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Minimally invasive cesarean: Improving an innovative technique

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Short operative time, less surgical dissection, and reduced risk of infection are among the advantages of this newly updated procedure.



  • A simplified abdominal incision makes the traditional extensive dissection associated with the Pfannenstiel incision unnecessary.
  • A soft, self-retaining abdominal retractor offers increased exposure, atraumatic retraction, incision protection, and adjustable height while facilitating delivery of the fetal head by creating a rigid border around the abdominal incision.
  • Bladder-flap omission has been associated with reduced operative time and incision-delivery interval, decreased blood loss, and less need for postoperative analgesics.

Is the extensive dissection of the Pfannenstiel incision necessary in cesarean delivery? Is bladder dissection essential? Must the visceral and parietal peritoneum be closed?

The success of our minimally invasive cesarean technique suggests the answer is “no.”

The approach described here features a short operative time; minimal instrumentation; reduced surgical dissection; decreased postoperative pain; and reduced risk of blood loss, infection, and wound complications. It is easily learned and cost-effective, with a brief postoperative recovery period.

Among the updates made from the technique’s initial publication in the mid-1990s1,2:

  • addition of routine perioperative oxygen (80%), to reduce the risk of surgical wound infection (see “Perioperative considerations”)
  • regular use of forced warm air covers applied to the anterior skin surface, to help patients maintain normothermia
  • addition of a soft, self-retaining abdominal retractor—which creates an atraumatic circle of exposure up to a calculated 177 cm2 for a 15-cm incision (versus 113 cm2 calculated for traditional retraction)
  • vertical, rather than lateral, digital extension of the initial transverse uterine incision
  • identification of a subgroup in whom peritoneal closure is strongly recommended
  • new data on the procedure’s effectiveness.3

Perioperative considerations

Routinely use prophylactic antibiotics. Several recent studies have concluded that perioperative antibiotics reduce the incidence of endometritis and wound infection following elective and nonelective cesarean section.37 Administer ampicillin or a first-generation cephalosporin at umbilical cord clamping. For patients allergic to penicillin and cephalosporins, choose an alternative, such as clindamycin.

Give antacids 30 minutes before anesthesia (general or regional) to prevent pneumonitis from inhalation of gastric contents.

Clip pubic hair, rather than shave, to reduce the risk of wound infection.

Insert a Foley catheter, empty the bladder, and keep the catheter in place.

Position the patient in a 10°left lateral tilt, to avoid hypotension associated with aortocaval occlusion.

Routinely administer supplemental perioperative oxygen (80%), with either general or regional anesthesia; this activates alveolar immune defenses and halves the risk of surgical wound infections.

Neutrophil oxidative killing and phagocytosis—the most important defenses against surgical pathogens—depend on the partial pressure of oxygen in contaminated tissue. Giving supplemental oxygen during and for the first 2 hours after the procedure (by mask) is a practical, inexpensive way to reduce the incidence of surgical wound infection.38,39

Using 80% oxygen during and, for a short period, after surgery does not cause pulmonary toxicity such as atelectasis or impaired pulmonary function.40

Ensure normal body heat during and after cesarean to reduce the risk of postoperative surgical infection.40,41 Forced warm air covers applied to the anterior skin surface are the most effective way for warming surgical patients.9 IV fluid warming, though appropriate when large volumes are to be administered, is unnecessary for smaller operations.41

Modified abdominal incision reduces dissection

Make a straight low transverse incision with a scalpel, at a point approximately 3 to 4 cm above the symphysis pubis (FIGURE 1A).

The length of the incision is individualized (13 to 15 cm), though difficult fetal extraction is more likely if the abdominal incision is less than 15 cm.4,5

Divide the subcutaneous tissue transversely with an electrocautery knife. In a cutting and coagulation blend mode, the knife divides the fat while achieving hemostasis. To improve hemostasis, coagulate the blood vessels that cross the subcutaneous fat layer in a brushing manner before dividing them. To prevent unnecessary dead space, avoid filleting the fat and separating adherent subcutaneous fat from the anterior rectus fascia beyond what is needed to expose the fascia.

Open the fascia transversely with the electrocautery knife to the same length as the skin incision. Coagulate the blood vessels that cross the fascia before dividing them. Identify the median raphe by pulling up the superior edge of the abdominal incision.

Separate the rectus muscles in the midline by vertical blunt finger dissection (FIGURE 1B). If digital dissection is inefficient due to a dense, thick, or scarred median raphe, use an electrocautery knife, a scalpel, or scissors.

Open the peritoneum. This is facilitated by upward traction and elevation of the superior edge of the abdominal incision that lifts the peritoneum, allowing easy digital perforation using the index or middle finger (FIGURE 1C).

If this maneuver is not feasible, open the peritoneum in the traditional fashion.

Stretch the full thickness of the abdominal wall to full size of the skin incision, using 1 or 2 fingers of each hand (FIGURE 1D). Incorporate the skin, subcutaneous tissue, fascia layer, rectus muscles, and peritoneum. An assistant’s hands may be required. When needed, extend the peritoneal opening transversely on either side, to the midline and away from the bladder.


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