What is the role of laparotomy in cesarean delivery (C-section)?

Updated: Dec 14, 2018
  • Author: Hedwige Saint Louis, MD, MPH, FACOG; Chief Editor: Christine Isaacs, MD  more...
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Answer

Answer

One option for entering the peritoneal cavity is to use a midline infraumbilical incision. This incision provides quicker access to the uterus. In pregnancy, entry is commonly enhanced by diastasis of the rectus muscles. This incision is associated with less blood loss, easier examination of the upper abdomen, and easy extension cephalad around the umbilicus.

If there are likely to be significant intra-abdominal adhesions from previous operations, a vertical incision may provide easier access and better visualization. Once the rectus sheath is reached, either the sheath can be incised with a scalpel for the entire length of the incision or a small incision in the fascia can be made with a scalpel and then extended superiorly and inferiorly with scissors. Then, the rectus muscles (and pyramidalis muscles) are separated in the midline by sharp and blunt dissection. This act exposes the transversalis fascia and the peritoneum.

The peritoneum is identified and entered at the superior aspect of the incision to avoid bladder injury. Before entry into the peritoneum, care is taken to avoid incising adjacent bowel or omentum. Once the peritoneal cavity is entered, the peritoneal incision is extended sharply to the upper aspect of the incision superiorly and to the reflection over the bladder inferiorly.

Most commonly, a transverse incision through the lower abdomen is made. The incision is a Maylard, Joel Cohen, or, more commonly, a Pfannenstiel incision. Transverse incisions take slightly longer to enter the peritoneal cavity, are usually less painful, have been associated with a smaller risk of developing an incisional hernia, are preferred cosmetically, and can provide excellent visualization of the pelvis.

The Pfannenstiel incision is curved slightly cephalad at the level of the pubic hairline. The incision extends slightly beyond the lateral borders of the rectus muscle bilaterally and is carried to the fascia. Then, the fascia is incised bilaterally for the full length of the incision. Then, the underlying rectus muscle is separated from the fascia both superiorly and inferiorly with blunt and sharp dissection. Clamp and ligate any blood vessels encountered. The rectus muscles are separated in the midline, and the peritoneum is entered.

A Maylard incision is made approximately 2-3 cm above the symphysis and is quicker than a Pfannenstiel incision. It involves a transverse incision of the anterior rectus sheath and rectus muscle bilaterally. Identify and possibly ligate the superficial inferior epigastric vessels (located in the lateral third of each rectus).

For most cesarean deliveries, only the medial two thirds of each rectus muscle usually needs to be divided. If more than two thirds of the rectus muscle is divided, identify and ligate the deep inferior epigastric vessels. The transversalis fascia and peritoneum are identified and incised transversely.

The Joel Cohen incision is a straight transverse incision made 3 cm below the level of a straight line joining the anterosuperior iliac spines. The skin incision is made and carried down to the anterior sheath of the rectus fascia. A 3-4 cm incision is made in the fascia and bluntly opened by stretching in a craniocaudal fashion. The rectus muscles are retracted laterally and the parietal peritoneum is bluntly opened by digital dissection. The peritoneum is then retracted cephalocaudally to avoid injury to the bladder.

In comparison to the Pfannensteil incision, the Joel Cohen incision is associated with less blood loss, shorter operating time, reduced time to oral intake, less risk of fever, shorter duration of postoperative pain, lower analgesic requirements, and shorter time from skin incision to birth of the baby. [79, 80] The Maylard incision with transection of the rectus muscles is associated with increased blood loss. [81]

No evidence reports an advantage of electrocautery over sharp knife dissection or digital dissection of the subcutaneous tissues, or whether sharp or blunt retraction of the fascial tissues is preferable. Blunt dissection tends to be associated with reduced blood loss. [82]


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