒ {€&Q†|& Q{Š€{Q& X|\ Š>X&|€X> ‚Š>†X€†‚|‡

A4 „Q&& ‰XQ†X€†‚|‡ ‚ƒ €„& €„†Œ|&‡‡&‡ ‚ƒ €„& {€&Q{‡ XQ& ‡„‚’| G ‡„‚’‡ €„& |‚QX> €„†Œ|&‡‡ ‚ƒ {€&Q{‡ˆ G †‡ €„&
€„†Œ|&‡‡ ‚ƒ €„& {€&Q{‡ †| Š‚‚Q ‚†|†|@ œGGž X|\ G†‡ €„& €„†Œ|&‡‡ ‚ƒ €„& {€&Q{‡ †| @‚‚\ ‚†|†|@ œG!Gž

B1 „& €QX&€‚Q ‚ƒ €„& |&&\>& †‡ ŠQ&‡&|€&\.

B2: Q&& &|\ œ’†€„‚{€ |&&\>&ž ‚ƒ X €„Q&X\ †‡ >&ƒ€ †| €„& >&|@€„ ‚ƒ XQ‚{|\ ^}
B3-4: ‚€„ ‡†\&‡ ‚ƒ €„& €„Q&X\ XQ& Š{>>&\ €‚@&€„&Q †| €„& ‡X& \†Q&€†‚| X|\ €†@„€&|ed ‹ „X|\ œ€„†‡ †‡ \‚|& ‹
€„& ‡{Q@&‚|ž
C1 „& †|€X€ ŠXQ€ ‚ƒ €„& {€&Q†|& ’X>> |&–€ €‚ †|†‡†‚| X|@>& ‹&‚&‡ ‰†‡{X>†•&\ X|\ XŠŠQ‚X„X‹>& ƒ‚Q ‡{€{Q†|@
C2-4: &&\>& †‡ †|‡&Q€&\ †|€‚ €„& †|€X€ ŠXQ€ ‚ƒ €„& {€&Q†|& ’X>>ˆ XŠŠQ‚–†X€&> ^ >X€&QX>> ƒQ‚ €„& ƒ†Q‡€ ‡€†€„
X|\ X‹‚{€ }$ œ{Š €‚ ~ž ƒQ‚ €„& X|@>& ‚ƒ €„& †|†‡†‚| &|&ˆ €„& ‡€XQ€†|@ Š‚‡†€†‚| ‚ƒ €„†‡ ‡€†€„ †‡
XŠŠQ‚–†X€&> ^ >X€&QX>> X|\ ~ QX|†X>> œŠ‚‡†€†‚| ‚ƒ €„& ‡€†€„&‡ †‡ †| €„& ‡X& „‚Q†•‚|€X> >†|& X‡ €„& ƒ†Q‡€
|&&\>& Š‚‡†€†‚|†|@ž

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Figure. 3: Q&X€†|@ €„& ƒ†Q‡€ Œ|‚€

A1-3 XŒ†|@ €„& ‡&‚|\ ‡€†€„

Important note: ‚‡†€†‚| ‚ƒ €„& ‡&‚|\ ‡€†€„ †‡ |&XQ €„& X|@>& ‚ƒ €„& †|†‡†‚|£

A4 „&Q& XQ& €’‚ ‡†\&‡ ‚ƒ €„& €„Q&X\ˆ ‚|& †‡ ’†€„ €„& |&&\>&ˆ €„& ‚€„&Q †‡ ƒQ&&

B1 †|@ €„& Œ|‚€ ’†€„ †|‡€Q{&|€ „& €„Q&X\ œ€„& ‡†\& ’†€„ X |&&\>&ž †‡ ’QXŠŠ&\ €’†& XQ‚{|\ €„& |&&\>&
„‚>\&Qˆ >‚Œ’†‡&

B2 ›†€„ €„& €†Š ‚ƒ |&&\>& „‚>\&Q €„& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„Q&X\ XQ& Š{>>&\ †| €„&
‚ŠŠ‚‡†€& \†Q&€†‚|‡ X|\ €†@„€&|ed.

B3 „& €„Q&X\ †‡ ’QXŠŠ&\ ‚|&ˆ >‚Œ’†‡&ˆ XQ‚{|\ €„& |&&\>& „‚>\&Q.

B4 ›†€„ €„& €†Š ‚ƒ €„& |&&\>& „‚>\&Q €„& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„& €„Q&X\ XQ& Š{>>&\ †|
€„& ‚ŠŠ‚‡†€& \†Q&€†‚|‡ X|\ €†@„€&|ed.
C1 ‚Q €„& ‡&‚|\ €†& €„& €„Q&X\ †‡ ’QXŠŠ&\ ‚|& XQ‚{|\ €„& |&&\>& „‚>\&Qˆ ‚{|€&Q >‚Œ’†‡& ›†€„ €„& €†Š ‚ƒ
|&&\>& „‚>\&Qˆ €„& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„& €„Q&X\ XQ& Š{>>&\ †| €„& ‚ŠŠ‚‡†€& \†Q&€†‚|‡
X|\ €†@„€&|ed.

C2 ›& X| ‡X €„X€ €„& Œ|‚€ †‡ >‚Œ&\ „& Œ|‚€ Q&X€&\ †| €„†‡ ’X †‡ ‚|‡†\&Q&\ ‡Xƒ&

C3-4 „& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ œ’„†„ †‡ ’†€„‚{€ |&&\>&ž †‡ XQŒ&\ ’†€„ Pean †|‡€Q{&|€

C4 &Š‚QXQ ‡†€{X€†‚| Pean †|‡€Q{&|€ †‡ „X|@†|@ ƒQ‚ €„& Q†@„€ ‡†\& ‚ƒ €„& ŠX€†&|€

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Figure. 4: XŒ†|@ €„& ƒ†Q‡€ Q{||†|@->‚Œ&\ ‡{€{Q&

A1-3 „& Q{||†|@->‚Œ&\ ‡{€{Q& ‡€XQ€‡ ’†€„ €„& ‡€†€„ ’„†„ †‡ ~-^ &\†X>> ƒQ‚ €„& †|†€†X> ‡{€{Q& X|\ XQ‚{|\
~  QX|†X>> ƒQ‚ €„& {€€†|@ ‡{QƒX& œ~‡€ Q{||†|@->‚Œ&\ ‡{€{Q&ž

A4 X X€€&|€†‚| €‚ €„& €QX&€‚Q ‚ƒ €„& €„Q&X\ „& €„Q&X\ ‡„‚{>\ Q&X€& X >‚‚Š X‡ †€ †‡ ‡„‚’| „& ‡{&&\†|@
‡€†€„ œ^|\ Q{||†|@->‚Œ&\ ‡{€{Q&ž †‡ X\& ’†€„ €„& ‡X& †|€&Q‡ŠX& œ~-^ &\†X>> ƒQ‚ €„& |&XQ&‡€ ‡{€{Q& X|\
XQ‚{|\ ~  QX|†X>> ƒQ‚ €„& {€€†|@ ‡{QƒX&ž
B1 „& ^|\ Q{||†|@->‚Œ&\ ‡{€{Q& †‡ ƒ†|†‡„&\ X|\ €„& rd Q{||†|@->‚Œ&\ ‡{€{Q& †‡ ‡€XQ€&\ ’†€„ €„& ‡X&
†|€&Q‡ŠX& œ~-2  &\†X>> ƒQ‚ €„& |&XQ&‡€ ‡{€{Q& X|\ XQ‚{|\ ~  QX|†X>> ƒQ‚ €„& {€€†|@ ‡{QƒX&ž

B2 „& rd Q{||†|@->‚Œ&\ ‡{€{Q& †‡ ƒ†|†‡„&\

B3-4 †|@ €„& Œ|‚€ ’†€„ †|‡€Q{&|€ „& €„Q&X\ œ€„& ‡†\& ’†€„ X |&&\>&ž †‡ ’QXŠŠ&\ €’†& XQ‚{|\ €„& |&&\>&
„‚>\&Qˆ >‚Œ’†‡& ›†€„ €„& €†Š ‚ƒ €„& |&&\>& „‚>\&Qˆ €„& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„Q&X\ XQ&
Š{>>&\ †| €„& ‚ŠŠ‚‡†€& \†Q&€†‚|‡

C1 †‡€X|& ‹&€’&&| €„& †|†€†X> ‡{€{Q& X|\ rd Q{||†|@->‚Œ&\ ‡{€{Q& †‡ XŠŠQ‚–†X€&> $ ‹&ƒ‚Q& €†@„€&|†|@
‹‚€„ €„Q&X\‡ X|\ Q&X€†|@ €„& ƒ†|X> Œ|‚€

C2 „& ‡{Q@&‚| €†@„€&|‡ €„& €„Q&X\‡ ‹ Š{>>†|@ €„& €’‚ ŠXQ€‡ ‚ƒ €„& €„Q&X\ †| €„& ‚ŠŠ‚‡†€& \†Q&€†‚|‡

C3  €†@„€&|†|@ €„& €„Q&X\ˆ €„& \†‡€X|& ‹&€’&&| €„& †|†€†X> ‡{€{Q& X|\ €„& rd Q{||†|@->‚Œ&\ ‡{€{Q& †‡ Q&\{&\

C4 „& \†‡€X|& ‹&€’&&| €„& †|†€†X> ‡{€{Q& X|\ rd Q{||†|@->‚Œ&\ ‡{€{Q& †‡ XŠŠQ‚–†X€&> „X>‰&\ X|\ †€ †‡ |‚’
X‹‚{€ ^$ >‚|@

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Figure. $ †|†‡„†|@ €„& ƒ†Q‡€ ‡€&Š X|\ ‡€XQ€†|@ €„& ‡&‚|\ ‡€&Š ‚ƒ €„& Q&ŠX†Q ‚ƒ €„& {€&Q{‡

A1-2 ‚Œ†|@ €„& Œ|‚€ „& €„Q&X\ †‡ ’QXŠŠ&\ ‚|& XQ‚{|\ €„& |&&\>& „‚>\&Qˆ >‚Œ’†‡& ›†€„ €„& €†Š ‚ƒ €„&
|&&\>& „‚>\&Qˆ €„& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„& €„Q&X\ XQ& Š{>>&\ †| €„& ‚ŠŠ‚‡†€& \†Q&€†‚|‡
X|\ €†@„€&|ed.

A3-4 ‚Q €„& ‡&‚|\ €†& €„& €„Q&X\ †‡ ’QXŠŠ&\ ‚|& XQ‚{|\ €„& |&&\>& „‚>\&Qˆ ‚{|€&Q >‚Œ’†‡& ›†€„ €„& €†Š
‚ƒ €„& |&&\>& „‚>\&Qˆ €„& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„& €„Q&X\ XQ& Š{>>&\ †| €„& ‚ŠŠ‚‡†€&
\†Q&€†‚|‡ X|\ €†@„€&|ed. „†‡ ‡†\& Œ|‚€ †‡ >‚Œ&\ |‚’

B1 „& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ œ’„†„ †‡ ’†€„‚{€ |&&\>&ž †‡ XQŒ&\ ’†€„ €„& ‡X& Pean †|‡€Q{&|€ X|\ >&ƒ€
„X|@†|@ ƒQ‚ €„& Q†@„€ ‡†\& ‚ƒ €„& ŠX€†&|€

C1 „& ‡&‚|\ ‡€&Š ‚ƒ Q&ŠX†Q ‚ƒ €„& {€&Q{‡ ‡€XQ€‡

C2-4: &Š&€†€†‚| ‚ƒ €„& ‡&”{&|& -šˆ ~ ƒQ‚ †@{Q& ~ X€ €„& ‚ŠŠ‚‡†€& X|@>& ‚ƒ €„& †|†‡†‚|

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„& ’„‚>& ŠQ‚&\{Q& €„X€ ’†>> ‹& ‡„‚’| †| †@{Q&‡ ` X|\ Ÿ †‡ €„& ‡X& X‡ €„& 1‡€ ‡€&Š ‚ƒ €„& Q&ŠX†Q ‚ƒ €„& {€&Q{‡ˆ
&–&Š€ &‰&Q€„†|@ „XŠŠ&|‡ X‡ X †QQ‚Q †X@& ›& X| ‡X €„X€ ~‡€ X|\ ^|\ ‡€&Š XQ& X–†X>> ‡&€Q†ˆ ’„&Q& €„&
X–†‡ ‚ƒ ‡&€Q †‡ €„& ‰&Q€†X> >†|& ’„†„ †‡ >‚X€&\ †| €„& †\\>& ‚ƒ €„& {€&Q†|& †|†‡†‚|

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Figure. 6: &‚|\ ‡€&Š - Q&X€†|@ †|†€†X> Œ|‚€ ‚| €„& ‚ŠŠ‚‡†€& X|@>& ‚ƒ €„& †|†‡†‚|

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Figure. 7: XŒ†|@ Q{||†|@->‚Œ&\ ‡{€{Q& ‚| €„& ‚ŠŠ‚‡†€& X|@>& ‚ƒ €„& {€&Q†|& †|†‡†‚|

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Figure. ¤ „†Q\ ‡€&Š ‚ƒ €„& Q&ŠX†Q ‚ƒ €„& {€&Q{‡

A1 „& XŠŠ&XQX|& ‚ƒ €„& ‚Š&QX€†‰& ƒ†&>\ Xƒ€&Q €„& 1‡€ X|\ ^|\ ‡€&Š XQ& ƒ†|†‡„&\

B1 „& €„†Q\ ‡€&Š ‚ƒ Q&ŠX†Q ‚ƒ €„& {€&Q{‡ ‡€XQ€‡ € †|>{\&‡ ‡{€{Q†|@ ‚ƒ €„& Q&X†|†|@ &|€QX> ŠXQ€ ‚ƒ €„& †|†‡†‚|

B2 {€{Q†|@ †‡ ‚|€†|{&\ {‡†|@ €„& |&&\>& X|\ €„Q&X\ ƒQ‚ €„& right ‡†\& œ>&ƒ€ ‡†\& ‚ƒ €„& †|†‡†‚| ƒQ‚ €„&
ŠX€†&|€¡‡ ‰†&’ž {||†|@->‚Œ&\ ‡{€{Q&‡ XQ& X\&

B3 ‰&Q |&’ ‡€†€„ †‡ X\& XŠŠQ‚–†X€&> ~-^ &\†X>> ƒQ‚ €„& >X‡€ ‡{€{Q& X|\ XQ‚{|\ ~  QX|†X>> ƒQ‚
€„& {€€†|@ ‡{QƒX&

B4 „& ‡X& ‡{€{Q†|@ ŠQ†|†Š>& †‡ {‡&\ {|€†> Q&X„†|@ €„& &|€QX> ŠXQ€ ‚ƒ €„& †|†‡†‚| X X€€&|€†‚| X@X†| €‚ €„&
€QX&€‚Q ‚ƒ €„& €„Q&X\ „& €„Q&X\ ‡„‚{>\ Q&X€& X >‚‚Š X‡ †€ †‡ ‡„‚’|

C1-3 „& ‡&”{&|& ^-š ‚ƒ €„†‡ ƒ†@{Q& †‡ Q&Š&X€&\ ‚| €„& ‚ŠŠ‚‡†€& ‡†\& ‚ƒ €„& †|†‡†‚| ‚’ ’& „X‰& €„&
ƒ‚>>‚’†|@ ‡†€{X€†‚| €„&Q& XQ& €’‚ €„Q&X\‡ œ@Q&&| X|\ &>>‚’ž †| €„& †\\>&ˆ &X„ &|\‡ ’†€„ X |&&\>&

C4 ›†€„ €„&‡& €’‚ €„Q&X\‡ ‡{Q@&‚| €†&‡ a Œ|‚€ X|{X>> œ>&ƒ€ €„Q&X\ ‚| €„& ‡„&& †‡ XŒ†|@ >‚‚Š XQ‚{|\ €„&
Q†@„€ €„Q&X\ž

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Figure. 9: XŒ†|@ X Œ|‚€ †| €„& &|€QX> ŠXQ€ ‚ƒ †|†‡†‚|

A1
|& ‚Q& Œ|‚€ †‡ X\& †| €„& ‡X& ’X œ€„& >&ƒ€ €„Q&X\ ‚| €„& ‡„&& XŒ&‡ X >‚‚Š XQ‚{|\ €„& Q†@„€
€„Q&X\ž.
A2-3 „& \†‡€X|& ‹&€’&&| €„& €’‚ ‡{€{Q&‡ †| €„& &|€QX> ŠXQ€ ‚ƒ €„& †|†‡†‚| †‡ XŠŠQ‚–†X€&> ^ ‹&ƒ‚Q&
€†@„€&|†|@ €„& €„Q&X\
A4 „e €„read †‡ €†@„€&|ed X|\ €„& \†‡€X|& †‡ Q&\{&\
B1 „& \†‡€X|& ‹&€’&&| €„& €’‚ ‡{€{Q&‡ †| €„& &|€QX> ŠXQ€ ‚ƒ €„& †|†‡†‚| †‡ now XŠŠQ‚–†X€&> }$-~
B2-3 |‚€„&Q Œ|‚€ †‡ €†&\ X|{X>> œ€„& Q†@„€ €„Q&X\ ‚| €„& ‡„&& †‡ XŒ†|@ a >‚‚Š XQ‚{|\ €„& >&ƒ€ €„Q&X\ž
B4 „& ƒ†|X> Œ|‚€ †‡ €†&\ X|{X>> œ>&ƒ€ €„Q&X\ ‚| €„& ‡„&& XŒ&‡ X >‚‚Š XQ‚{|\ €„& Q†@„€ €„Q&X\ž
C1-2 „& &|€QX> Œ|‚€ †‡ Q&X€&\ X|\ >‚Œ&d

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Figure. ~} ‚{Q€„ ‡€&Š ‚ƒ €„& Q&ŠX†Q ‚ƒ €„& {€&Q{‡

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A1 „& ƒ‚{Q€„ ‡€&Š ‚ƒ Q&ŠX†Q ‚ƒ €„& {€&Q{‡ ‡€XQ€‡

A2-4 „&Q& XQ& ƒ‚{Q €„Q&X\‡ˆ €’‚ ‚ƒ €„& XQ& †| €„& †\\>& X|\ &|\ ’†€„ a |&&\>&ˆ ‚|& ƒQ&& &|\ ‚Q†@†|X€&‡ ƒQ‚
>&ƒ€ ‡†\& Œ|‚€ X|\ X|‚€„&Q ƒQ&& &|\ ‚Q†@†|X€&‡ ƒQ‚ €„& Q†@„€ Œ|‚€
„& >&ƒ€ €„Q&X\ ƒQ‚ €„& †\\>& †‡ ’QXŠŠ&\ €’†& XQ‚{|\ €„& |&&\>& „‚>\&Qˆ >‚Œ’†‡& ›†€„ €„& €†Š ‚ƒ €„& |&&\>&
„‚>\&Qˆ €„& >&ƒ€ ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„Q&X\ XQ& Š{>>&\ †| €„& ‚ŠŠ‚‡†€& \†Q&€†‚|‡
B1-2 ’‚ ‡†\&‡ ‚ƒ €„& €„Q&X\ XQ& €†@„€&|ed X|\ €„& \†‡€X|& ‹&€’&&| €„& €’‚ ‡{€{Q&‡ †‡ Q&\{&\
B3-4 ‚Œ†|@ €„& >&ƒ€ Œ|‚€ „& ‡X& €„Q&X\ œ’†€„ a |&&\>&ž †‡ ’QXŠŠ&\ ‚|& XQ‚{|\ €„& |&&\>& „‚>\&Qˆ
>‚Œ’†‡& ›†€„ €„& €†Š ‚ƒ €„& |&&\>& „‚>\&Qˆ €„& ‡X& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„Q&X\ XQ&
Š{>>&\ †| €„& ‚ŠŠ‚‡†€& \†Q&€†‚|‡ X|\ €†@„€&|ed.
C1 ‚Q €„& ‡&‚|\ €†& €„& €„Q&X\ †‡ ’QXŠŠ&\ ‚|&‡ XQ‚{|\ €„& |&&\>& „‚>\&Qˆ ‚{|€&Q>‚Œ’†‡& ›†€„ €„& €†Š ‚ƒ
€„& |&&\>& „‚>\&Qˆ €„& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„& €„Q&X\ XQ& Š{>>&\ †| €„& ‚ŠŠ‚‡†€&
\†Q&€†‚|‡ X|\ €†@„€&|ed.
C2 „& ƒ†|X> >&ƒ€ Œ|‚€ †‡ >‚Œ&\.
C3-4 „& Q†@„€ €„Q&X\ ƒQ‚ €„& †\\>& †‡ ’QXŠŠed €’†& XQ‚{|\ €„& |&&\>& „‚>\&Qˆ >‚Œ’†‡& ›†€„ €„& €†Š ‚ƒ €„&
|&&\>& „‚>\&Qˆ €„& Q†@„€ ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„& €„Q&X\ XQ& Š{>>&\ †| €„& ‚ŠŠ‚‡†€&
\†Q&€†‚|‡

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Figure. ~~ †|†‡„†|@ €„& Q&ŠX†Q ‚ƒ €„& {€&Q{‡

A1 ’‚ ‡†\&‡ ‚ƒ €„Q&X\ XQ& €†@„€&|ed X|\ €„& \†‡€X|& ‹&€’&&| €„& €’‚ ‡{€{Q&‡ †‡ Q&\{&\
A2-3 ‚Œ†|@ €„& Q†@„€ Œ|‚€ „& ‡X& €„Q&X\ œ’†€„ a |&&\>&ž †‡ ’QXŠŠ&\ ‚|& XQ‚{|\ €„& |&&\>& „‚>\&Q
>‚Œ’†‡& ›†€„ €„& €†Š ‚ƒ €„& |&&\>& „‚>\&Qˆ €„& ‡X& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„& €„Q&X\
XQ& Š{>>&\ †| €„& ‚ŠŠ‚‡†€& \†Q&€†‚|‡ X|\ €†@„€&|ed.
A4 ‚& €„& ‡&‚|\ €†& €„& €„Q&X\ †‡ ’QXŠŠ&\ ‚|& XQ‚{|\ €„& |&&\>& „‚>\&Qˆ ‚{|€&Q>‚Œ’†‡& ›†€„ €„& €†Š ‚ƒ
€„& |&&\>& „‚>\&Qˆ €„& ƒQ&& &|\ ‚ƒ €„& €„Q&X\ †‡ @QX‡Š&\ ’‚ ‡†\&‡ ‚ƒ €„Q&X\ XQ& Š{>>&\ †| €„& ‚ŠŠ‚‡†€& \†Q&€†‚|‡
X|\ €†@„€&|ed.
B1 „†‡ †‡ €„& ƒ†|X> Q†@„€ Œ|‚€
B2 >> Œ|‚€‡ XQ& >‚Œ&\ „&Q& XQ& €’‚ ŠX†Q‡ ‚ƒ €„Q&X\ &|\‡
B3 ‡†|@ ‡†‡‡‚Q‡ €’‚ &|\‡ X€ €„& Q†@„€ ‡†\& XQ& {€
B4 ‡†|@ ‡†‡‡‚Q‡ €’‚ &|\‡ X€ €„& >&ƒ€ ‡†\& XQ& {€
C1
Š&QX€†‰& ƒ†&>\ XŠŠ&XQX|& Xƒ€&Q €„& Q&ŠX†Q ‚ƒ €„& {€&Q{‡ †‡ ‚Š>&€&\

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Recapitulation

C2 „& {€&Q†|& †|†‡†‚| X€ €„& ‡€XQ€ ’X‡ XŠŠQ‚–†X€&> ~}  >‚|@ ƒ€&Q €„& ‡{€{Q†|@ €„& >&|@€„ ‚ƒ €„& {€&Q†|&
†|†‡†‚| †‡ Q&\{&\ €‚ XŠŠQ‚–†X€&> $

C3: „†‡ †‡ Q‚‡‡-‡&€†‚| ‰†&’ \&‚|‡€QX€†|@ €„& &ƒƒ&€‡ ‚ƒ €’‚ ‡{€{Q†|@ €&„|†”{&‡ ‚| €„& >&|@€„ X|\ €„†Œ|&‡‡
‚ƒ €„& {€&Q†|& †|†‡†‚| ’‚ Q&‡{>€‡ XQ& ŠQ&‡&|€&\ – a Š‚‚Q ‚|& œ€‚Š Š†€{Q&ž X|\ a @‚‚\ ‚|& œ‹‚€€‚ Š†€{Q&ž

Š‚Q€X|€ |‚€&‡

Bad result œ†@ ~~ˆ ˆ €‚Š Š†€{Q&ž would occur if the needle passes through the endometrium while
suturing. | €„& ‡€X|\XQ\ €&„|†”{& ‚ƒ {€&Q{‡ Q&ŠX†Qˆ X€ €„& &|\ ‚ƒ €„& ŠQ‚&‡‡ˆ €„& †|†‡†‚| †‡ X‡ >‚|@ X‡ €„& †|†€†X>
†|†‡†‚|

Better result œ†@ ~~ˆ ˆ ‹‚€€‚ Š†€{Q&ž is obtained if Vejnovic modification of the cesarean section
technique is performed:

1. In this case, the length of the incision is approximately halved.

2. It is particularly important in reducing the risk of complications in the subsequent pregnancies.

CONCLUSION
„†‡ ŠXŠ&Q ŠQ‚‰†\&‡ X ‹Q†&ƒ ‚‰&Q‰†&’ ‚ƒ €„& {‡& ‚ƒ ^ X|\  X|†X€†‚|‡ ƒ‚Q &\{X€†‚| †| ‰XQ†‚{‡ ƒ†&>\‡ „&
X†| €‚Š† ‚ƒ €„†‡ ’‚QŒ †‡ Q&X€†|@ a ‡€‚Q‹‚XQ\ †| ’„†„ &|‚‰† ‚\†ƒ†X€†‚| ‚ƒ Q&ŠX†Q†|@ {€&Q{‡ X€ X&‡XQ&X|
‡&€†‚| †‡ ‡„‚’| X&>ˆ †€ ’X‡ |‚€&\ †| ‚\&Q| @|X&‚>‚@†X> ŠQX€†& €„X€ €„& Š‚‡‡†‹†>†€†&‡ ƒ‚Q @‚‚\ X|\
”{X>†€ &\{X€†‚| ‚ƒ |&’ \‚€‚Q‡ X|\ Q&‡†\&|€‡ are X>‚‡€ &–„X{‡€&\
| €„& ‚€„&Q „X|\ˆ &–Š&Q†&|&\ \‚€‚Q‡
„X‰& |‚€†&\ €„X€ ‡‚& ‚ƒ €„& \†‡X\‰X|€X@&‡ ‚ƒ €„& ‡€X|\XQ\ ŠQ‚&‡‡ ‚ƒ &\{X€†‚| X| ‹& ‚‰&Q‚& ‹ €„& {‡& ‚ƒ
|&’ €&„|‚>‚@†&‡ „†‡ †‡ ’„&Q& X|†X€†‚|ˆ X |&’ €‚‚> †| &\{X€†‚| ’„†„ „X‡ ‡&‰&QX> X\‰X|€X@&‡ˆ X| „&>Š „&
a|†X€†‚| \‚&‡ |‚€ „XŠŠ&| †| €„& ‚Š&QX€†|@ €„&X€Q& ’„&Q& \‚€‚Q‡ X|\ ‡{Q@&‚|‡ \‚ |‚€ „X‰& &|‚{@„ €†& €‚ €&X„
‹&X{‡& €„& „X‰& €‚ ‚Š&QX€& X|\ ‚Š>&€& €„& ‚Š&QX€†‚| X€ €„& ‚Š€†{ €†&. „& X|†X€†‚| ‚ƒ €„†‡ ŠQ‚&‡‡
‚ƒƒ&Q‡ X| ‚ŠŠ‚Q€{|†€ €‚ a ‚{|@ \‚€‚Q €‚ Q&Š&X€&\> ‡&& €„& ‚Š&QX€†‚| ‚| €„& ‡Q&&|ˆ X|\ ’†€„ €„& X|†X€†‚|
X| ‡&@&|€‡ ‚ƒ €„& ‚Š&QX€†‚| X| ‹& &|>XQ@&\ ‚Q ‡„‚’| †| ‡>‚’ ‚€†‚|ˆ X|\ €„& ’„‚>& ŠQ‚&\{Q& X| ‹&
’X€„&\ a ‚{|€>&‡‡ |{‹&Q ‚ƒ €†&‡ „†‡ ‚ƒƒ&Q‡ {>€†Š>& ‹&|&ƒ†€‡ˆ €‚ &–Š&Q†&|&\ \‚€‚Q‡ X|\ &‰&| ‚Q& €‚ €„&
‚{|@&Q ‚|&‡ „†‡ ŠQX€†X>> &X|‡ €„X€ X ‚{|@ \‚€‚Q ’†>> ‹& ŠQ&‡&|€ X€ €„& Q&X> ‚Š&QX€†‚| ‚|> ’„&| €„&
‹&‚& ƒX†>†XQ ’†€„ X>‚‡€ €„& ’„‚>& ŠQ‚&\{Q& †| €„& ‰†Q€{X> ’‚Q>\ X|\ Xƒ€&Q €„X€ˆ \{Q†|@ €„& X€{X> ‚Š&QX€†‚|ˆ
€„& ’†>> ‹& X‹>& €‚ Q&‚‰& X>> \‚{‹€‡ †| ‚|‡{>€X€†‚| ’†€„ X| &–Š&Q†&|&\ ‡{Q@&‚|
| €„& ‚€„&Q „X|\ˆ €„& €†&
X| &–Š&Q†&|&\ ‡{Q@&‚| |&&\‡ €‚ ‹& ‡Š&|€ ‚| €„& &\{X€†‚| ‚ƒ ‚{|@ \‚€‚Q‡ †‡ ‡†@|†ƒ†X|€> Q&\{&\ X|\ €„&
ŠQ‚&‡‡ ‚ƒ &\{X€†‚| †|Q&X‡&‡ ‡†@|†ƒ†X|€> †| &ƒƒ††&| X|\ ‡Š&&\ X|\ €„&Q&ƒ‚Q& †| €„& ”{X>†€

„†‡ ŠXŠ&Q ŠQ&‡&|€‡ X \&€X†>&\ ‡€‚Q‹‚XQ\ ’„†„ †‡ †>>{‡€QX€&\ †| ~~ ƒ†@{Q&‡ˆ &X„ ’†€„ X X–†{ ‚ƒ ~^ Š†€{Q&‡
| †|€&@QX> ŠXQ€ ‚ƒ €„& ‡€‚Q‹‚XQ\ XQ& €„& \&€X†>&\ ‚&|€‡ˆ ’„†„ ‡„‚{>\ >XQ†ƒ €„& ‡†€{X€†‚| €‚ &‰&Q Q&X\&Q
„& ‡€‚Q‹‚XQ\ †‡ Q&X€&\ ‹X‡&\ ‚| €„& ƒ†> ‡„‚’†|@ X ŠQ‚&\{Q& ‚ƒ Q&ŠX†Q†|@ €„& {€&Q{‡ ‹ {‡†|@ X ‡Š‚|@& ‚\&>
†|‡€&X\ ‚ƒ a {€&Q{‡. „†‡ †‡ \‚|& †| ‚Q\&Q €‚ X„†&‰& X ‹&€€&Q ‡„‚€ €„X| ’†€„ X ‰†\&‚ ‚ƒ real ‚Š&QX€†‚| ‚|\†€†‚|‡. €
‡„‚’‡ €„& ‡{Q@†X> ŠQ‚&\{Q& ’†€„‚{€ „X‡€&ˆ †| X Q&>X–&\ X€‚‡Š„&Q& X>‚|@ ’†€„ X| ‡†@|†ƒ†X|€ ‚&|€‡ ‚|
€„& \&€X†>‡ ‚ƒ €„& ‚Š&QX€†‚| €„X€ X ‡{Q@&‚| ‚{>\ &Š„X‡†•& X|\ Q&Š&X€ „†‡ X>‡‚ X‰‚†\&\ ‹>‚‚\ ‚| €„& ‡&|&ˆ
’„†„ †| Q&X> €&Q‡ Q&\{&‡ €„& €QX|‡ŠXQ&| ‚ƒ €„& Q&‚Q\†|@ | €„†‡ ’Xˆ €„& ŠQ&-ŠQ‚\{€†‚| ‚ƒ €„& ŠQ‚&‡‡ ‚ƒ
Q&ŠX†Q†|@ €„& {€&Q{‡ ‹ X ‚\†ƒ†&\ &|‚‰† €&„|†”{& †‡ ‚Š>&€&\ X|\ ‚{Q |&–€ ‚‹ ’†>> ‹& €‚ Q&X€& X|
&\{X€†‚|X>  X|†X€†‚| ‚| €„†‡ €‚Š† X|\ €„{‡ ‚Š>&€& €„& †\&X

ACKNOWLEDGEMENTS
„& Q&‡&XQ„ ƒ‚Q €„†‡ ŠXŠ&Q ’X‡ ƒ†|X|†X>> ‡{ŠŠ‚Q€&\ ‹ €„& Q‚‰†|†X> &Q&€XQ†X€ ƒ‚Q †&|& X|\ &„|‚>‚@†X>
&‰&>‚Š&|€ ‚ƒ €„& {€‚|‚‚{‡ Q‚‰†|& ‚ƒ ‚‰‚\†|X €„Q‚{@„ €„& ƒ†|X|†|@ ‚ƒ €„& ŠQ‚&€   &‰&>‚Š†|@ ‚ƒ
ed{X€†‚|X> ^ ¥ ‰†‡{X> X|†X€†‚| Q&ŠX†Q†|@ {€&Q{‡ X€ X&‡XQ&X| ‡&€†‚|  ›& X>‡‚ €„X|Œ €„& X|‚|‚{‡
Q&‰†&’&Q‡ ƒ‚Q €„&†Q ƒ&&\‹XŒ

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REFERENCES
1. „& €‚Q ‚ƒ &|‡€Q{X€†‚|ˆ ~™š` „€€Š‡¥¥’’’‚{€{‹&‚¥’X€„¦‰§&„>\¨^•@
—&‡‡&\ ~‡€ ŠQ†> 2016].
2. ‚|X>\ †| X€„X@† X|\ˆ ~™$™. „€€Š‡¥¥’’’‚{€{‹&‚¥’X€„¦‰§@ŒX}¤‰©
—&‡‡&\ ~‡€ ŠQ†> 2016].
 ‚’ X XQ |@†|& ›‚QŒ‡ˆ 2011. „€€Š‡¥¥’’’‚{€{‹&‚¥’X€„¦‰§š›¨–&ŒX©
—&‡‡&\ ~‡€ ŠQ†> 2016].
š ‚Š{€&Q QXŠ„†‡ - |@†|&&Q†|@ |†X€†‚| €{\†&‡ˆ X{>€ ‚ƒ &„|†X> †&|&‡ˆ 2011.
„€€Š¥¥’’’QX{|XQ‡ŒX-@QXƒ†ŒX‚¥†|\&–Š„Š¥‡€{\&|€‡Œ†-QX\‚‰† —&‡‡&\ ~‡€ ŠQ†> 2016].
$ Q|&ˆ ˆ ~™™™ „& Q€ ‚ƒ X‚{€ |\ €‚Q‹‚XQ\†|@ &†–>†Šˆ ‚ ‘†>\XQ&ˆ Q&>X|\
6. &|‚‰†ˆ ˆ ‚‡€Xˆ  ˆ @|X€‚‰ˆ ˆ ^}~^ &’ &„|†”{& ƒ‚Q X&‡XQ&X| &€†‚| Geburtshilfe und
Frauenheilkundeˆ ‚> Ÿ^ ‚ ™ ŠŠ ¤š}-¤š$
Ÿ &|‚‰†ˆ ˆ ^}}¤ X&‡XQ&X| \&>†‰&Q - &|‚‰† ‚\†ƒ†X€†‚| Srpski arhiv za celokupno lekarstvoˆ
‚> ~` ŠŠ ~}™-~~$
8. &|‚‰†ˆ ˆ QX„‚‰Xˆ ˆ &‡&>‚‰‡Œ†ˆ ˆ ‘‚>&\†|ˆ ˆ ^}~~ {Q@†X> ’‚{|\‡ ‚Š>†X€†‚|‡ †| €’‚
\†ƒƒ&Q&|€ €&„|†”{&‡ ‚ƒ X &‡XQ†X| ‡&€†‚| &X>€„&\ˆ ‚> $ ‚ ` ŠŠ ~Ÿ$š-~Ÿ`~
™ X>†„|†ˆ ˆ &|\X••†ˆ †X||X>‹&Q€‚ˆ ^}~$ ‰XŠ{€ ŠQ‰† - "{†Q†|‚ Q†‡€†X|† † \{@‚&€QXª|† X|††QX|†
ƒ†>ˆ Q‰X€‡Œ† ƒ†>‡Œ† >&€‚Š†‡ˆ ‚ ¤šˆ Q‚X€†X

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