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Introduction: The uterine caesarean scar defect, also known as uterine niche or isthmocele, is an irregularity in the anterior uterine wall at the site of a previous cesarean section scar. It is associated with obstetrical complications such as caesarean scar ectopic pregnancy, uterine rupture and, the placental accreta spectrum. Women with cesarean scar defects are frequently asymptomatic, but they may also experience abnormal vaginal bleeding, chronic pelvic pain, and infertility. Methods: This systematic review aims to determine the best hysterotomy closure technique to prevent subsequent development of uterine scar defects. An electronic search in Medline, Embase, Cochrane Database of Systematic Reviews, ClinicalTrials.gov was performed from January 2001 until December 2020 for studies evaluating hysterotomy closure techniques. Results: Our systematic search strategy identified 1781 titles. Six studies fulfilled inclusion criteria and were included in the final analysis. The results supported the superiority of the double-layer closure over the single-layer. Conclusions: Hysterotomy closure with continuous running suture in two layers represents a suitable option to prevent cesarean scar defect formation. Particularly, the first layer should include the decidua, and the second layer should overlap the first.

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