Cesarean section in morbidly obese women: Supra or subumbilical transverse incision?

Department of Gynecology and Obstetrics, University of Dijon School of Medicine, Bocage Teaching Hospital, 2 boulevard Marechalde Lattre de Tassigny, Dijon cedex, France.
Acta Obstetricia Et Gynecologica Scandinavica (Impact Factor: 2.43). 08/2009; 88(9):1049-52. DOI: 10.1080/00016340903128462
Source: PubMed
ABSTRACT
The obstetrician is more and more frequently faced with the decision to perform a cesarean section in obese women. We describe a technique of supra or subumbilical transverse cesarean section (depending on the height of the projection of the upper edge of the pubic symphysis) specifically designed for morbidly obese women with a voluminous panniculus. We evaluated feasibility and associated morbidity in a retrospective descriptive series of 18 patients operated between 2003 and 2008. We assessed the quality of access to the lower uterine segment and facility to extract the fetus. The mean body mass index was 47.7 kg/m(2) (range 40.1-60.8). The incision was subumbilical in 13 women (72.2%) and supraumbilical in 27.7%. With this technique, the exposition, the section of the lower uterine segment, and extraction of the baby are simple. It can be easily generalized and quickly learnt.

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SHORT REPORT
Cesarean section in morbidly obese women: supra or subumbilical
transverse incision?
HERVE
´
TIXIER
1
,SE
´
GOLE
`
NE THOUVENOT
1
, LAURE
`
NE COULANGE
1
,
CAROLINE PEYRONEL
1
, LAURENCE FILIPUZZI
1
,PAUL SAGOT
1,2
&
SERGE DOUVIER
1
1
Department of Gynecology and Obstetrics, University of Dijon School of Medicine, Bocage Teaching Hospital, 2 bd Mare
´
chal
de Lattre de Tassigny, BP 77908, 21079 Dijon cedex, France, and
2
INSERM EA 4184, Epide
´
miologie des Populations, IFR
Sante
´
-STIC, Faculty of Medicine, Dijon, France
Abstract
The obstetrician is more and more frequently faced with the decision to perform a cesarean section in obese women. We
describe a technique of supra or subumbilical transverse cesarean section (depending on the height of the projection of
the upper edge of the pubic symphysis) specifically designed for morbidly obese women with a voluminous panniculus. We
evaluated feasibility and associated morbidity in a retrospective descriptive series of 18 patients operated between 2003 and
2008. We assessed the quality of access to the lower uterine segment and facility to extract the fetus. The mean body mass
index was 47.7 kg/m
2
(range 40.160.8). The incision was subumbilical in 13 women (72.2%) and supraumbilical in 27.7%.
With this technique, the exposition, the section of the lower uterine segment, and extraction of the baby are simple. It can be
easily generalized and quickly learnt.
Key words: Obesity, cesarean, incision
Introduction
Despite progress in the management of the medical,
psychological, and surgical aspects of obesity, it is
a major public health problem. The World Health
Organization defines obesity as a body mass index
(BMI) ]30 kg/m
2
and morbid obesity by a BMI
]40 kg/m
2
. The incidence of obesity has continued
to grow in recent years whatever the age group.
Today, approximately 25% of American (1) and
13.1% of French people (2) are obese.
The incidence of pregnancy-related pathology is
higher in obese patients (3). Obstetricians are often
confronted with difficult decisions when such
patients are about to give birth. Indeed, in obese
patients, labor is induced twice as frequently and
vaginal delivery has to be interrupted more
frequently due to an abnormal fetal heart rate or
fetopelvic disproportion (4). There are thus 1.63
times more cesarean sections in obese women (58).
From a surgical point of view, obesity complicates
exposure, increases the duration of the operation,
blood loss, and the length of hospitalization (9).
We describe here an incision for cesarean section
that can be used in obese patients presenting with a
voluminous abdominal panniculus. We evaluated the
feasibility, the interest, and complications of this
type of incision.
Material and methods
This retrospective descriptive study concerns a series
of patients managed at the obstetrics department
at the Centre Hospitalier Universitaire in Dijon,
France, over a period of five years from May 2003 to
May 2008. All of the patients presenting with
morbid obesity (BMI]40) and a voluminous
Correspondence: Herve´ Tixier, Department of Gynecology and Obstetrics, University of Dijon School of Medicine, Bocage Teaching Hospital, 2 bd Marechal
de Lattre de Tassigny, BP 77908, 21079 Dijon cedex, France. E-mail: herve_tixier@yahoo.fr
Acta Obstetricia et Gynecologica. 2009; 88: 10491052
(Received 10 April 2009; accepted 11 May 2009)
ISSN 0001-6349 print/ISSN 1600-0412 online # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.1080/00016340903128462
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Page 1
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
recorded.
Operating technique
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
9-1,
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
2/0 (Braided
Lactomer
9-1, Tyco Healthcare, France) while the
aponeuroses were closed using two hemi-continuous
sutures with Polysorb
1 (Braided Lactomer
9-1,
Tyco Healthcare, France). The skin was closed with
staples.
Results
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
2
(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
context.
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.
Umbilicus
Panniculus
Projection of the
pubic
symphysis
Abdominal and low uterine
segment incisions
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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Discussion
Supraumbilical upper abdominal midline incision
for pelvic surgery in the morbidly obese patient has
been known since 1990 (10,11). In contrast to the
description of Houston et al. (12), we do not
consider that a high transverse incision is appro-
priate in patients who do not have an abdominal
panniculus. Moreover, the technique is quite differ-
ent. Houston et al. (12) used high transverse
incisions in all of the morbidly obese patients.
Thus, in patients without a panniculus, the uterus
was approached from the fundus. The hysterotomies
were corporeal, fundal, and vertical. The fragility of
this type of incision is well known and is thus
inappropriate when future pregnancies are possible
in such obese patients who already suffer from high
obstetrical morbidity. Moreover, parietal complica-
tions were identical to those found in low transverse
incisions, which is only to be expected since they are
made in the thickest part of the fatty tissue. We
reserve this technique for obese patients with a
voluminous panniculus. The interest in this specific
indication lies in the projection of the pubic sym-
physis being used as a landmark. There are two
advantages: it facilitates the approach to the lower
uterine segment and the extraction of the fetus, since
the subcutaneous tissue is cut where the fat layer is
the least thick, which reduces the risk of parietal
complications. We systematically determine the
extent of the abdominal panniculus and consider
the possible need for this intervention even when
vaginal delivery has been authorized. Patients are
examined in the standing position, then in dorsal
decubitus, without moving the panniculus, which is
left in the apron position so as to establish the site
of the incision depending on the projection of the
upper edge of the pubic symphysis.
In our series, the approach to the lower uterine
segment was straightforward for all of the patients
and allowed the baby to be extracted in good
condition. The intervention was carried out with
only one surgical assistant, which is rarely possible
with low incisions in such patients. The technique is
Figure 2. Operating technique for the cesarean section with a supraumbilical cutaneous incision. (A) Projection of the pubic bone which is
situated above the umbilicus when the panniculus is voluminous. (B) Cutaneous incision. (C) Transversal opening of the rectus sheath. (D)
Straightforward approach to the lower uterine segment.
High transverse cesarean sections 1051
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Page 3
quickly learnt and barely differs from the classical
suprapubic cesarean section. It can thus be general-
ized quite easily.
The post-operative period was particularly
straightforward: drains were unnecessary, and the
length of hospital stay was the same as that for
patients undergoing a standard section. The parietal
complications were minor and probably less serious
than those encountered in the usual technique.
These findings need to be evaluated in a prospective
study involving a larger number of patients.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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