Técnicas quirúrgicas en cesárea segmentaria. Revisión de evidencias

Aim: To know which have been the variations of the Pfannenstiel-Kerr technique and how they have influenced maternal morbidity and mortality. Methods: An electronic search was carried out in PubMed, Medline and Cochrane, of works in English and Spanish languages, regardless of the country of origin, preferably randomized and controlled between 2010 and 2020, on variations in the original surgical technique, with emphasis on the differences between the PfannenstielKerr and Miglav-Ladash techniques. Results: The more importants variations regarding morbidity and mortality were: 1. Preferring the transverse skin incision, especially the Joel Cohen type; 2. Lateral blunt dissection of the subcutaneous and cranio-caudal aponeurosis, after its incision; 3. Digital and lateral separation of the rectus abdominis muscles; 4. Digitally and laterally prolong the hysterotomy; 5. Uterine incision closure, without externalizing the uterus, in one or two suture planes, indifferently; 6. Do not suture the visceral and parietal peritoneum or approach the rectus abdominis; 7. Closure of the subcutaneous to separate points, if the thickness is greater than 2 cm. Conclusions: Modifications to the original technique achieved a statistically significant decrease in operative time, the number of sutures, the requirement for analgesics, blood loss, febrile morbidity, as well as operative wound infection and hospital stay. Keywords: Cesarean section, Surgical technique, Pfannenstiel-Kerr, Misgav-Ladach.

Febrile morbidity post laparoscopic myomectomy for symptomatic large submucous myoma in an adolescent girl

The occurrence of post-operative fever after myomectomy without an apparent infectious cause has been reported in various studies. We here in report a case of an 18-year girl with abnormal uterine bleeding and severe anemia resulting from a large 5 cm submucosal fibroid. She underwent laparoscopic myomectomy. Surgery was uneventful. Post-operative she had fever of 100.4°F which lasted for 48 hours. Antibiotic coverage was continued for 48 hours. Her urine culture and hemogram were negative for infection. Early postoperative fever is most commonly caused by inflammatory changes rather than infectious causes. Large submucous fibroids can be managed by laparoscopy with excellent clinical outcomes and minimal morbidity.

An evidence-based cesarean section suggested for universal use

Objectives This article suggests a unified way to perform Cesarean sections. Even in the same departments, different modifications are in use. Therefore, one cannot rely on the early or late outcome of the procedure as long as all the surgical steps are not standardized. Methods The Misgav Ladach (Stark) Cesarean Section presented here is an evidence-based operation. Its basic principles are a modified Joel-Cohen abdominal incision, one-layer continuous suturing of the uterus using a big needle, leaving peritoneum open, closing fascia continuously and a few Donati skin sutures. Results This method has been subjected to scores of comparative studies with other methods in use, proving its advantages over them concerning duration, blood loss, febrile morbidity, need for analgesics, and costs. Conclusions It is suggested that this method should be used as the standardized universal method which will enable comparison between obstetricians and institutions, and offer the parturient the best possible outcome.

Study of maternal and perinatal outcome of caesarean delivery in late first stage and second stage of labour

Background: Second-stage caesarean sections are known to be associated with increased maternal and perinatal complications as compared to late first stage caesarean sections. The objective of the study was to evaluate the maternal and perinatal outcome of caesarean deliveries in the late first stage and second stage of labour.Methods: The prospective observational study of caesarean deliveries done in the late first stage (~8 cm of cervical dilatation) and second stage of labour was conducted at Lady Goshen Hospital, Mangalore and Kasturba Medical College Attavar, Mangalore from August 2018 to June 2020. Comparison of maternal and perinatal outcomes were assessed in late first stage and second stages of caesarean delivery.Results: In the present study intraoperative complications such as extensions of uterine incisions, atonic PPH and bladder base injury and post-operative complications like need for blood transfusion, febrile morbidity and prolonged catheterisation were found more in second stage of labour. Perinatal complications such as hyperbilirubinemia and respiratory distress were found to be more in second stage of labour.Conclusions: As caesarean deliveries are increasing, it is better to make an institutional protocol regarding duration of second stage of labour, use of instrumental delivery to guide us about timely intervention (operative vaginal/caesarean) in advanced labour, thereby aiming to reduce the maternal and perinatal complications.

Changing gloves during cesarean section for prevention of postoperative infections: a systematic review and meta-analysis

This systematic review and meta-analysis was conducted to assess associations between changing gloves during cesarean section (CS) and postoperative infection. A literature search was conducted using the major electronic databases MEDLINE, Scopus, ISI Web of Science, PubMed, CINAHL, and CENTRAL from their inception to September 2020. Randomized controlled trials (RCTs) comparing glove change during CS to no glove change were included. Outcomes of interest were endometritis, febrile morbidity, and incisional surgical site infection (SSI). GRADE approach was applied to assess the quality of evidence. Ten reports of six studies involving 1707 participants were included in the analyses. Glove change was associated with a reduction in the risk of incisional SSI following CS (pooled RR 0.49, 95% CI 0.30, 0.78; moderate quality of evidence). Compared to no glove change, glove change during CS did not reduce the risks of endometritis (pooled RR 1.00, 95% CI 0.80, 1.24; low quality of evidence) or febrile morbidity (pooled RR 0.85, 95% CI 0.43, 1.71; very low quality of evidence). Changing gloves during CS was associated with a decreased risk of incisional SSI. The risks of postoperative endometritis and febrile morbidity were not altered by changing gloves.

Laparoscopically assisted uterovaginal canalization and vaginoplasty for patients with congenital cervical and vaginal atresia: a step-by-step guide and long-term outcomes

Objective: To study the long-term outcomes of laparoscopically assisted uterovaginal canalization and vaginoplasty in patients with congenital cervical and vaginal atresia and to introduce the surgery step-by-step.Methods: A prospective observational study was conducted including 10 patients diagnosed with congenital cervical and vaginal atresia underwent laparoscopically assisted cervicovaginal canalization between January 2016 and Jun 2020 in a tertiary teaching hospital. Clinical characteristics and perioperative data were recorded. Patients were followed up in outpatient clinic at 3, 6 and 12 months postoperatively, and once a year thereafter. Menstruation cycles and degree of dysmenorrhea were recorded. Gynecological examination was performed to measure vaginal length and to examine whether there was restenosis.Results: All procedures went smoothly, with no case requiring conversion to laparotomy or no intraoperative complications occurred. Postoperative febrile morbidity occurred in one patient (1/10, 10%). The median (quartile) follow-up time was 26.0 (21.3, 48.3) months. All patients resumed menstruation, including nine patients (9/10, 90%) with regular monthly menstruation. Eight patients (8/10, 80%) experienced mild-to-moderate dysmenorrhea; the remaining 2 patients (2/10, 20%) had no dysmenorrhea. Cervical restenosis occurred in one patient (1/10,10%) 12 months postoperatively, and cervical dilation was performed. So far, eight months after the second surgery, no restenosis has been found. The mean postoperative vaginal length was 7.9 ± 1.3 cm by the time of last follow up. Only one patient prepared for pregnancy for two years, but she had not conceived yet.Conclusion: Laparoscopically assisted uterovaginal canalization and vaginoplasty is an easy, safe and promising management option for correcting congenital cervical and vaginal atresia.

Comparison of Intraoperative and Postoperative morbidity between in situ and extra-abdominal Uterine repair at Cesarean delivery

In-situ and extra abdominal repair of uterine wound during cesarean section are two valid approaches. This study was carried out to compare intra operative and post operative morbidity in women undergoing caesarean delivery using these two techniques. This is a prospective interventional randomized controlled study. The study subjects include 170 women undergoing Lower segment caesarean section (LSCS) at Southern Railway HQ hospital, Chennai. Intra operative and post operative parameters were analysed in all the study subjects. In in-situ group, 12.6 % women experienced intra operative pain and 30.1% women in extra abdominal group. Intra operative nausea and vomiting was seen in 16.1% women in in-situ group and 28.9% women in extra abdominal group. 1.1% women in in-situ had post-operative febrile morbidity and 8.4 % had in extra abdominal group. The median fall in haemoglobin was 1.30 g/dL and 1.40 g/dL in in-situ and extra abdominal group respectively. In-situ repair of the uterine wound at cesarean delivery is associated with lesser incidence of intra operative pain , intra operative nausea or vomiting and post operative febrile morbidity compared to extra abdominal repair technique.

The impact of intraoperative gloves changing by the surgical team on the post operative wound infection after a Caesarean section, in a tertiary care hospital

Background:Cesarean delivery is a major obstetrical surgical procedure aiming to save the lives of mothers and fetuses. Cesarean deliveries were initially performed to separate the mother and the fetus in an attempt to save the fetus of a moribund patient. Access to nonmedical interventions during labor, such as continuous support during labor and delivery, should be increased. The safe practice during cesarean can provide the protection from infection. Objective:To compare the outcome with changing gloves intra-operatively by entire team versus standard practice (no changing gloves) during cesarean section Material & methods: study design:Randomized controlled trial. Setting:Department of Obstetrics & Gynaecology, Shalamar Hospital Lahore for 6months. Data collection:After meeting the inclusion criteria 160females were enrolled. Then females were randomly divided into two groups. Group A females operated with changing gloves of entire team and group B operated with no changing gloves. During ward follow-up, females were evaluated for febrile morbidity. At the time of stiches removal wound infection was observed. All the collected data was entered and analyzed on SPSS version 21. Results:The mean age of females was 29.06±6.79years, the mean gestational age at delivery was 38.88±1.47weeks. In changing gloves group the wound infection was found in 4(5.0%) females while in no changing gloves group the wound infection was found in 15(18.8%) females (p-value=0.013). Conclusion:The adopting changing gloves practice by entire team during cesarean section showed better outcome in terms of wound infection and febrile morbidity than no changing glove practice.

A retrospective study of obstetric hysterectomy cases at tertiary care centre

Background: Postpartum haemorrhage (PPH) is a life-threatening condition. The objective of this study was to determine the incidence, demographic characteristics, indications, and feto-maternal outcomes associated with obstetric hysterectomy in a tertiary care centre.Methods: This is a retrospective analytical study conducted over a period of six years, from March 2014 to April 2020. A total of 68 cases of obstetric hysterectomy were studied at tertiary care centre in Ahmedabad, Gujarat, India.Results: Present study reported 68 obstetric hysterectomies per 44663 total deliveries (incidence - 0.15%), out of them 20 following 26446 vaginal deliveries (0.07%) and 48 following 18217 caesarean section (0.26%). Morbidly adherent placenta (29.41%) was the most common indication followed by atonic postpartum haemorrhage (25.00%) and uterine rupture (17.64%). The most frequent sequelae were disseminated intravascular coagulation (26.47%) and febrile morbidity (10.29%), maternal mortality was 16.17% whereas neonatal mortality was 26.47%.Conclusions: The incidence of obstetric hysterectomy has been found to be more following caesarean sections. There is a change in the indications of obstetric hysterectomy in the past two decades with placenta accreta spectrum being the commonest in present study. This is because of rising number of caesarean sections. Patients who underwent emergency obstetric hysterectomy due to atonic PPH had a higher mortality.