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EDITORIAL
Year : 2022 | Volume
: 12
| Issue : 2 | Page : 79-81
Hysterotomy repair during cesarean delivery – In or out, does it really matter?
Adithya Bhat, Preet M Singh
Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
Correspondence Address:
Dr. Adithya Bhat
660 S. Euclid Ave. Box 8054, St. Louis, MO, 63110
USA
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/JOACC.JOACC_46_22
Cesarean delivery is the most common surgery performed in the world. By 2030, more than 38 million deliveries will be performed annually via cesarean, with a global rate that is projected to increase from 21% to 28.5% of all deliveries.[1] Although the incidence of cesarean delivery is less in India, rates have still doubled from 8.5% to 17.2% between 2005 and 2015.[2] As a major abdominal operation, cesarean delivery is associated with increased morbidity compared with vaginal delivery.[3] Variation with regard to surgical techniques for hysterotomy closure has persisted for decades, with both intra-peritoneal and externalized approaches commonly practiced. Advocates of externalization believe that this maneuver results in less bleeding, whereas those who support intra-peritoneal repair suggest that it results in less patient discomfort and surrounding tissue injury. Despite a large number of randomized controlled trials comparing the two techniques for major peri-operative outcomes, clinical equipoise remains, with differences in practice largely due to cultural, institutional, and individual provider preferences. Identifying the superior technique has been an enduring research topic with major public health ramifications.
In this meta-analysis and trial sequential analysis published in the International Journal of Obstetric Anesthesia,[4] we found equivalence between methods for estimated blood loss and surgical duration and a statistically significant reduction in post-operative analgesic requirement and time to return of bowel function with intra-peritoneal repair. These findings contradict the longstanding belief that intra-peritoneal repair invites additional surgical risk previously found by randomized controlled trials.[5],[6],[7],[8]
As practicing anesthesiologists, we have all witnessed firsthand the profound impact that externalization of the uterus can have on the patient experience. As if on cue, women who were previously overwhelmed with joy at the birth of their child suddenly experience intense nausea, angina, and anxiety. We look over the drapes to see the uterus fully externalized and flipped onto the patient's belly. In no other procedure is an abdominal organ so intentionally and routinely extracted from the viscera in an awake patient. We again anticipate the same maternal discomfort once the uterus is re-internalized, and many of us reach for prophylactic anti-emetic or analgesic medication to mitigate the second wave of unpleasantness the mother will inevitably experience. We have seen maternal discomfort during externalization prevent proper skin-to-skin bonding of the mother and infant, frighten or even incapacitate the mother's support person, and disrupt the surgical field because of abdominal movement during retching. Often times, treatment of this perceived pain with additional local anesthetic through an in situ epidural catheter is ineffective and hypotension-inducing. We routinely administer intravenous opioids to treat the visceral pain of externalization, which inevitably results in maternal drowsiness. In rare circumstances, we must administer benzodiazepines to reduce maternal anxiety and in the process deny the mother clear re-collection of her birthing experience.
The influence of severe post-surgical pain on the development of chronic pain syndromes is well documented.[9],[10] Up to 11% of women develop chronic post-surgical pain after cesarean delivery 1 year later, with up to 10% of these patients experiencing severe pain.[11],[12],[13],[14],[15],[16] Given the anticipated increase in cesarean volume globally, the reduction of severe pain after cesarean represents an important public health objective. The development of chronic pain syndromes is especially relevant today as opioid use disorder in the United States has reached epidemic levels[17] with over 80% of women filling opioid prescriptions after cesarean delivery[18] and up to 1 in 300 women becoming dependent on opioids after cesarean delivery.[19] The downstream consequences of untreated post-cesarean pain include delayed functional recovery, un-anticipated re-admissions, reduced rates of breastfeeding, and the development of mental illness including post-partum depression.[20],[21],[22] We believe that the biologically plausible and statistically significant reduction in post-operative analgesic requirement associated with intra-peritoneal repair merits additional consideration in light of the high burden of opioid-related illness around the world.
Both post-operative analgesia requirement and return of bowel function are cornerstone to the concept of enhanced recovery after cesarean delivery (ERAC). ERAC constitutes an evidence-based and multi-disciplinary approach to standardize the peri-operative care of women undergoing cesarean delivery to expedite functional recovery, facilitate earlier maternal-infant bonding, and decrease post-surgical morbidity.[23] Functional recovery leads to a shortened length of stay, faster return to activities of daily living, and improved patient satisfaction. Where implemented, ERAC has resulted in lowered opioid usage without significant change in pain scores, complication rates, or re-admission, including 40% lower morphine equivalent usage within 24 hours of discharge.[24] Moreover, the influence of post-surgical opioid use on delayed return of the bowel function is well described.[25] Accordingly, it may be prudent to consider intra-peritoneal hysterotomy repair as part of a comprehensive ERAC strategy.
An interesting modifier of surgical outcome that is challenging to standardize and mitigate in randomized trials is the skill of the obstetrician performing the cesarean. For obvious reasons, a trainee with only three years of surgical experience is more likely to commit surgical errors than a surgeon with 20 years of experience. Trainees are sometimes included in research protocols; problematically, surgeons with less experience are more likely to introduce variations in their practice that might influence peri-operative outcomes. For example, incision length, retraction technique, visualization during surgical bleeding, and iatrogenic injury to adjacent pelvic structures are all highly influenced by surgical skill and are often difficult to control for despite their potential influence on major peri-operative outcomes. Future studies should restrict participation to small groups of highly experienced surgeons to better mitigate the influence of this confounder.
Randomized controlled trials are expensive, time-consuming, and laborious. In a global research environment that is over-saturated with research proposals and constrained by limited funding, it is essential that future studies comparing these two methods focus on peri-operative outcomes for which additional data are likely to influence practice changes. Study protocols will need to ensure strict management of environmental conditions and minimize deviations in surgical and anesthetic practice, including standardizing post-operative analgesic regimens. Consolidating the current body of evidence, we believe that intra-peritoneal hysterotomy repair, when performed by a surgeon comfortable in this technique, offers patient-centric benefits which may have important downstream consequences. In an era where ERAC protocols are becoming increasingly prevalent, the benefits of intra-peritoneal repair are especially noteworthy.
Conflict will always exist when it comes to deciding between methods – ardent supporters of either technique will invariably defend their practice and their institutional heritage.
Surgeons who routinely perform externalized repair should make a concerted effort to identify barriers to performing internalized repair, and if externalized repair is absolutely required, the surgical consent should include the risks that accompany this maneuver. Ultimately, obstetricians and anesthesiologists have a shared responsibility to minimize peri-operative complications, resource utilization, and patient dissatisfaction. Obstetric anesthesiologists, in particular, often deal with unpredictable circumstances, on labor and delivery wards. Dynamic changes in our clinical bandwidth are especially pronounced overnight, when many labor and delivery wards operate with reduced anesthesia staffing, often largely comprised of trainees. It is vitally important that we collaboratively address modifiable risks to patient morbidity, and working with our surgical colleagues to acknowledge hysterotomy repair as one such modifiable risk is an important step in the right direction. With time, we hope that a gradual shift toward first performing intra-peritoneal repair, with externalized repair performed only as a backup in extenuating circumstances, will become the status quo for hysterotomy repair during cesarean delivery.
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