Peritoneal closure and adhesions.

We have read the debate on peritoneal closure by Cheong et al. with interest (Cheong et al., 2001). The authors state that the long term benefits and hazards of non-closure of the peritoneum are unknown, and expect adhesion related problems. Among the various outcome measures concerning long-term morbidity, adhesion formation/reformation is probably one of the most important ones. The presence of adhesions during surgery may result in longer operating time and increased intra-operative complications, including damage to the bowel, bladder, ureters, and bleeding (Cheong et al., 2001). In 1997 and 1998 we changed the practice of peritoneal closure at Caesarean section. During this period closure and non-closure of the parietal peritoneum was performed. Out of all the women who had their first Caesarean section during those two years, we identified 61 women who had a repeat Caesarean at our institution until June 2000. A retrospective, non-randomized cohort study revealed that women without peritoneal closure at the first Caesarean delivery (n ϭ 30) had a shorter skin-incision–delivery interval (6.7 versus 9.1 min, P Ͻ 0.01) and a shorter total operating time (39 versus 44 min, P ϭ 0.05) at repeat Caesarean section, when compared 249 with traditional wound closure at the first operation (Nather et al., 2001). In each group, one patient with significant intra-abdominal adhesions was reported. No damage to bowels or bladder was observed at the second operation. There was no increased blood loss at the repeat operation, indicated by the difference in pre-and postoperative haemoglobin (Nather et al., 2001). Our data do not support the fears of Cheong et al. (2001) but rather support the findings of Tulandi et al. (1988). Due to a small sample size, this study (Tulandi et al., 1988) lacked the power to prove a benefit of peritoneal non-closure, but those data indicate that this practice is not detrimental for the operated women. Closure of laparotomy incisions with or without peritoneal suturing and second-look laparoscopy. Thank you for giving me the opportunity to express my view on this important subject. At repeat Caesarean, Joura et al. observed that the incision-delivery and operating times among women whose peritoneums were previously sutured were longer than in those whose peritoneums were not sutured. Although the reason for these differences was not stated, this could be due to adhesion-related difficulty in entering the abdominal cavity. Curiously, the correspondents found only one patient per group with 'significant' intra-abdominal adhesions. …