Caesarean rates keep rising, and the consequences show up years later as scar ectopic pregnancy, placenta praevia accreta, secondary subfertility, chronic pelvic pain and intermenstrual bleeding. This review examines whether where the hysterotomy is placed and how the uterus is closed can reduce the defect that underlies all of them.
The suggested direction is towards closure techniques that avoid compressing and devascularising tissue: unlocked rather than locked sutures, interrupted rather than continuous, purse-string, endometrium-free rather than endometrium-inclusive, and monofilament or barbed material. Hysterotomy placement in relation to myometrial thickness and uterine vascularity is presented as the other half of the problem. The authors are candid that study designs, outcome measures and follow-up intervals are so heterogeneous that no definitive recommendation follows.
Two cautions belong alongside this. Most of the literature defines the defect on imaging rather than by symptoms, so a technique that produces a better-looking niche has not been shown to produce a better outcome. And surgical repair of an established defect — which does help women with bleeding or subfertility — involves excising scar and reconstructing myometrium, which could theoretically raise the risk of rupture in a later pregnancy. The reasonable position is to pay attention to closure technique because it costs nothing, and to resist the claim that any particular one is proven.
- Place the hysterotomy with myometrial thickness in mind, not by habit
- Unlocked, interrupted and endometrium-free closure are plausible; none is proven to change outcomes
- Imaging-defined niche is not the same as symptoms — judge techniques by what women report
- Offer repair for bleeding or subfertility, and counsel about theoretical rupture risk in a later pregnancy
- Record the closure technique in the operation note; without that, none of this can ever be audited
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