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The fifteen minute cesarean delivery
Letters to the Editors
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The fifteen minute cesarean delivery TO THE EDITORS: Hofmeyr et al1 wrote a very interesting comparison of the various techniques for performing a cesarean delivery. However, I was struck by the operating times, which, with 1 exception,2 range from 27.5 to 56.5 minutes. The one exception (the Misgav Ladach technique) involves a good deal of finger dissection, which I find awkward, and only a single-layer uterine closure. It is possible to do a cesarean delivery in 15 minutes without rushing and to include a doublelayer uterine closure and a subcuticular skin closure. The biggest time saver is a 2-layer, 1-suture, 1-knot uterine closure. I tag the closure stitch and then sew away from myself with a locking first layer. Without cutting or tying the suture, I then bring it back with a parallel Lambert-type imbricating stitch, tying the suture to the previously tagged end. The procedure takes 2 minutes and provides a hemostatic closure with no raw edges to invite adhesions. The second biggest time saver is to avoid electrocautery until the very last. As a cutting tool, the scalpel is a much faster and less destructive way of getting to and partially through the fascia. Typically all those bleeders encountered on entry will have stopped by closure and cautery will not be needed at all. It is also faster and gentler on epithelial surfaces to use suction or saline rinse, rather than sponges to keep the field clean. Leaving the uterus in the abdomen and making the uterine incision above the bladder, instead of reflecting it, likewise saves time and trauma. A nice side effect of the aforementioned approach is that pelvic adhesions seem to be very rare, even on higher-order repeats. I have no formal study of the subject but have personally performed more than 4000 cesarean deliveries and nearly always find a completely clean pelvis on reentry. Robert D. Dyson, MD, PhD Gateway Women’s Clinic 177 NE 102nd Ave. Portland, OR 97220 [email protected]
REFERENCES 1. Hofmeyr J, Novikova N, Mathai M, Shah A. Techniques for cesarean section. Am J Obstet Gynecol 2009;201:431-44. 2. Darj E, Nordstrom M. The Misgav Ladach method for cesarean section compared to the Pfannenstiel method. Acta Obstet Gynecol Scand 1999;78:37-41. © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.02.020
REPLY Thank you for the comments on our systematic review of randomized trials of various methods of cesarean section.1 We agree that the operating times reported for the various methods studied in the randomized trials appear long, compared with our experience. What is of importance is the comparisons of the time taken for different methods under similar circumstances in randomized trials. The Misgav-Ladach method was significantly faster than other methods, using a single layer locking continuous suture similar to that described by the author for his first layer. There is observational study evidence that a second layer, as described by Gyamfi et al, may reduce the risk of scar dehiscence in subsequent pregnancies,2 although this has not been studied in randomized trials. Justus G. Hofmeyr, FCOG Natalia Novikova, PhD Women’s Health & Neonatology Royal Prince Alfred Hospital Camperdown 2050 NSW Australia [email protected] REFERENCES 1. Hofmeyr JG, Novikova N, Mathai M, Shah A. Techniques for cesarean section. Am J Obstet Gynecol 2009;201:431-44. 2. Gyamfi C, Juhasz G, Gyamfi P, Blumenfeld Y, Stone JL. Single- versus double-layer uterine incision closure and uterine rupture. J Matern Fetal Neonatal Med 2006;19:639-43. © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.02.021
Examining cancer therapy outcomes using observational data TO THE EDITORS: The recent article by Dr Bansal and colleagues1 addressed a major clinical concern. Using the Surveillance Epidemiology and End Results (SEER) Tumor Registry (1988-2005), survival was compared between women with stage IB-IIA cervical cancers treated with either primary radiotherapy or radical hysterectomy. Women treated with radical hysterectomy as compared to primary radiation had a 59% reduction in cancer-specific mortality rate (hazard ratio [HR], 0.41; 95% confidence interval [CI], 0.35– 0.50).1 Large databases like the SEER Tumor Registry and the Medicare database are widely available for population-based cancer outcome e18
American Journal of Obstetrics & Gynecology AUGUST 2010
studies. Advantages of these data include the excellent external validity and the facility to study populations that usually are not enrolled in clinical trials like minorities, the elderly, and individuals with coomorbidities.2 However, survival analysis among individuals treated with different cancer therapies using observational data may pose major biases. Selection bias are likely to distort the results and affect the validity of these studies.2 Control for confounding factors available in large databases may improve the validity, but unmeasured factors can persist.2 A recent study found that men with localized prostate cancer with active treatment (either radical prostatectomy or
www.AJOG.org
The fifteen minute cesarean delivery TO THE EDITORS: Hofmeyr et al1 wrote a very interesting comparison of the various techniques for performing a cesarean delivery. However, I was struck by the operating times, which, with 1 exception,2 range from 27.5 to 56.5 minutes. The one exception (the Misgav Ladach technique) involves a good deal of finger dissection, which I find awkward, and only a single-layer uterine closure. It is possible to do a cesarean delivery in 15 minutes without rushing and to include a doublelayer uterine closure and a subcuticular skin closure. The biggest time saver is a 2-layer, 1-suture, 1-knot uterine closure. I tag the closure stitch and then sew away from myself with a locking first layer. Without cutting or tying the suture, I then bring it back with a parallel Lambert-type imbricating stitch, tying the suture to the previously tagged end. The procedure takes 2 minutes and provides a hemostatic closure with no raw edges to invite adhesions. The second biggest time saver is to avoid electrocautery until the very last. As a cutting tool, the scalpel is a much faster and less destructive way of getting to and partially through the fascia. Typically all those bleeders encountered on entry will have stopped by closure and cautery will not be needed at all. It is also faster and gentler on epithelial surfaces to use suction or saline rinse, rather than sponges to keep the field clean. Leaving the uterus in the abdomen and making the uterine incision above the bladder, instead of reflecting it, likewise saves time and trauma. A nice side effect of the aforementioned approach is that pelvic adhesions seem to be very rare, even on higher-order repeats. I have no formal study of the subject but have personally performed more than 4000 cesarean deliveries and nearly always find a completely clean pelvis on reentry. Robert D. Dyson, MD, PhD Gateway Women’s Clinic 177 NE 102nd Ave. Portland, OR 97220 [email protected]
REFERENCES 1. Hofmeyr J, Novikova N, Mathai M, Shah A. Techniques for cesarean section. Am J Obstet Gynecol 2009;201:431-44. 2. Darj E, Nordstrom M. The Misgav Ladach method for cesarean section compared to the Pfannenstiel method. Acta Obstet Gynecol Scand 1999;78:37-41. © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.02.020
REPLY Thank you for the comments on our systematic review of randomized trials of various methods of cesarean section.1 We agree that the operating times reported for the various methods studied in the randomized trials appear long, compared with our experience. What is of importance is the comparisons of the time taken for different methods under similar circumstances in randomized trials. The Misgav-Ladach method was significantly faster than other methods, using a single layer locking continuous suture similar to that described by the author for his first layer. There is observational study evidence that a second layer, as described by Gyamfi et al, may reduce the risk of scar dehiscence in subsequent pregnancies,2 although this has not been studied in randomized trials. Justus G. Hofmeyr, FCOG Natalia Novikova, PhD Women’s Health & Neonatology Royal Prince Alfred Hospital Camperdown 2050 NSW Australia [email protected] REFERENCES 1. Hofmeyr JG, Novikova N, Mathai M, Shah A. Techniques for cesarean section. Am J Obstet Gynecol 2009;201:431-44. 2. Gyamfi C, Juhasz G, Gyamfi P, Blumenfeld Y, Stone JL. Single- versus double-layer uterine incision closure and uterine rupture. J Matern Fetal Neonatal Med 2006;19:639-43. © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.02.021
Examining cancer therapy outcomes using observational data TO THE EDITORS: The recent article by Dr Bansal and colleagues1 addressed a major clinical concern. Using the Surveillance Epidemiology and End Results (SEER) Tumor Registry (1988-2005), survival was compared between women with stage IB-IIA cervical cancers treated with either primary radiotherapy or radical hysterectomy. Women treated with radical hysterectomy as compared to primary radiation had a 59% reduction in cancer-specific mortality rate (hazard ratio [HR], 0.41; 95% confidence interval [CI], 0.35– 0.50).1 Large databases like the SEER Tumor Registry and the Medicare database are widely available for population-based cancer outcome e18
American Journal of Obstetrics & Gynecology AUGUST 2010
studies. Advantages of these data include the excellent external validity and the facility to study populations that usually are not enrolled in clinical trials like minorities, the elderly, and individuals with coomorbidities.2 However, survival analysis among individuals treated with different cancer therapies using observational data may pose major biases. Selection bias are likely to distort the results and affect the validity of these studies.2 Control for confounding factors available in large databases may improve the validity, but unmeasured factors can persist.2 A recent study found that men with localized prostate cancer with active treatment (either radical prostatectomy or