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ORIGINAL / RESEARCH
The Misgav Ladach Lower Segment Caesarean Section Experience at a Tertiary Hospital
Anita Shetty, Michelle Fonseca, Sanjay Rao, VR Badhwar
An ongoing open prospective study was carried out at LTMGH; Mumbai. The study was conducted over a time period of two years (2001-2002). The study compared the Misgav Ladach technique of Caesarean section with the conventional method of lower segment caesarean section. Results showed that the Misgav Ladach technique offers promising results provided the patients are well selected.
INTRODUCTION
Lower segment caesarean section is the most
frequently performed surgery by obstetricians
today. Since time immemorial right from the days of Julius Caesar there have been countless efforts to improve the technique. One such innovative breakthrough technique is the Misgav Ladach method of caesarean section.
Originally developed in the Misgav Ladach Hospital in Israel, the procedure which was devised by Dr. Michael Stark has a minimalist surgical approach. As opposed to the conventional method of caesarean section, after the skin incision is taken the abdominal wall layers are separated manually using the index and third fingers. The uterine incision is also stretched manually. The uterus is closed in a single layer and the abdomen is closed in two layers-skin and fascia. Various studies conducted across the globe have shown that the technique if properly used could change the way lower segment caesarean sections are being performed.
MATERIAL AND METHODS
*Registrar; **Associate Professor; ***Lecturer; ****Professor and Head of the Department;
LTMC and LTMG Hospital, Sion, Mumbai - 400 022.
In an ongoing open prospective study done over a span of two years (2001-2002) at Lokmanya Tilak Municipal Hospital, a tertiary referral centre at Mumbai, 198 women who underwent a primary Caesarean section were evaluated.
The patients were divided into two groups. The first group compared the study group. This category included the patients who had undergone the Misgav Ladach technique of Caesarean section with:
1. Joel Cohen’s incision - a straight transverse incision about 3 cms below a line joining the anterior superior iliac spines.
2. Minimal use of instruments - Using the index and third fingers, abdominal wall layers is stretched in a caudal cranial direction thereby enabling separation of layers. Parietal peritoneum is also opened in the same way transversely to avoid damage to the bladder.
3. Manual lateral stretching of the uterine incision with exteriorization of the uterus.
4. Single layer uterine closure.
5. Non-closure of the visceral and parietal peritoneal layers.
6. Closure of the abdomen in two layers - Skin and Fascia.
The control group included the patients who had undergone the conventional method of caesarean section with:
1. Pfannensteil incision.
2. Use of instruments/sharp dissection while opening the abdomen and extending the incision on lower uterine segment.
3. Double layer uterine closure.
4. Closure of the visceral and parietal peritoneal layers.
5. Abdominal wall closure in layers.
The two groups were comparable in terms of baseline variables of age, parity and risk factors. The type of anaesthesia used was decided by the anaesthetist irrespective of the group. In all 138 patients were given spinal anaesthesia, out of which 72% belonged to the study group. Sixty patients were given general anaesthesia out of which 27% belonged to the study group.
The operations were performed by registrars with a minimum of two years experience and trained in the Misgav Ladach technique of caesarean section.
In both the groups the skin incisions were sutured using delayed absorbable suture material. A wound check was done on the fifth postoperative day. Thereafter the wound was checked regularly till the day of suture removal. All the patients received the same combination of broad-spectrum antibiotics and non-steroidal anti inflammatory drugs for pain relief. These patients were then followed up at the postnatal out patient department.
During hospitalization the following parameters were carefully assessed:
1. Mean operating time (from incision to skin closure).
2. Postoperative pain (assessed subjectively on the basis of patient requirement of analgesics).
3. Febrile morbidity based on temperature charts.
4. Wound behaviour under which the following criteria were considered:
a. Induration
b. Wound approximation
c. Wound discharge
d. Keloid formation
5. Blood loss was assessed on the basis of pre and post-operative haemoglobin levels as estimated by Sahli’s method.
RESULTS
Table 1 shows the various indications for which LSCS was performed. The commonest indication for LSCS was foetal distress (73% in the study group and 60% in the control group). Other indications included Malpresentation, CPD, Nonprogress of labour etc.
The mean operating time and blood loss is shown in Table 2. The duration of surgery was reduced (11.92 minutes less in the study group). This led to a reduced duration of anaesthesia. Baby delivery was also found to be faster in the study group. This can prove to be invaluable in cases such as cord prolapse where time is of essence.
Indications Study Group
(n=99)Control Group
(n=99)Foetal distress 60% 60% CPD 8% 15% Malpresentation 5% 10% BOH — 4% APH 3% 1% Non progress of labour 5% 5% Failed induction 2% 2% Cord prolapse 2% — Heart disease 2% — Twins — 1% Immuno compromised — 1% Diabetes — 1% Group Study Group
(n=99)Control Group
(n=99)Mean operating time 45.09 mins 57 mins
Mean blood loss
a. Pre op Hb levels
9.2
9.5Study Group
(n=99)Control Group
(n=99)Induration 10% 15% Pain 35% 40% Febrile morbidity 7% 8% Non approximation 5% 5% Discharge/sepsis 5% 10% Keloid formation — 2%
Visceral injury:
a. Bowel
b. Bladder
—
—
1%
—There was no significant difference between the two groups in terms of mean blood loss as estimated by Hb levels pre and post LSCS.
Wound behaviour is presented in Table 3. Patients in the control group showed a slight increase in the incidence of pain. There was
also a higher percentage of wound discharge and wound induration. 2% of patients had keloid formation.
DISCUSSION
Peritoneum heals by formation of a new layer within 24 to 48 hours. Studies have revealed that reduced need for postoperative analgesia and a quicker return of bowel function when both visceral and perietal peritoneum was left open.1,2 Hence suturing of the visceral and perietal peritoneal layer seems to be an unnecessary step.
Postpartum involution of the uterus results in a loosening of the sutures. Therefore once haemostasis has been achieved, a double layer uterine closure does not have a significant advantage over a single layer uterine closure, Hauth and colleagues3 recommended a single layer closure over a double layer closure based on their trial.
However, the technique does not have its own limitations. To name a few, it is generally not recommended in obese patients, patients with previous scars on abdomen, who may require sharp dissection and patients with dense adhesions on the lower uterine segment.
In our study we found the Misgav Ladach technique to be advantageous in that the operating time is reduced. Consequently the duration of anaesthesia is also shortened. This can be invaluable in cases such as foetal distress and cord prolapse where time is of essence.
Patients showed a better wound healing and a lesser incidence of postoperative pain. This leads to a decrease in hospital stay.
Suture materials can also act as a nidus for infection and postoperative adhesion formation. In this procedure because of minimal tissue handling and decreased suture materials there can be lesser induration/adhesion formation.
CONCLUSION
Our study shows that the Misgav Ladach technique with its faster and minimalist approach offers promising results. The technique is easy to learn and perform. After careful selection of the patients, the Misgav Ladach technique of lower segment caesarean sections is a safe method in the practice of modern obstetrics.
ACKNOWLEDGEMENT
We thank the Dean Dr ME Yeolekar for permitting us to use hospital data for publication.
REFERENCES
1. Hull DB, Varma HW. Randomised study of closure of the peritoneum at Caesarean delivery. Obstet Gynecol 1991; 77 : 818-20.
2. Pietrantoni M, Parsons MT, O’Brien WF, Collins E, Knuppel RA, Spellacy WN. Peritoneal closure or non-closure at caesarean. Obstet and Gynaecol 1991; 77 : 293-6.
3. Houth JC, Owen I, Davis RO. Transcerse uterine incision closure: one versus two layers.
Am J Obstet Gynaecol 1992; 167 : 1108-11.
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