The Impact of Uterine Incision Closure Techniques on Post‐cesarean Delivery Niche Formation and Size

Abstract

OBJECTIVE-To compare the prevalence and size of residual niche in the nongravid uterus following Cesarean delivery (CD) with different hysterotomy closure techniques (HCTs).METHODS-Saline infusion sonohysterogram (SIS) was performed in women after one prior CD, documenting the presence or absence of a postoperative niche and measuring its depth, width, length, and residual myometrial thickness. Women were grouped by HCT: Technique A (endometrium-free) and Technique B (routine nonendometrium-free). The primary outcome was the prevalence of a clinically significant niche, defined as a depth of >2 mm. HCT groups were compared using χ 2 , T-test (ANOVA), and analyzed using logistic regression and two-sided test (P < .05).RESULTS-Forty-five women had SIS performed, 25 and 20 via Technique A and B, respectively. Technique groups varied by average interval time from CD to SIS (13.6 versus 74.5 months, P = 0.006) but were otherwise similar. Twenty niches were diagnosed, 85% of which were clinically significant, including five following Technique A, nine following Technique B with double-layer closure, and three following Technique B with single-layer (P = .018). The average niche depth was 2.4 mm and 4.9 mm among the two-layer subgroups following Techniques A and B, respectively (P = .005). A clinically significant niche development was six times higher with Technique B when compared to Technique A (OR 6.0, 95% CI 1.6-22.6, P = .008); this significance persisted after controlling for SIS interval on multivariate analysis (OR 4.4, 95% CI 1.1-18.3, P = .04). The average niche depth was 5.7 AE 2.9 mm following Technique B with single-layer.CONCLUSION-Hysterotomy closure techniques determine the prevalence of post-Cesarean delivery niche formation and size. Exclusion of the endometrium at uterine closure reduces the development of significant scar defects.

Cesarean scar niche: An evolving concern in clinical practice

“…Furthermore, a recent retrospective cohort looked at the effect of “endometrium free” hysterotomy closure on the development of clinically significant scar niche 33 . Forty‐five nulliparous women undergoing their first cesarean section had either technique A (endometrium free) versus technique B (nonendometrium free) hysterotomy closure.…”

Uterine Scar Evaluation during the Postpartum: Pleading for Extradecidual Suturing during Cesarean Section

“…All rights reserved. defect (OR: 26.05 [2.36 to 287.61] 14 A recent study assessing niche by sonohysterography assumed that exclusion of the endometrium at uterine closure reduces the development of significant scar defects 15 .…”

FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery

“…• In one study, 25 patients at primary cesarean underwent endometrium-free closure and 20 underwent closure including endometrium. 62 All patients underwent saline infusion sonogram between 6 and 30 months postoperatively. The niche rate was 6-fold higher in those with closures including endometrium (OR 6.0; 95% CI, 1.6-22.6).…”

“…Observational data support excluding the endometrial layer: In one study, 25 patients at primary cesarean underwent endometrium‐free closure and 20 underwent closure including endometrium 62 . All patients underwent saline infusion sonogram between 6 and 30 months postoperatively.…”