Non-closure of peritoneal surfaces at caesarean section - a systematic review

Background. Caesarean section (CS) is a very common surgical procedure worldwide. Suturing the peritoneal layers at CS may or may not confer benefit, hence the need to evaluate whether this step should be omitted or not. Objectives. To assess the effects of non-closure as an alternative to closure of the peritoneum at CS on intraoperative, immediate and later postoperative, and long-term outcomes. Search strategy. We searched the Cochrane Pregnancy and Childbirth Group Trials Register (November 2002) and the Cochrane Central Controlled Trials Register (October 2003). Selection criteria. Randomised controlled trials that compared leaving the visceral and/or parietal peritoneum unsutured at CS with suturing the peritoneum, in women undergoing elective or emergency CS. Data collection and analysis. Trial quality was assessed and data were extracted by two reviewers. Main results. Nine trials involving 1811 women were included and analysed. The methodological quality of the trials was variable. Non-closure of the peritoneum reduced operating time when both layers or one layer was not sutured. For both layers, the operating time was reduced by 7.33 minutes (95% confidence interval (Cl): -8.43 - -6.24). There was significantly less postoperative fever and reduced postoperative stay in hospital for non-closure of the visceral peritoneum and non-closure of both layers. There were no other statistically significant differences. The trend for analgesia requirement and wound infection tended to favour non-closure, while endometritis results were variable. Longterm follow-up in 1 trial showed no significant differences. The power of the latter study to show differences was low. Conclusions. There was improved short-term postoperative outcome if the peritoneum was not closed. Long-term studies following CS are limited, but data from other surgical procedures are reassuring. At present there is no evidence to justify the time taken and cost of peritoneal closure.