Human Reproduction, Vol. 17, No. 1, 249-250,
January 2002
© 2002 European Society of Human Reproduction and Embryology
Letters to the Editor |
Peritoneal closure and adhesions
Department of Obstetrics and Gynecology, McGill University, 687 Pine Ave. West, Montreal, Quebec, Canada H3A 1A1
Correspondence: E-mail: togas.tulandi{at}muhc.mcgill.ca
Dear Sir,
Thank you for giving me the opportunity to express my view on this important subject. At repeat Caesarean, Joura et al. observed that the incision-delivery and operating times among women whose peritoneums were previously sutured were longer than in those whose peritoneums were not sutured. Although the reason for these differences was not stated, this could be due to adhesion-related difficulty in entering the abdominal cavity. Curiously, the correspondents found only one patient per group with `significant' intra-abdominal adhesions.
In their review, Cheong et al. suggest that besides shorter operating time, there is insufficient evidence of benefit to non-closure of the peritoneum (Cheong et al., 2001
). However, the authors did not encounter a negative effect of not closing the peritoneum. The best available data came from our previous non-randomized study (Tulandi et al., 1988). We found no difference in the complication rate, wound healing and the incidence of adhesions at a second-look laparoscopy among 163 women with peritoneal suturing and among 165 others with no peritoneal suturing.
Suturing the peritoneum appears to have a more anatomic result than leaving it to heal by secondary intention. However, the presence of ischaemic tissue by sutures causes a predisposition to adhesion formation (Buckman et al., 1976). In animal models (Ellis, 1962; Conolly and Stephens, 1968), laparotomy closure without peritoneal suturing healed with a lower incidence of adhesions to the wound compared with animals with peritoneal suturing. The most serious complication of intra-abdominal adhesion is bowel obstruction. Indeed, the most common cause of small-bowel obstruction is post-surgical adhesions and it is commonly found after an abdominal hysterectomy (Al-Took et al., 1999). In the study by Al-Took et al. adhesions involving the site of closure of the pelvic peritoneum were responsible for bowel obstruction in 85% of cases, with adhesions to the anterior abdominal wall occurring in another 15% (Al-Took et al., 1999).
Cheong et al. proposed prospective studies to verify if closure of the peritoneum is needed (Cheong et al., 2001). The difficulties in conducting such a study are the needs for randomization, second-look laparoscopy and long-term follow-up. In our bowel obstruction study, the median interval of surgery to small-bowel obstruction was 5.3 years. In any event, the evidence to date suggests that peritoneal suturing is not only unnecessary, but could also be associated with a greater risk of small-bowel obstruction.
References
Al-Took, S., Platt, R. and Tulandi, T. (1999) Adhesion-related small bowel obstruction after gynecologic operations. Am. J. Obstet. Gynecol., 180, 313–315.[Web of Science][Medline]
Buckman, R.F., Buckman, P.D., Hufnagel, H.V. and Gerwin, A.S. (1976) A physiologic basis for the adhesion-free healing of deperitonealized surfaces. J. Surg. Res., 21, 67–76.[Medline]
Cheong, Y.C., Bajekal, N. and Li, T.C. (2001) Peritoneal closure—to close or not to close. Hum. Reprod., 16, 1548–1552.
Conolly, W.B. and Stephens, F.O. (1968) Factors influencing the incidence of intraperitoneal adhesions: an experimental study. Surgery, 63, 976–979.[Medline]
Ellis, H. (1962) The etiology of postoperative abdominal adhesions. Br. J. Surg., 50, 10–16.[Web of Science][Medline]
Tulandi, T., Hum, H.S. and Gelfand, M.M. (1988) Closure of laparotomy incisions with or without peritoneal suturing and second look laparoscopy. Am. J. Obstet. Gynecol., 158, 536–537.[Web of Science][Medline]
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