THE IMPACT BETWEEN PERITONEAL CLOSURE AND NON-

CLOSURE ON THE RISK OF ADHESION IN CAESAREAN

SECTION

ABSTRACT

This study examines how the study of the impact of peritoneal closure with no closure
at caesarean section on the risk of adhesions. Systematic Literature Review Research is
is the selected methods by researchers in this study. Researchers will describe facts, data
and information obtained from literature studies such as books, journals to research
results related to the research topic. In this study, it is known that the incidence of births
worldwide by Caesarean section (CS) is increasing. Many births after CS have
previously been performed by repeat surgery, either with elective CS or after an
unsuccessful delivery attempt. The formation of these adhesions is associated with
increased maternal morbidity in patients with recurrent CS. In studies, non-closure of
the peritoneum appears to save time and costs and therefore lacks the adhesions that
cause infertility. However, not closing the parietal peritoneum will cause adhesions
without causing infertility. These adhesions can cause long operating times, recovery,
and increased postoperative pain in the second ceasarean section.
Keywords: Adhesi, Caesarean, Peritoneal

ABSTRAK
Penelitian ini mengkaji tentang bagaimana kajian dari dampak penutupan peritoneum
dengan tanpa penutupan pada operasi Caesar terhadap resiko adhesi. Penelitian
Sistematic Literature Review adalah penelitian yang digunakan peneliti pada penelitian
ini. Peneliti akan melakukan pendeskrisian fakta, data dan informasi yang diperoleh dari
kajian kepustakaan seperti buku, jurnal hingga hasil penelitian yang berhubungan denga
topik penelitian. Pada penelitian ini diketahui bahwasannya Insiden kelahiran di seluruh
dunia melalui Operasi Caesar (CS) meningkat. Banyak kelahiran setelah CS
sebelumnya dilakukan dengan operasi berulang, baik dengan CS elektif atau setelah
percobaan persalinan yang gagal. Pembentukan adhesi ini banyak dikaitkan dengan
peningkatan morbiditas ibu pada pasien dengan CS berulang. Dalam kajian, tanpa
penutupan peritoneum tampaknya menghemat waktu dan biaya sehingga tidak memiliki
adhesi yang menyebabkan infertilitas. Namun tidak tertutupnya peritoneum parietal
akan menyebabkan perlengketan tetapi tidak akan mempengaruhi kesuburan tetapi
perlengketan tersebut dapat menyebabkan waktu operasi yang lama, pemulihan,
peningkatan rasa sakit pasca operasi pada operasi caesar kedua.
Kata kunci: Adhesi, Caesar, Peritoneal
INTRODUCTION
The well-being of babies and mothers is the cornerstone of midwifery.
Childbirth was accomplished by vaginal birth for many years. With the increasing use
of antibiotics and the number of operations, infant and maternal mortality and morbidity
become important after vaginal delivery (Bjørnstad & Ræder, 2020). Surgeons prefer
caesarean section (CS) over vaginal delivery to reduce fetal and maternal mortality.
Currently, the increasing number of unnecessary caesarean section is a big problem in
the global world. Many countries are trying to use different procedures to increase
vaginal births. All policies, to encourage patients and doctors to vaginal delivery are not
enough to reduce the number of unnecessary caesarean section in the world (Poole,
2013).

Caesarean section is one of the most frequently performed major surgical

procedures worldwide, accounting for up to 70% of deliveries, depending on the facility
being assessed and the country involved. In general, worldwide rates are around 5% to
over 20% of all deliveries. Figures between 20% and 25% have been reported from the
UK, US and China. A rate of 57% was reported from a private hospital in South Africa
(Sorrentino et al., 2022). There are many possible ways to perform a caesarean section
and the surgical techniques used for a caesarean section vary. The technique used may
depend on many factors including the clinical situation and operator choice. Some of
these techniques have been evaluated through randomized trials (Wilkinson et al.,
2018).

In general, an incision in the abdomen that opens the abdominal cavity is called
a laparotomy. The incisions commonly used in abdominal exploration are vertical
incisions, transverse incisions and oblique/transverse incisions. Vertical incisions
include midline and para-median incisions. Nearly all abdominal and retroperitoneal
surgical interventions can be performed with a midline incision. Generally, the term
laparotomy is called a midline incision (Mahdi et al., 2019). The peritoneum is the
innermost layer of the abdominal wall, which once opened the abdominal cavity
becomes available. After abdominal surgery, some surgeons suture this lining and
believe that this action can strengthen the wound and abdominal wall, but on the other
hand some surgeons close the abdominal cavity without suturing this lining and believe
that closing this layer can extend the time and cost of surgery and even postoperative
pain for patients (Tofigh & Jafarzadeh, 2021).

Peritoneal sutures are performed via absorbable or delayed sutures. There is

controversy over the choice of technique (continuous or interrupted) to close this layer,
even among surgeons who believe in closing this layer. Overall, there are still differing
opinions regarding the closure of this layer (Ten Broek et al., 2013). One of the reasons
some surgeons choose to suture this lining is to preserve the anatomical structure of the
abdominal wall and also to reduce the risk of infection, rupture and incisional hernias,
bleeding and adhesions. These adhesions are the most common sequelae of intra-
abdominal and pelvic surgery and are a significant cause of morbidity among
postoperative patients. The incidence of adhesive small bowel obstruction (SBO) is 2%.
Among patients with a known cause of SBO, adhesions are the most common cause.
Using good surgical technique is recommended as the first step in preventing adhesions
(Lee et al., 2022). However, evidence of different surgical techniques to reduce
adhesion formation needs confirmation.

On the other hand, the reasons other surgeons will not suture this lining are its
rapid healing within 48 to 72 hours without sutures and reduced operative time,
analgesic requirement, wound infection and length of stay. peritoneal closure persists,
even exceeding the technique that should be done (Roofthooft et al., 2021). Based on
previous studies, there appears to be agreement regarding peritoneal closure in obstetric
operations such as hysterectomy and caesarean section, but the disagreement seems to
continue in other fields of surgery (Bhaumik, 2016). Thus, despite the disagreements
that exist, the aim of this systematic literature review was to compare the impact of
peritoneal closure versus non-closure on the risk of adhesions in cesarean section.

METHOD

The literature review in this study was carried out through a systematic selection
that was traced from international databases. The author searches data sources from
various databases, including using PubMed (https://pubmed.ncbi.nlm.nih.gov//), and
Google Scholar. The literature search technique uses keywords that match the questions
from the research. The list of keywords that will be used as the basis for the literature
search are Peritoneal, Caesarean and Adhesion. Search articles using English and the
year of publication is limited to the last 10 years (2013-2023).

RESULTS AND DISCUSSION

Research Results Scheme or Diagram (PRISMA)

Chart 1. illustrates the process of selecting articles using the guidelines from
Preferred Reporting Systematic Reviews and Meta-analysis (PRISMA). An initial
search found that the number of articles from 2013-2023 was 276 articles. Next, the
articles are screened. A total of 7 articles were entered into the next stage. The quality of
the articles was reviewed so that as many as 7 articles were synthesized in the final
review report from the literature.

Article identified through database (n=276)

Identification a. PubMed: 241

b. Google Scholars: 35

Screening
Articles are checked for Article deleted via Mendeley n
duplication n=269 = 14

Article
meets
inclusion Screened articles Expelled (n=269) because:
requirement a. Articles published by title (n=263)
n = 269 b. Article issued based on abstract (n=6)
s

Synthesized
article
Article read full text n = 7

Chart 1. PRISMA Diagram

The researcher selected the articles extracted data on each article obtained from
each database. The results of the article were reviewed regarding the study of The
Impact Of Peritoneal Closure With Non-Closure On The Risk Of Adhesions In
Caesarean Section.

Table 1. Literature Review of the Impact between Peritoneal Closure and Non-
Closure on The Risk of Adhesion in Caesarean Section
Researcher Method Purpose Result

(Tofigh & Clinical Trial To compare the short- The non-peritoneal closure
Jafarzadeh, term and long-term group had lower rates of
2021) benefits of peritoneal fever, infection, and analgesic
closure with non- requirements than the
closure in an peritoneal closure group, but
academic medical these differences were not
center statistically significant.
Adhesion rates and incidence
of incisional hernia one year
after surgery did not differ
significantly between the two
groups. Pain intensity was
significantly lower in the non-
closure group than in the
closure group in the first two,
six, and 24 hours.
(Mooij et Cross- To assess maternal Out of 3966 births, 450 were
al., 2020) Sectional and neonatal with CS (11.3%), of which
morbidity and 321 were CS 1, 80 CS 2, 36
mortality after CS 3, 12 4 and one 5 CS (71,
recurrent CS in a rural 18, 8, 3 and 0.2 respectively
hospital in a low- %). Adhesion was considered
income country (LIC) severe at 56% second CS and
and to analyze the 64% third CS. In the 2nd CS,
effect of surgical the adhesions were not
technique on adhesion associated with peritoneal
formation. closure in the 1st CS, but were
associated with the use of a
previous midline skin
incision. There was no
increase in maternal morbidity
when there was severe
adhesions. Adhesions after CS
are common and occur more
frequently after midline skin
incisions in the first CS than
with transverse incisions.
(Kokanalı Prospective To investigate During laparoscopic surgery,
et al., 2019) Study whether adhesions were detected in the
characteristics of skin upper part of the abdominal
scars are related to the cavity in 30 women, in the
presence and severity middle in 46 women and in
of abdominal or the lower part in 82 women.
pelvic adhesions in The total abdominal scar score
women who have was significantly improved in
undergone a previous women with adhesions in all
cesarean section three abdominal areas.
Multiple C-section scars and
palpable scars are more
common in women with
adhesions. A significant
positive correlation was found
between skin scar and
adhesion scores in all
abdominal regions.
(Çim et al., Prospective To assess whether Adhesion after surgical
2018) Study abdominal scar operations is critical because
characteristics and of complications for the
peritoneal closure are patient, complications of
associated with pelvic relaparotomy, and high costs.
adhesions Depressed abdominal scars
and hypopigmentation may be
associated with pelvic
adhesions. The results of this
study suggest that covering or
non-closing of the parietal
peritoneum is not associated
with hip adhesions.
(Gultekin, Retrospectiv To determine the non- Unclosure of the parietal
2017) e Study closing of the parietal peritoneum may take time
peritoneum on the during the first operation but
caeserean section uncovering it will inscrease
omentum adhesions to the
scarpa fascia and will longer
the time for the second re-
cesarean. Therefore, recovery
at the second operation will be
delayed in non-closure
patients
(Takreem, Comparative To compare the Sixty-five cases of peritoneal
2015) Study results of peritoneal closure and 30 cases of non-
and non-closure peritoneal closure were
during cesarean followed up. There were more
section cases of adhesions in the non-
closure group (p<0.05).
Peritoneal closure is useful in

(Bamigboye Intervention
& Hofmeyr, Review
2014)
routine cesarean sections.
To assess the effect of There was a reduction in
non-closure as an operating time in all
alternative to subgroups. There was also
peritoneal closure in reduced post-cesarean hospital
cesarean section on stay except in the subgroup
intraoperative and where the parietal peritoneum
immediate and long- alone was not sutured where
term postoperative there was no difference in
outcomes hospital stay. Evidence of
adhesion formation is limited
and inconsistent. There is
currently insufficient evidence
of benefit to justify the
additional time and use of
suture materials required for
peritoneal closure. Stronger
evidence of long-term pain,
adhesion formation, and
infertility is needed

Risk of Cesarean Adhesion due to Peritoneal Closure and Non-Closing

Caesarean section (CS) is the most common surgical procedure performed
worldwide. The traditional lower segment cesarean section surgical approach includes
closure of the visceral and parietal peritoneum (O'Sullivan, 2021). Suggested
advantages of peritoneal closure include restoring normal anatomy and re-adjacent
tissue, reducing the incidence of infection by rebuilding the natural anatomical barrier,
reducing wound dehiscence, reducing bleeding, and minimizing the incidence of
adhesion formation. Adhesions that develop after CS procedures are associated with
several side effects, which manifest as chronic pain, delayed female conception, and
varying degrees of intestinal obstruction (Wilkinson et al., 2018). In addition,
postoperative adhesions have been associated with prolonged delivery of the baby
during recurrent CS. Peritoneal healing has been previously reported to occur with
metaplasia of the underlying connective tissue. The peritoneum regenerates within 5-8
days after surgery (Seyam et al., 2018).

Adhesions are one of the most important postoperative complications seen after
laparotomy. Development of adhesions after a CS procedure will increase the time of
subsequent CS operations; increased incidence of unintentional trauma to the bowel,
bladder, and ureters; and increased bleeding complications as well. It has been
previously reported that between 6 and 8% of women who undergo cesarean section are
readmitted to the operating room for the management of complications of adhesions that
develop after a previous CS. So, adhesions can be considered as one of the important
causative factors in secondary female infertility (Sholapurkar, 2018).

Controversy still exists regarding the formation of adhesions after closure of the
peritoneum or leaving it open in previous CS. Both opinions have reasonable
justification. Opinions in favor of nonclosure report that peritoneal healing occurs by
simultaneous multisite healing as a result of migration of mesothelial cells with
mesothelial matrix formation without the need for peritoneal repositioning. They also
added that peritoneal closure will cause foreign body reaction to the suture material,
ischemia, and tissue necrosis, impairing natural healing besides increasing the incidence
of adhesion formation (Bjørnstad & Ræder, 2020).

Recently, a meta-analysis compared adhesions after peritoneal closure or non-

closure during CS based on three well-organized RCTs; the authors of this meta-
analytic work concluded that peritoneal closure has the advantage of significantly
reducing adhesion formation. Because the CS procedure has many technical
modifications, it is not sufficient to differentiate groups regarding adhesion formation
by peritoneal closure alone and non-closure, because other variables such as a longer
abdominal operating time or bladder compression may also occur. contributed to the
development of adhesions after previous laparotomy (Gultekin, 2017).

Most of the studies recommending peritoneal closure during CS procedures have

never considered the long-term side effects and complications expected after successive
surgical procedures including adhesion formation (Bamigboye & Hofmeyr, 2014). After
caesarean section, peritoneal closure has become standard practice, as it is considered
possible

1. Restoration of anatomy and tissue approximation for healing.

2. Re-establishment of the peritoneal barrier to reduce the risk of infection.
3. Reduction of the risk of herniation or wound dehiscence.
4. Minimizes the formation of adhesions (Bamigboye & Hofmeyr, 2014).
 The peritoneum has the innate ability to heal itself quickly. Being a mesothelial
organ with the capacity to initiate multiple repair sites, the peritoneum can
simultaneously heal all wounds. In case of non-closing peritoneum, spontaneous
reperitonealization will appear within 48 to 72 hours and complete healing after 5-6
days (Mokhtari et al., 2022). Non-coverage of the peritoneum contributes to less
adhesion. When injured, the peritoneum initially responds by producing fibrin matrix
and continues with fibrinolysis to break down the fibrin. Reapproximation of the
peritoneal rim with suture material is thought to result in tissue ischemia, necrosis,
foreign body tissue reaction, suppression of fibrinolysis and thereby increasing the risk
of adhesion formation (Jaafar et al., 2019). In addition, non-closure of the peritoneum
reduces the number of surgical interventions and saves valuable operative time and
costs. A previously published double-blind randomized trial, which was performed to
compare post-cesarean pain intensity between the peritoneal closure and non-closure
groups, has concluded that there is no difference in postoperative pain in the two groups
at successive cesarean sections (Di Buono et al. al., 2020).

CONCLUSION

Caesarean section is a very common surgical procedure worldwide. Suturing the

peritoneal lining in caesarean section can provide benefits or not, therefore it is
necessary to evaluate whether this step should be omitted or not. In caesarean section,
closure or non-closure of the parietal and/or visceral peritoneum has both short and long
term advantages and disadvantages. Based on a review of the literature it is known that
peritoneal non closure is recommended because it reduces the time of the surgical
procedure and reduces the duration of anesthesia and drugs, in addition to faster
recovery and early hospital discharge. Surgical time, hospital stay, pain, adhesion
formation, febrile morbidity, and infection were less in non-closure patients during
cesarean delivery.

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