abdominal panniculus were included during the
study period. All of the pregnancies were singleton.
The women were included whatever the indication
for and timing of the cesarean (elective or emer-
gency, during or outside labor). After surgery, all of
the patients underwent a thorough examination
every day during the hospital stay including exam-
ination of the abdominal wall, the uterus, the lochia,
and temperature. All of the patients were seen six
weeks after the section during the post-delivery
consultation. Post-operative complications were
The principle was to improve the approach to the
lower uterine segment by making an incision two
finger-widths above the projection of the pubic
symphysis. In patients with a voluminous pannicu-
lus, this corresponded to a supra or subumbilical
incision (Figures 1 and 2A).
The patients were examined upon admission to
the labor room, and the site of the incision (supra or
subumbilical) was determined by the duty obstetri-
cian, without moving the panniculus, which re-
mained in the apron position. The site for the
incision was determined systematically, even when
vaginal delivery was authorized.
The high transverse incision (Figure 2B) facili-
tated access to the fascia of the rectus abdominalis.
Above the panniculus, the fatty tissues are not
particularly thick. A transverse opening of the
aponeurosis (Figure 2C) and of the parietal perito-
neum was done. Then the approach to the lower
uterine segment was easy. A Ricard retractor was put
in place (Figure 2D), and an aid placed between the
legs of the patient protected the bladder using a
suprapubic valve following separation of the bladder
from the uterus. A transverse segment hysterotomy
was performed except in cases of extremely prema-
ture births (vertical hysterotomy). The baby was
extracted. The placenta was delivered by hand and
the uterus checked manually for remnants. The
hysterotomy was closed with hemi-continuous
sutures with Polysorb
0 (Braided Lactomer
Tyco Healthcare, France). After verification of
hemostasis and the adnexae, the peritoneal cavity
was cleaned. The peritoneum was then closed using
a continuous suture with Polysorb
9-1, Tyco Healthcare, France) while the
aponeuroses were closed using two hemi-continuous
sutures with Polysorb
1 (Braided Lactomer
Tyco Healthcare, France). The skin was closed with
The mean age of the patients was 30 years and four
months (range 1941). Mean number of pregnancies
was 2.5 (range 17). Mean BMI was 47.7 kg/m
(range 40.160.8) and all of the patients presented a
voluminous panniculus. Seven patients (38.9%) had
already had a cesarean section with a classic Pfannen-
stiel incision. The mean duration of the pregnancy
was 37.2 weeks of amenorrhea (range 28.241.2).
Eight patients (44.4%) underwent elective section,
while 10 (55.5%) had emergency section half of
which (27.8% of total) were carried out before labor.
For 16 patients (88.9%) the hysterotomy was seg-
mentary and horizontal while for two (11.1%), it was
corporeal and vertical because of the prematurity.
Only one patient had general anesthesia because of
failure of spinal/epidural analgesia in an emergency
For 13 patients (72.2%) a subumbilical incision
was used while five (27.7%) had a supraumbilical
incision. Mean duration of the operation was 47
minutes (range 2060). The time to reach the lower
uterine segment was 8½ minutes (range 2189).
Extraction of the fetus was straightforward in all
cases. The operations were performed by experi-
enced surgeons and by trainee obstetricians. The
mean Apgar score at 5 minutes was 9.7 (range 710),
the mean arterial pH 7.28 (range 7.187.38), and
mean venous pH 7.29 (range 7.127.35).
Only one per-operative complication, postpartum
hemorrhage, occurred because of a uterine atony
and was easily stopped using medical management.
In the medium term there were only two minor
hematomas of the abdominal wall with spontaneous
resorption without suture failure or complications
due to local infection.
Projection of the
Abdominal and low uterine
Figure 1. Site of the supraumbilical transverse incision. Note that
because the panniculus is voluminous, anatomical landmarks are
modiﬁed. The projection of the lower uterine segment is thus
above the umbilicus.
1050 H. Tixier et al.
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