IMPACT OF DOUBLE LAYER UNLOCKED SUTURE VS SINGLE LAYER LOCKED SUTURE IN PREVENTION OF CAESAREAN SCAR ISTHMOCELE – RANDOMISED CONTROLLED TRIAL AT A TERTIARY CARE CENTRE IN MAHARASHTRA.
Main Article Content
Keywords
Cesarean delivery, Uterine scar, Niche development, Single layer, Double layer, Suturing technique
Abstract
ABSTRACT
Background: The increasing rates of cesarean sections (CS) have led to a rise in complications such as cesarean scar defects, which can manifest as niches or thinning of the residual myometrium, potentially resulting in postmenstrual spotting, chronic pelvic pain, and other serious conditions. Optimal uterine closure techniques are critical for preventing these defects, but evidence comparing single-layer locked versus double-layer unlocked sutures is limited. Thus, the current study was conducted to assess compare the impact of single layer locked versus double layer unlocked suture.
Methodology: This randomized controlled trial was conducted at a tertiary care center over 18 months, enrolling 300 women undergoing their first cesarean section. Participants were randomly assigned to either single-layer locked sutures (Group A) or double-layer unlocked sutures (Group B). Follow-up was performed at six months using transvaginal sonography to assess the presence of cesarean scar defects and residual myometrial thickness.
Results: Group A demonstrated a higher need for additional sutures, increased bleeding rates, and a greater need for blood transfusions compared to Group B. At the six-month follow-up, Group A had a higher incidence of niches, significantly lower residual myometrial thickness, and narrower adjacent myometrial thickness compared to Group B. These findings align with other studies suggesting that double-layer unlocked sutures may provide better outcomes.
Conclusion: The double-layer unlocked suture technique is more effective than the single-layer locked technique in preventing cesarean scar isthmocele and promoting better uterine scar healing. It resulted in lower prevalence and narrower width of niches, better preservation of residual myometrial thickness, and greater adjacent myometrial thickness, making it a preferable choice for cesarean deliveries.
References
2. Nezhat C, Zaghi B, Baek K, Nezhat A, Nezhat F, Lindheim S, Nezhat C. Outcomes of laparoscopic cesarean scar defect repair: retrospective and observational study. Journal of Clinical Medicine. 2023 May 28;12(11):3720.
3. Wang J, Pang Q, Wei W, Cheng L, Huang F, Cao Y, et al. Definition of large niche after Cesarean section based on prediction of postmenstrual spotting:Chinese cohort study in non-pregnant women. Ultrasound Obstet Gynecol. 2022;59:450–6.
4. Kremer TG, Ghiorzi IB, Dibi RP. Isthmocele: an overview of diagnosis and treatment. Revista Da Associacao Medica Brasileira. 2019; 65: 714–721.
5. Vachon-Marceau, C., Demers, S., Bujold, E., Roberge, S., Gauthier, R.J., Pasquier, J.C., Girard, M., Chaillet, N., Boulvain, M. and Jastrow, N. (2017) Single versus Double-Layer Uterine Closure at Cesarean: Impact on Lower Uterine Segment Thickness at Next Pregnancy. American Journal of Obstetrics and Gynecology, 217,65-e1. https://doi.org/10.1016/j.ajog.2017.02.042.
6. Yılmaz Baran Ş, Kalaycı H, Doğan Durdağ G, et al. Single- or double-layer uterine closure techniques following cesarean: A randomized trial. Acta Obstet Gynecol Scand. 2021;100:531–537. https://doi.org/10.1111/aogs.14018
7. van der Voet LF, Bij de Vaate AM, Veersema S, Brolmann HA, Huirne JA. Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 2014;121(2):236–44.
8. Stegwee SI, Jordans IP, Van Der Voet LF, Bongers MY, De Groot CJ, Lambalk CB, De Leeuw RA, Hehenkamp WJ, Van De Ven PM, Bosmans JE, Pajkrt E. Single-versus double-layer closure of the caesarean (uterine) scar in the prevention of gynaecological symptoms in relation to niche development–the 2Close study: a multicentre randomised controlled trial. BMC pregnancy and childbirth. 2019 Dec;19:1-1.
9. Yıldız E, Timur B. Comparison of classic single-layer uterin suture and double-layer purse-string suture techniques for uterus closure in terms of postoperative short-term uterine isthmocele: A prospective randomized controlled trial. Turkish Journal of Obstetrics and Gynecology. 2023 Sep;20(3):206.
10. Sumigama S, Sugiyama C, Kotani T, Hayakawa H, Inoue A, Mano Y, Tsuda H, Furuhashi M, Yamamuro O, Kinoshita Y, Okamoto T, Nakamura H, Matsusawa K, Sakakibara K, Oguchi H, Kawai M, Shimoyama Y, Tamakoshi K, Kikkawa F. Uterine sutures at prior caesarean section and placenta accreta in subsequent pregnancy: a case-control study. BJOG. 2014 Jun;121(7):866-74; discussion 875. doi: 10.1111/1471-0528.12717. Epub 2014 Mar 26. PMID: 24666658.
11. Alper E, Aksakal E, Usta I, Urman B. The Novel Parallel Closure Technique Compared to Single-Layer Closure of the Uterus After Primary Cesarean Section Decreases the Incidence of Isthmocele Formation and Increases Residual Myometrial Thickness. Cureus. 2024 May 23;16(5):e60932. doi: 10.7759/cureus.60932. PMID: 38910631; PMCID: PMC11193476.
12. Hosseini R, Mansoorli S, Pirjani R, Eslamian L, Rabiee M. A comparison of the effects of Two suture materials on isthmocele formation: A cohort study. Journal of gynecology obstetrics and human reproduction. 2021 Apr 1;50(4):101933.
13. E Khamees R, H Khedr A, Shaaban M, Bahi-Eldin M. Effect of single versus double layer suturing on healing of uterine scar after cesarean delivery. Suez Canal University Medical Journal. 2018 Oct 1;21(2):140-5.
14. Turan GA, Gur EB, Tatar S, Gokduman A, Guclu S. Uterine closure with unlocked suture in cesarean section: Safety and Quality. Pakistan journal of medical sciences. 2014 May;30(3):530.
15. Yılmaz Baran Ş, Kalaycı H, Doğan Durdağ G, Yetkinel S, Alemdaroğlu S, Çok T, Bulgan Kılıçdağ E. Single‐or double‐layer uterine closure techniques following cesarean: A randomized trial. Acta obstetricia et gynecologica Scandinavica. 2021 Mar;100(3):531-7.
16. Incedere A, Kandemir S, Dogan OE. Comparison of different uterine incision closure methods used in cesarean section in terms of postoperative cesarean incision scar thickness and isthmocele formation: a prospective, randomized study. Clinical and Experimental Obstetrics & Gynecology. 2021 Dec 15;48(6):1448-53.
17. Bujold E, Goyet M, Marcoux S, Brassard N, Cormier B, Hamilton E, et al. The role of uterine closure in the risk of uterine rupture. Obstet Gynecol 2010 Jul;116:43–50.
18. Tekiner NB, Çetin BA, Türkgeldi LS, Yılmaz G, Polat İ, Gedikbaşı A. Evaluation of cesarean scar after single- and double-layer hysterotomy closure: a prospective cross-sectional study. Arch Gynecol Obstet. 2018;297:1137-1143.
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Dr. Neethika Raghuwanshi
Associate Professor at Department of Obstetrics and gynaecology, Government medical college, Akola
Dr. Guramrit Kaur
Junior resident – 3 at Department of Obstetrics and gynaecology, Government medical college, Akola