Parietal Peritoneum Closure to Treat Bowel Evisceration Following Uneventful Cesarean Delivery

Abstract

Background: Bowel evisceration after cesarean delivery is a rare but serious complication needing repeat laparotomy. The current technique of nonclosure of the peritoneum might be a predisposing factor. In addition, importance should be given to suturing techniques and avoidance of excessive dissection of muscle from rectus fascia. Case: A multigravida female with a previous cesarean scar underwent repeat section at 38 weeks of gestation. She had no intraoperative or postoperative complaints. A few hours after stitch removal on the seventh postoperative day, the patient had a sense of “something giving way,” and presented to the emergency room with total small bowel prolapse arising out of the cesarean wound. Immediate bowel reduction was performed with the patient under general anesthesia, with closure of the parietal peritoneum and application of tension sutures. Results: Her stitches were removed on postoperative day 10, and she had complete healing of the wound. Conclusions: Although peritoneal closure is associated with less postoperative pain and fever, and decreased operative time, there are no statistically significant data on wound dehiscence, adhesion formation, or long-term effects on subsequent pregnancy. Closure of the parietal peritoneum is good surgical practice, and might prevent prolapse through a small gap in the rectus fascia in the event of raised intraabdominal pressure. During cesarean delivery, making a midline knot while simultaneously approximating the rectus fascia ensures that there will be better tissue-holding capacity and effective fascial healing. (J GYNECOL SURG 30:234)

Introduction

Bowel or omental evisceration caused by rectus fascial dehiscence is a rare but severe postoperative complication after cesarean delivery, and is an important reason for repeat laparotomy.¹ Omental evisceration has been reported since 1929, but total bowel evisceration has not been reported to date.^2,3 A case of bowel evisceration after cesarean delivery, with no intra/postoperative risk factors is presented, and possible causes, as well as preventive steps that can reduce this complication, are discussed in this article.

Case

A woman, gravida 4, para 1, abortus 2 with 1 living issue underwent repeat elective lower segment cesarean delivery in view of contracted pelvis at 38 weeks of gestation. She had had a previous cesarean delivery 5 years prior with same the indications and no postoperative complications. This was followed by two medical terminations of pregnancy, as the patient had conceived as a result of failed contraception. There were no postabortal complaints. She was free of any medical or surgical disease, and the current pregnancy was uneventful. She was scheduled for an elective cesarean delivery at 38 weeks of gestation. The skin was opened after revision of the scar by Joel-Cohen incision (straight transverse incision through the skin only, 3 cm below the level of the anterior superior iliac spines) at the previous scar site. The rectus sheath was incised and muscle separated via sharp dissection. There were mild adhesions between the uterus and abdominal wall, which were sharply dissected. There were no intraoperative complications. The uterus was closed in double layers by Polyglactin-910. The visceral and parietal peritoneum was not closed as per current practice. The rectus was closed by continuous polypropylene suture. The skin was closed with an interrupted silk No.1 suture. The patient received prophylactic antibiotics for 2 days. Postdelivery, there was no fever, cough, constipation, or any foci of infection. On day 7, stitch removal was performed with a healthy stitch line. Following stitch removal, the skin integrity was maintained, and the patient was asked to come for a follow-up appointment in the postnatal clinic. After 2 hours, she reported to the gynecology emergency department with complaints of a sensation of “something giving way,” and a mass protruding from the stitch line. Her vital signs were stable. On abdominal examination, small bowel evisceration was noted to be present (Fig. 1).

FIG. 1.

Small bowel evisceration after cesarean delivery.

Results

The patient was immediately taken to the operating room for reduction and repair under general anesthesia. Urgent hemoglobin was 11.6 gm/dL, and renal-function test results were normal. A wound swab for a bacterial culture was sent to the laboratory. Peripoperatively, the rectus fascia had “given way,” but the proline suture was intact with no break. The uterine closure had healed. The parietal peritoneum was closed, and tension sutures were applied. The wound swab culture produced sterile results. On day 10, the stitch was removed. Healing was complete. The patient was discharged after 24 hours of observation, and, on follow-up, she had no complaints of an incisional hernia.

Discussion

With advances in perioperative care, availability of broad-spectrum antibiotics, abdominal wound dehiscence after cesarean delivery has markedly decreased, but it still remains a problem causing significant morbidity. This is attributable to patient factors, technical factors, and the rise in number of cesarean deliveries performed. Patient factors include age, coexisting diseases (diabetes, anemia, hypoproteinemia, obesity, malnutrition, steroid administration, chronic pulmonary disease), emergency surgery, labor-related factors (chorioamnionitis, postpartum hemorrhage), postoperative coughing, and infection. The technical factors are type of incision, peritoneal closure, suture material, and surgical techniques.⁴ Joel-Cohen based methods include blunt separation of tissues along natural tissue planes with a minimum of sharp dissection and nonclosure of both layers of the peritoneum are used commonly worldwide. Advantages are reduced operative time, less postoperative pain and fever, and shorter hospital stay. Data regarding adhesion formation, wound dehiscence, and long-term effects on subsequent pregnancy are not adequately powered.^5,6 Nonclosure of the peritoneum may cause easy prolapse of the omentum through a gap in the repaired rectus sheath in the early postoperative period during bowel straining, which might prevent effective rectus fascia healing leading to bowel evisceration during increased intraabdominal pressure, as in standing and straining. Peritoneal closure restores the anatomy. Also, the peritoneal cavity is walled off from the abdominal wall, which reduces infection, wound dehiscence, and adhesions, and promotes effective healing. Smead-Jones closure (mass closure, i.e., the closure of all layers of the abdominal wall except the skin as one structure) to prevent a burst abdomen can be used.

The second important point is suturing of the rectus fascia. A break of the rectus sheath suture or improper suturing techniques result in weakened fascia, causing dehiscence. There are no well-randomized studies regarding continuous versus interrupted suturing, or the use of absorbable versus nonabsorbable sutures for rectus fascia in cesarean delivery, although there are reviews of skin and subcutaneous closure.⁷ The authors of this article used nonabsorbable polypropylene sutures for rectus fascia repair in cesarean delivery, because tying a knot in the middle of the fascia and continuing the same single suture in a continuous manner (done during repeat repair of abdominal wall) could provide better tissue-holding capacity, preventing evisceration.

Conclusions

This was an intriguing case, because except for the presence of a previous cesarean scar, the patient had no other risk factors for wound dehiscence. Closure of the parietal peritoneum and making a midline knot while approximating the rectus fascia are advocated in cesarean delivery to prevent bowel evisceration.

Footnotes

Disclosure Statement

No competing financial interests exist.

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