Ronald M. Cyr, MD

Disclosures

June 27, 2003

Question

The current trend is not to close the visceral and parietal peritoneal layers during lower-segment cesarean section. Please clarify:

 

  1. Should both visceral and parietal layers be left unclosed or should the visceral layer alone be closed?

  2. Similarly, should peritonization of the stumps be done during total abdominal hysterectomy?

  3. Similarly, should the peritoneal layer be left unclosed during vaginal hysterectomy.

Dr. A. Khosla

Response from Ronald M. Cyr, MD

Ronald M. Cyr, MD
Department of General Obstetrics and Gynecology in the Division of Women's Health, University of Michigan, Ann Arbor

It would seem logical to suture all the layers we cut at surgery, including the peritoneum. This is indeed what surgeons have taught and practiced for more than a hundred years. As recently as 20 years ago, gynecologists spent almost as much time closing peritoneum and burying pedicles as doing the actual hysterectomy. Recent atlases and textbooks still describe closure of the parietal and visceral peritoneum as standard technique.

However, numerous studies published in the past 25 years have found no benefit to suturing peritoneum. In a randomized study of vertical laparotomy incisions involving 326 patients, Ellis and Heddle[1] concluded that closing peritoneum did not reduce hernias or dehiscence. Tulandi and colleagues,[2] using second-look laparoscopy in infertility patients initially operated via Pfannenstiel incision, found that natural healing of the peritoneum was preferable to reapproximation of peritoneal edges with either staples or sutures. A rabbit study showed that suturing the parietal peritoneum caused more adhesions.[3]

At cesarean section, nonclosure of either visceral or parietal peritoneum is associated with less postoperative pain and fewer adhesions.[4,5,6]

A recent study by Janschek and coworkers[7] found a quicker return to normal bowel function when peritoneal closure was omitted at vaginal hysterectomy. In a review of that article,[8] I offered a rationale for my own practice of not suturing the peritoneum following simple vaginal hysterectomy for benign disease.

In light of such reports, many surgeons no longer suture either peritoneum or subcutaneous fat. I stopped closing parietal peritoneum at laparotomy and cesarean section in the mid-1980s and visceral peritoneum a few years later and have not routinely sutured peritoneum at simple vaginal hysterectomy for the past 5 years. Anecdotally, I am not aware of any complications from this practice, but it has reduced operating time.

It seems that routine peritoneal closure is yet another surgical ritual -- a time-honored procedure unsupported by clinical evidence.

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