Joel-Cohen or Pfannenstiel incision at cesarean delivery: does it make a difference? Can Joel-Cohen incision and single layer reconstruction reduce cesarean section morbidity? Modified Joel-Cohen technique for caesarean delivery. Pfannenstiel versus Maylard incision for cesarean delivery: A randomized controlled trial. A randomized clinical trial of two surgical techniques for cesarean section. The Misgav Ladach method for cesarean section compared to the Pfannenstiel method. [Comparative study of Pfannenstiel's incision and transverse abdominal incision in gynecologic and obstetric surgery]. [In Process Citation] Closure of Pfannenstiel skin incisions. Staples vs. subcuticular suture.
To evaluate whether the technique to open the abdomen might influence the operative time and the maternal and neonatal outcome.
                All consecutive women who underwent a cesarean section at a gestational age greater than or equal to 32 weeks were randomly allocated to have either the Joel-Cohen or the Pfannenstiel incision. Exclusion criteria were two or more previous cesarean sections and previous longitudinal abdominal incision. During the study period 366 patients underwent a cesarean delivery. Of these patients, 56 did not meet the inclusion criteria. The remaining patients were allocated to the Joel-Cohen (n = 152) group and to the Pfannenstiel (n = 158) group. Extraction time was defined as the time interval from skin incision to the clamping of the umbilical cord.
                The total operative time was similar in both groups [Joel-Cohen 32 min (12-60) vs. Pfannenstiel 33 min (18-70)]. The extraction time was shorter in the Joel-Cohen group than in the Pfannenstiel group [190 s (60-600) vs. 240 s (50-600), p = 0.05]. This remained statistically significant after adjustment for confounding variables (Hazard = 1.26, p = 0.05). No difference was found between groups in terms of intraoperative and postoperative complications. No difference was found in the neonatal neurodevelopmental assessment at 6 months of age in relation to the abdominal incision performed.
                The Joel-Cohen method of opening the abdomen at cesarean delivery is faster then the Pfannenstiel technique at delivering the fetus. However, considering the absence of benefits to the mother and the fetus there is no clear indication for performing a Joel-Cohen incision. To compare an innovative cesarean section based on Joel-Cohen incision with the traditional Pfannenstiel technique in terms of operative data and post-operative recovery.
                Out of 158 randomized patients, 83 patients underwent the innovative cesarean section (Joel-Cohen incision, one-layer locked uterine suture, no peritoneization) and 75 the traditional operative approach (Pfannenstiel incision, double layer closure of the uterus, visceral and parietal peritoneization). Operative data and post-operative morbidity were compared; sample size was calculated to detect a 13% difference in the occurrence of post-operative fever with a statistical power of 80%.
                Post-operative fever was not different in the two groups. Total operating time was shorter with the innovative technique: 31.6 +/-1.38 min vs. 44.4+/-1.44 (P=0.0001) and fewer sutures were used: 3.6+/-0.13 vs. 6+/-0.13 (P=0.001). Patients operated by the new technique began moving sooner and intestinal function restarted earlier.
                The proposed technique made for shorter operating times and faster recovery but no decrease in puerperal morbidity. To investigate whether a series of changes in the current caesarean section operative routine, based on new knowledge, would be beneficial.
                A prospective controlled trial.
                Labour ward with approximately 3000 deliveries annually in a suburban area of Gothenburg, Sweden.
                Seventy-two pregnant women scheduled for delivery by caesarean section were randomised to either modified Joel-Cohen technique (n = 36) or Pfannenstiel technique (n = 36).
                Blood loss during surgery and operating time.
                The median estimated intra-operative blood loss was 250 mL in the modified Joel-Cohen group and 400 mL in the Pfannenstiel group (P = 0.026). The proportion of women with > or = 300 mL was 16/36 in the modified Joel-Cohen group vs 28/36 in the Pfannenstiel group (OR 0.229, 95% CI 0.082-0.637). Median operating time was 20 min in the modified Joel-Cohen group compared with 28 min in the Pfannenstiel group (P < 0.001). The proportion of women with > or = 25 min was 1/36 in the modified Joel-Cohen group vs 33/36 in the Pfannenstiel group (OR 0.003, 95% CI 0.000-0.026).
                We conclude that the modified Joel-Cohen technique of caesarean delivery reduced intraoperative blood loss and operating time compared with the Pfannenstiel technique. To compare the Pfannenstiel incision with transverse muscle-cutting Maylard incision in women who had cesarean delivery.
                Patients were assigned randomly to a Pfannenstiel or Maylard incision. Postoperative treatment was similar for each group. Surgical characteristics, complications, postoperative pain (visual analog scale, analgesic use), and related quality of life (1- and 3-month self-administered questionnaires) were analyzed. Abdominal wall muscle recovery was compared objectively by dynamometer.
                Fifty-four women had a Pfannenstiel incision and 43 had the Maylard incision. There were no differences in intraoperative characteristics, postoperative morbidity, or pain. Women's responses to the Nottingham Health Profile questionnaire at 1 and 3 months postoperatively and clinical and isokinetic testing for abdominal wall strength were similar between the two groups.
                Transecting the rectus muscle was no more deleterious than the Pfannenstiel incision. There was no difference in objectively measured abdominal wall strength. The Joel-Cohen incision followed by nonclosure of pelvic and parietal peritoneum has been advocated as an alternative method to the Pfannenstiel incision with peritonealization at cesarean section. A randomized trial was designed to compare intra- and postoperative morbidity between the two techniques. Women to undergo a cesarean section were randomly allocated to have either the Joel-Cohen incision with the parietal and pelvic peritoneum left open (group 1) or to have the Pfannenstiel incision with both peritoneal layers sutured (group 2). The myometrium was closed with 1-0 polyglactin 910 suture using a continuous single-layer nonlocking technique. Patients in group 2 had the peritoneum approximated with 2-0 polyglactin 910 suture. The fascia was sutured with continuous 1-0 polyglactin 910 suture in all cases. Opening time was defined as the interval from skin incision to the opening of the uterine cavity. Febrile morbidity was defined as a temperature > or =38 degrees C on two occasions 4 hours (hr) apart excluding the first postoperative day. Endometritis was defined as postpartum temperature > or =38 degrees C on two occasions 4 hr apart, with uterine tenderness and/or foul-smelling lochia. One hundred forty-nine and 150 patients were allocated to group 1 and to group 2, respectively. A shorter median (range) opening time [4 min (2-21) vs. 6 min (2-19), respectively, p < 0.01] and a shorter median (range) operative time [30 min (10-65) vs. 40 min (20-110), respectively, p < 0.01] were observed in group 1. No difference was found in terms of intraoperative complications, proportion of patients who required transfusion, endometritis, sepsis, febrile morbidity, and urinary tract infections. A higher rate of wound infections was found in group 2 than in group 1 [14 of 150 (9.3%) vs. 2 of 149 (1.3%), respectively, p < 0.01]. The Joel-Cohen incision without peritonealization resulted in a shorter opening and total operative time than the Pfannenstiel laparotomy with peritonealization. This was accomplished with a reduction of wound infections. The aim of the study was to evaluate the outcome of two different methods of cesarean section (CS).
                The study was designed as a prospective, randomized, controlled trial.
                All CS were performed at the University Hospital in Uppsala, Sweden.
                Fifty women admitted to hospital for a first elective CS were consecutively included in the study. They were randomly allocated to two groups.
                One group was operated on by the Misgav Ladach method for CS and the other group by the Pfannenstiel method. All operations were performed by the same surgeon.
                Duration of operation, amount of bleeding, analgesics required, scar appearance and length of hospitalization.
                Operating time was significantly different between the two methods, with an average of 12.5 minutes with the Misgav Ladach method and 26 minutes with the Pfannenstiel method (p<0.001). The amount of blood loss differed significantly, with 448 ml and 608 ml respectively (p=0.017). Significantly less analgesic injections and tablets (p=0.004) were needed after the Misgav Ladach method.
                The Misgav Ladach method of CS has advantages over the Pfannenstiel method by being significantly quicker to perform, with a reduced amount of bleeding and diminished postoperative pain. The women were satisfied with the appearance of their scars. In this study no negative effects of the new operation technique were discovered. The ease of execution and the post-operative quality of 2 types of incision commonly performed in pelvic surgery were compared in a prospective randomised study: Pfannenstiel's incision was used in 59 patients and Mouchel's low transverse abdominal incision (LTA) in 60 patients. Results were evaluated 8 days and 3 months after the operation. There was no difference in immediate post-operative results between these two groups of patients. At the 3 month examination, hypoaesthesia of the skin was less frequent in patients who had been operated upon through the LTA incision. The authors conclude that the transmuscular incision is innocuous. This paper was intended to settle the question whether the so-called gentle sectio caesarea with a high skin incision as described by Cohen in 1972 [2] could be applied in combination with a sectio on the level of the classic Pfannenstiel's incision which would be more satisfying cosmetically. Furthermore a comparison was to be drawn between the postoperative condition of those patients on whom this surgical method had been performed and the condition following a classic Pfannenstiel's incision. Between January 1997 and July 1997 we compared the classic method of Pfannenstiel's incision with the variant of Cohen's method as described above in a prospective randomised study. On applying this surgical technique, the abdomen was opened according to Cohen's method using a surgical knife but for the skin, and the tissue layers underneath were opened blunt with two fingers. Following the extraction of the child only three sutures were made: Uterus, fascia and skin. Redon drainages were not inserted. We were able to show that this method of applying mainly blunt "incision" to sectio caesarea the tissue is at least equal to the sharp opening of the abdominal cavity. In some respects, such as the early postoperative mobilisation, it is, in fact, superior, because the blunt opening causes less bleeding and the reduction to three sutures only, deliberately leaving the two peritoneal membranes open, as well as leaving away the redon drainages, considerably increases the patients' postoperative well-being. It is for these reasons that we call for this method to become part of the routine procedures in caesarean sectio. To compare skin closure with staples and subcuticular suture.
                Obstetric patients undergoing cesarean section with a Pfannenstiel incision were prospectively randomized to skin closure with staples or subcuticular suture. Pain and cosmesis were assessed postoperatively.
                Patients reported significantly less pain following subcuticular closure at both the time of discharge (P < or = .01) and the postoperative visit (P < or = .002). Incisions closed with subcuticular suture were found to be more cosmetically attractive by both patients (P = .04) and physicians (P = .01) at the postoperative visit.
                Pfannenstiel skin incisions closed with subcuticular closure following cesarean section result in less postoperative discomfort and are more cosmetically appealing at the six-week postoperative visit as compared to incisions closed with staples.
The Joel-Cohen incision has advantages compared with the Pfannenstiel incision. These are: less fever, pain and analgesic requirements; less blood loss; shorter duration of surgery and hospital stay. These advantages for the mother could be extrapolated to savings for the health system. However, these trials do not provide information on severe or long-term morbidity and mortality.