Abstract
Abstract
Introduction
Cases
Case 1
A 42-year-old woman was referred to the surgical casualty department with severe colicky abdominal pain, distension, and bilious vomiting. Two days previously, she had undergone a mini-laparotomy via a Pfannenstiel incision for a ruptured ectopic pregnancy. Closure of the incision had involved approximation of the rectus sheath, but without closure of the peritoneum or the rectus muscles.
On examination she was mildly dehydrated with a distended abdomen. There was mild tenderness just above the closed skin incision, which itself was intact, with no signs of infection. Bowel sounds were exaggerated. Plain radiographs of the abdomen demonstrated multiple fluid levels and dilated jejunal loops suggestive of small bowel obstruction.
Given the clinical picture, it was decided to re-explore the abdomen via the previous incision. The suture line holding together the divided anterior rectus sheath was found intact. When this was removed, a loop of small bowel was found herniating between the two recti muscles into a space above the right rectus muscle and underneath the anterior rectus sheath. The loop was reduced into the peritoneal cavity. The small bowel proximal to the loop was found to be distended and no other cause was found for the obstruction. The incision was closed with suturing of the peritoneum and approximation of the two rectus muscles in the midline with a few interrupted sutures. The patient recovered completely with no adverse effects.
Case 2
A 58-year-old woman was referred with worsening abdominal pain, distension, and bilious vomiting 7 days after undergoing abdominal hysterectomy for fibroids. The surgery had been performed through the Pfannenstiel approach with non-closure of the peritoneum. Abdominal radiographs and ultrasound scan suggested small bowel obstruction. Exploration was performed via the previous incision and analogous to the previous case, a loop of jejunum was found herniating between the two recti underneath the closed rectus sheath. Reduction of the loop resulted in complete resolution of symptoms.
Discussion
The Pfannenstiel incision involves dividing the anterior rectus sheath transversely, separating the sheath from the underlying rectus muscles, separation of the recti in the midline, and opening of the peritoneum. Closure of the incision involves suturing of the rectus sheath, whereas closure of the peritoneum is the subject of much controversy and is discussed subsequently. It is considered necessary to approximate the rectus muscles only in the event of significant separation. 1
The separation of the anterior rectus sheath from the underlying muscle creates a potential space, which is usually of no significance. However in the event of significant diastasis of the recti in the midline, it is possible for a loop of intestine to force its way in to the space underneath the sheath, giving rise to potential obstruction. Larkin et al. reported an instance of partial internal herniation following peritoneal non-closure, in a patient presenting with abdominal pain 1 year after cesarean delivery. 2 Laparoscopy had revealed a large peritoneal defect communicating with a cavity between the rectus muscle and the sheath. This finding was similar to that of these two cases, although the authors are unaware of any other instances in which the presentation was acute intestinal obstruction.
Such a complication is less likely in the event of closure of the parietal peritoneum or approximation of the rectus muscles in the midline.
Most trials analyzing this issue involve cesarean delivery: the most common indication for use of the Pfannenstiel incision. A Cochrane review in 2003 found no overall benefit in peritoneal closure and suggested that there was improved short-term postoperative outcome with non-closure of the peritoneum, as well as reduced duration of surgery. 3 The authors concluded that there was no justification for the closure of the peritoneum although they did acknowledge that long-term data were lacking. The current National Institute for Health and Clinical Excellence (NICE) guidelines for cesarean delivery do not recommend that the peritoneum be closed following surgery. 4
More recent reviews appear to be at variance with this view, however, with Cheong 5 and Shi 6 both suggesting that adhesion formation occurs less with peritoneal closure. There appear to be no trials examining the appropriateness of rectus muscle approximation alone.
Conclusions
Therefore, the issue of peritoneal closure in the Pfannenstiel incision appears unresolved, but it is important to highlight that non-closure may result in such uncommon, although potentially serious, complications. In the event that non-closure is contemplated, rectus muscle approximation should be considered, especially in instances of significant diastasis.
Footnotes
Disclosure Statement
No competing financial interests exist.