Appendix I: by Pan, Yaogui & Li Mingjie
Extraperitoneal cesarean section
Clinical Summary of 8 Cases
Introduction
The ultimate goal of ending a pregnancy is to deliver the fetus and its appendages, thereby restoring the pregnant woman to her original physiological state. When vaginal delivery is not possible due to birth canal obstruction, or if the fetus is in distress and natural delivery is not a viable option, alternative delivery methods must be considered.
Historical Background
Historical records indicate that as early as 500 years ago, there were classical cesarean sections known as "imperial incisions." In modern medicine, this has evolved into lower segment cesarean sections. Both of these surgical approaches are classified as intraperitoneal cesarean sections. These methods can lead to the contamination of the abdominal cavity with substances like amniotic fluid, meconium, and blood, resulting in symptoms such as enteroparalysis, abdominal distension, and abdominal pain. In severe cases, they may cause complications like intestinal adhesions and peritonitis, leading to poor prognoses. This is particularly concerning for individuals with intrauterine infections.
The Advent of Extraperitoneal Cesarean Section
In 1909, Latzk pioneered the extraperitoneal cesarean section. This technique began to be implemented gradually in China during the 1960s and has only recently started to gain widespread acceptance, along with improvements in the procedure. During the annual meeting of the Obstetrics and Gynecology Department of our province in October 1980, the provincial hospital reported a clinical summary of 30 cases performed since January of that year. Following the meeting, our institution started performing this surgical technique in November and has completed eight cases over the past two months. Herein, we report our preliminary findings and experiences.
Clinical Data
In 1980, our department performed a total of 45 cesarean sections (excluding minor surgeries). These consisted of 12 classical cesarean sections, 25 lower uterine segment cesarean sections, and 8 extraperitoneal cesarean sections. Since November, 8 out of 10 cesarean sections have been performed using the extraperitoneal method. All cases have fully recovered and were discharged from the hospital.
The clinical details of the 8 extraperitoneal cesarean sections were compared to the other surgical methods (averages were used for the comparison). It should be noted that this procedure was newly introduced in November, making a year-long comparison with other methods irrelevant.
Key Observations
The primary advantage of the extraperitoneal cesarean section is the significantly reduced time for intestinal gas evacuation—averaging just 14 minutes and 12 seconds. In contrast, the other two methods require two to three days, thus delaying food intake, increasing fluid requirements, and incurring additional costs.
Surgical Indications
The surgical indications for an extraperitoneal cesarean section are consistent with those for any cesarean section. However, the necessity for this method becomes more pressing in cases of intrauterine infection. In our study, the indications included:
- Three cases of birth canal obstruction (cephalopelvic disproportion)
- Four cases of intrauterine distress (premature rupture of membranes)
- One case of threatened uterine rupture due to cephalopelvic disproportion, resulting in a stillbirth
Anesthesia
All cases were performed under total epidural anesthesia. The resulting muscle relaxation facilitated blunt dissection, and patients remained calm during the procedure.
Surgical Techniques
We employed the Noton method in all cases. A 10-12 cm longitudinal incision was made in the midline between the navel and pubic area. The abdominal wall was dissected layer-by-layer, leaving the peritoneum intact. The uterus was exposed adequately before making the incision. The extraction of the fetus and its appendages, as well as uterine wall suturing, followed standard procedures used in lower segment cesarean sections.
Bladder and peritoneal folds naturally reverted to their original positions without the need for suturing. However, meticulous hemostasis and surgical field cleaning were carried out to minimize postoperative bleeding and heat absorption.
Complications
No cases of bladder injury were reported in the group. Mild hematuria was noted in two cases within 24 hours post-surgery but resolved spontaneously. In three cases, the peritoneum was accidentally torn and was sutured before uterine incision without prolonging the time for intestinal gas evacuation.
Discussion
The most salient advantage of extraperitoneal cesarean sections is that they avoid opening the abdominal cavity, reducing the risk of contamination and subsequent complications. Our data indicate that if the surgical procedure is executed meticulously—with proper dissection, thorough hemostasis, and diligent cleaning of the surgical field—the risk of infection is minimal. Average recovery time is notably short at 4.4 days, with no reported infections.
A significant challenge of the procedure lies in the delicate task of blunt dissection outside the peritoneum. Both the peritoneum and bladder wall are sensitive to injury, which has long discouraged the adoption of this method. However, recent evidence suggests that the procedure is not as daunting as once thought. Indeed, with adequate anatomical understanding and surgical skill, the procedure can be safely and efficiently executed. Even cases involving fetal distress or emergent conditions are not contraindications for skilled surgeons. In our study, except for one case resulting in a stillbirth, all other cases resulted in a safe outcome for both mother and child.
Naming the Procedure
Lastly, regarding the nomenclature for this surgical method, we align with the views of the Department of Obstetrics and Gynecology at Nanjing Workers' Hospital [2]. Given that the procedure involves dissecting the uterus without opening the abdominal cavity, a more accurate name might be "Extraperitoneal Uterine and Fetal Extraction" as opposed to the more ambiguous term "Extraperitoneal Cesarean Section."
Summary
This paper presents a review of eight cases of extraperitoneal cesarean sections conducted in our hospital since November 1980, comparing them with other surgical methods performed within the same timeframe. Our findings, corroborated by a comprehensive review of the literature and hands-on surgical experience, suggest that this method offers advantages in terms of faster postoperative recovery and easier mastery of the surgical technique. With enough skill, this approach could essentially serve as a viable alternative to more traditional methods.
It's important to note that we are in the preliminary stages of employing this surgical technique. Our insights are admittedly limited, and we recognize the need for further data accumulation and refinements in our approach.
References
- Clinical application of extraperitoneal cesarean section. Chinese Journal of Obstetrics and Gynecology, November 1965 (4) P315
- Nanjing Workers' Hospital: Clinical application value of extraperitoneal cesarean section. Chinese Journal of Obstetrics and Gynecology, November 1965 (4) P29
- Anhui Provincial Hospital: Clinical summary of extraperitoneal cesarean section. Provincial Annual Meeting of Gynaecology and Obstetrics in 1980 (Internal Data)
- Su Yingkuan et al. Gynaecology and Obstetrics Surgery (P440). People's Health Publishing House, 1973
This paper was originally published in Proceedings of Provincial Society of Obstetrics and Gynecology Seminar,1981/01/05； Changhang Hospital, Pan Yaogui & Li Mingjie
from 潘耀桂、李名杰：腹膜外剖腹产术
