Extraperitoneal Cesarean Section: Operative Technique

~approach to the extraperitoneal lower uterine segment~

Hedric B. Hanson M.D.

Anchorage, Alaska

Disclosures: None

Hedric B. Hanson MDAnchorage, Alaska

PresentedMaricopa Medical Center

February 1, 2013

Mortality

Brief CD History

1800-1900

1900-2000 2000

IPCS+AntibioticEPCS

EBM

44Berghella V. Et al. Evidence-based surgery for Cesarean Delivery, Am J Obstet Gynec (2005); 193: 1610

MOST surgical decisions

during CD

LACK evidence-based guidance

5

The Joel-Cohen incision appears to have advantages compared with the Pfannensteil incision.1

Blunt uterine incision expansion2

Prophylactic antibiotics

Spontaneous placental removal

Non-closure of both parietal and visceral peritoneum

Subcutaneous closure or drainage if > 2 cm thickness

SOME surgical decisions during CD have evidence-based guidance

Berghella V. Et al. Evidence-based surgery for Cesarean Delivery, Am J Obstet Gynec (2005); 193: 1610

66

...lacks rigorous critical analysis!

USPSTF Recommendation: I Quality: Poor

Opening Peritoneum

Berghella V. Et al. Evidence-based surgery for Cesarean Delivery, Am J Obstet Gynec (2005); 193: 1610

The Critical Question in CD

77

.IS NOT MENTIONED!

THE EXTRAPERITONEAL SPACE

The ANOTHER Step in CD

Focus

• Anatomy

• Review World Resources 1940-2012

• Operative Technique~ Dr. Fauck’s Video

• Implications~

Anatomy

The Abdominal Wall

• Dissection of layers-blunt vs sharp

11

11

EPS

12

12

The Extraperitoneal Space

1313

1414

The Blanket The Blanket Method: a Novel Method of Teaching

Peritoneal Relations of Female Reproductive Organs

1515

The Blanket-size of uterus changes relationships-

1616

UB

Gravid Uterus

R

The Blanket~CHANGES WITH GRAVID UTERUS

17

17

Anatomical RelationshipsChanges in the Lower Uterine Segment

Growth of the Gravid Uterus

18

18

19

19

Level of Cervix in Non-pregnant Female

20

20

Level of Lower Uterine Segment @ Term

21

21

Paravesical SpaceVesicle-uterine Space

22

22

EPS

EXIT

REMAIN

★ Bladder is the problem blocking access!

★ Bladder displacement:

• Supravesical approach

• Paravesical approach

Bladder

25

This is the problem…….

26

Supravesical Approach

Peritoneum

Bladder

BladderLower Uterine Segment

27

Paravesical Approach

Peritoneum

Lower Uterine Segment

28

Displacement of Bladder

Lower Uterine Segment

Medial Umbilical Ligament

Peritoneal Reflection

29

29

The Retrospective Review World Resources

1940 to 2012

hyperlink

3030

Study Design:

Sources Pub Med China National Infrastructure Database

Selection Criteria: Operative Expertise

Volume Incision-to-Delivery (IDT) Operative Time (OT)

>15 cases <10 minutes <45 minutes

Selection Criteria: Operative Description

Approach Dissection Ligaments Fascia Bladder Drains

31

Articles Identified Database SearchPub Med (n=117)

Additional articles identified from other sources (n=6)

Articles Screened(n=216)

Articles Excluded (n=83)

Articles Assessed for Eligibility(N=133)

Articles Excluded (Criteria of Review)(n=79)

Full-Text Articles Fully Eligibility(N=40)

Studies included but missing data criteria:(N=14)

Studies Included in Review

(N=54)

Articles Identified Database SearchChinese National Knowledge Infrastructure Database (n=93)

Figure 1. Flow Diagram of Selection Process

Papers from 1988-2012

Country Articles(Number)

Extraperitoneal CD

China 28 8,884

India 2 5,328

Bulbaria 1 151

US 0 0

54 Papers reviewed

3333

Summary of Results

Sources 54 Articles

Operative Expertise

Volume IDT OT Bladder Injury

Operative Description Descriptive Narrative Found

CD Approach Dissection Ligaments Peri-Uterine Fascia Bladder Drainage

9

Results

Sources 54 Articles (>18,000 cases)

Operative Expertise

Volume

15-3658IDT (min)

2-13OT (min)

12-45 Bladder Injury

0-12.5%

Author Date Language

## CDa Approachb OTc IDd Bladder Injury %

Pf JC Para Supra

8

Table 1. Operative Data

Author Date Language

## CDa Approachb OTc IDd Bladder Injury %

Pf JC Para SupraIrwin7 1940 English 32 PF PV 45 12.5Stearns8 1943 English 16 SV 18.7Waters9 1944 English 250 PF/V SV 36 1.6

English 180 PF/V PVNorton10 1946 English 160 PF/V SV 5.6Ricci11 1946 English 175 V PV 45 3.4Caccierelli12 1948 English 100 PF SV 30 0Anz,Ward13 1950 English 32 PF PV 3.3Bourgeois14 1950 English 41 V SV 4.2Gilbert15 1953 English 57 PV SV 0Paternite16 1954 English 91 V PV 35 10 2Marr JP17 1958 English 125 V PV 45 5.7Durfee R18 1960 English 100 PF SV 40 11 0Wu C19 1972 English 170 PF PV 35 10 1Joschko20 1974 English 254 PF PV 36.2 7.2 3.5Hanson21 1978 English 45 PF PV 29 6.9 2Perkins22 1978 English 50 PF PV 35 10 0Morozov23 1981 Czech 560 PF PV 47 6.6 0Chemukha24 1982 Russian 300 PF PV 40 7.8 0.6Wallace25 1983 English 91 PF PV 38 9 2Hanson26 1983 English 345 PF PV 21 6.5 0.3

English 16 PF PV 20 3.5 0English 31 PF PV 22 6 0English 61 PF PV 24 5 0

Liu Z27 1988 Chinese1342 PF PV 34 16 0Duvenaishki281991 Bulgaria

n151 PF PV 40 4 0

Li Yalin29 1996 Chinese 578 PF PV 40 2Qiu X30 1997 Chinese 800 PF PV 29 2.2 0

Chinese 80 PF SV 40 2 7.5Wang M31 1998 Chinese 249 PF PV 33 7 0Rao R32 1999 English 3628 PF PV 30 10 0.1Kang R33 2000 Chinese 100 PF SV 28 4 0Yang X34 2000 Chinese 150 PF PV 38 12.5 0Liu H35 2000 Chinese 237 PF PV 46 9 0Li X36 2000 Chinese 364 PF PV 29 11 0Lu Y37 2000 Chinese 165 PF PV 30 5 0Li D38 2001 Chinese 200 PF PV 40 13 0Meng J39 2002 Chinese 380 JCPV 24 7 0

Chinese 151 PF SV 40 15 0Liang H40 2002 Chinese 126 PF SV 36 16 0Zeng Y41 2002 Chinese 105 PF PV 38 10Yin G42 2002 Chinese2436 PF PV 33 0Wei Y43 2002 Chinese 155 PF PV 55 13.6 0

2002 Chinese 181 Vert PV 44 8 0Hzu Y44 2004 Chinese 398 PF PV 35 0Yang W45 2004 Chinese 130 PF PV 30 5 0

Chinese 110 JCPV 41 9.7 0Ruan Y46 2004 Chinese 464 PF PV 23 5.9 0Xie R47 2005 Chinese 140 PF PV 35 6 0Li Y48 2006 Chinese 206 PF PV 44 13.5 0Li M49 2008 Chinese 140 JCPV 23 4 0Fan Y50 2008 Chinese 198 PF PV 35 5.9 0Desari D51 2009 English 1000 PF PV 12 2 0Zhao R52 2010 Chinese 148 PF PV 51 5 0Zhang X53 2010 Chinese 225 PF PV 38.6 4 0Li Y54 2011 Chinese 234 PF PV 23 7.1 0Zhang H55 2010 Chinese 178 PF PV 40 9 0Li R56 2010 Chinese 120 JCPV 28 9.2 0

Chinese 100 PF PV 42 16 0Yang H57 2011 Chinese 151 PF PV 14.2 0

Author Date Language

## CDa Approachb OTc IDd Bladder Injury %

Pf JC Para Supra

8

Table 1. Operative Data

Author Date Language

## CDa Approachb OTc IDd Bladder Injury %

Pf JC Para SupraIrwin7 1940 English 32 PF PV 45 12.5Stearns8 1943 English 16 SV 18.7Waters9 1944 English 250 PF/V SV 36 1.6

English 180 PF/V PVNorton10 1946 English 160 PF/V SV 5.6Ricci11 1946 English 175 V PV 45 3.4Caccierelli12 1948 English 100 PF SV 30 0Anz,Ward13 1950 English 32 PF PV 3.3Bourgeois14 1950 English 41 V SV 4.2Gilbert15 1953 English 57 PV SV 0Paternite16 1954 English 91 V PV 35 10 2Marr JP17 1958 English 125 V PV 45 5.7Durfee R18 1960 English 100 PF SV 40 11 0Wu C19 1972 English 170 PF PV 35 10 1Joschko20 1974 English 254 PF PV 36.2 7.2 3.5Hanson21 1978 English 45 PF PV 29 6.9 2Perkins22 1978 English 50 PF PV 35 10 0Morozov23 1981 Czech 560 PF PV 47 6.6 0Chemukha24 1982 Russian 300 PF PV 40 7.8 0.6Wallace25 1983 English 91 PF PV 38 9 2Hanson26 1983 English 345 PF PV 21 6.5 0.3

English 16 PF PV 20 3.5 0English 31 PF PV 22 6 0English 61 PF PV 24 5 0

Liu Z27 1988 Chinese1342 PF PV 34 16 0Duvenaishki281991 Bulgaria

n151 PF PV 40 4 0

Li Yalin29 1996 Chinese 578 PF PV 40 2Qiu X30 1997 Chinese 800 PF PV 29 2.2 0

Chinese 80 PF SV 40 2 7.5Wang M31 1998 Chinese 249 PF PV 33 7 0Rao R32 1999 English 3628 PF PV 30 10 0.1Kang R33 2000 Chinese 100 PF SV 28 4 0Yang X34 2000 Chinese 150 PF PV 38 12.5 0Liu H35 2000 Chinese 237 PF PV 46 9 0Li X36 2000 Chinese 364 PF PV 29 11 0Lu Y37 2000 Chinese 165 PF PV 30 5 0Li D38 2001 Chinese 200 PF PV 40 13 0Meng J39 2002 Chinese 380 JCPV 24 7 0

Chinese 151 PF SV 40 15 0Liang H40 2002 Chinese 126 PF SV 36 16 0Zeng Y41 2002 Chinese 105 PF PV 38 10Yin G42 2002 Chinese2436 PF PV 33 0Wei Y43 2002 Chinese 155 PF PV 55 13.6 0

2002 Chinese 181 Vert PV 44 8 0Hzu Y44 2004 Chinese 398 PF PV 35 0Yang W45 2004 Chinese 130 PF PV 30 5 0

Chinese 110 JCPV 41 9.7 0Ruan Y46 2004 Chinese 464 PF PV 23 5.9 0Xie R47 2005 Chinese 140 PF PV 35 6 0Li Y48 2006 Chinese 206 PF PV 44 13.5 0Li M49 2008 Chinese 140 JCPV 23 4 0Fan Y50 2008 Chinese 198 PF PV 35 5.9 0Desari D51 2009 English 1000 PF PV 12 2 0Zhao R52 2010 Chinese 148 PF PV 51 5 0Zhang X53 2010 Chinese 225 PF PV 38.6 4 0Li Y54 2011 Chinese 234 PF PV 23 7.1 0Zhang H55 2010 Chinese 178 PF PV 40 9 0Li R56 2010 Chinese 120 JCPV 28 9.2 0

Chinese 100 PF PV 42 16 0Yang H57 2011 Chinese 151 PF PV 14.2 0

Author Date Language

## CDa Approachb OTc IDd Bladder Injury %

Pf JC Para Supra

8

Table 1. Operative Data

Author Date Language

## CDa Approachb OTc IDd Bladder Injury %

Pf JC Para SupraIrwin7 1940 English 32 PF PV 45 12.5Stearns8 1943 English 16 SV 18.7Waters9 1944 English 250 PF/V SV 36 1.6

English 180 PF/V PVNorton10 1946 English 160 PF/V SV 5.6Ricci11 1946 English 175 V PV 45 3.4Caccierelli12 1948 English 100 PF SV 30 0Anz,Ward13 1950 English 32 PF PV 3.3Bourgeois14 1950 English 41 V SV 4.2Gilbert15 1953 English 57 PV SV 0Paternite16 1954 English 91 V PV 35 10 2Marr JP17 1958 English 125 V PV 45 5.7Durfee R18 1960 English 100 PF SV 40 11 0Wu C19 1972 English 170 PF PV 35 10 1Joschko20 1974 English 254 PF PV 36.2 7.2 3.5Hanson21 1978 English 45 PF PV 29 6.9 2Perkins22 1978 English 50 PF PV 35 10 0Morozov23 1981 Czech 560 PF PV 47 6.6 0Chemukha24 1982 Russian 300 PF PV 40 7.8 0.6Wallace25 1983 English 91 PF PV 38 9 2Hanson26 1983 English 345 PF PV 21 6.5 0.3

English 16 PF PV 20 3.5 0English 31 PF PV 22 6 0English 61 PF PV 24 5 0

Liu Z27 1988 Chinese1342 PF PV 34 16 0Duvenaishki281991 Bulgaria

n151 PF PV 40 4 0

Li Yalin29 1996 Chinese 578 PF PV 40 2Qiu X30 1997 Chinese 800 PF PV 29 2.2 0

Chinese 80 PF SV 40 2 7.5Wang M31 1998 Chinese 249 PF PV 33 7 0Rao R32 1999 English 3628 PF PV 30 10 0.1Kang R33 2000 Chinese 100 PF SV 28 4 0Yang X34 2000 Chinese 150 PF PV 38 12.5 0Liu H35 2000 Chinese 237 PF PV 46 9 0Li X36 2000 Chinese 364 PF PV 29 11 0Lu Y37 2000 Chinese 165 PF PV 30 5 0Li D38 2001 Chinese 200 PF PV 40 13 0Meng J39 2002 Chinese 380 JCPV 24 7 0

Chinese 151 PF SV 40 15 0Liang H40 2002 Chinese 126 PF SV 36 16 0Zeng Y41 2002 Chinese 105 PF PV 38 10Yin G42 2002 Chinese2436 PF PV 33 0Wei Y43 2002 Chinese 155 PF PV 55 13.6 0

2002 Chinese 181 Vert PV 44 8 0Hzu Y44 2004 Chinese 398 PF PV 35 0Yang W45 2004 Chinese 130 PF PV 30 5 0

Chinese 110 JCPV 41 9.7 0Ruan Y46 2004 Chinese 464 PF PV 23 5.9 0Xie R47 2005 Chinese 140 PF PV 35 6 0Li Y48 2006 Chinese 206 PF PV 44 13.5 0Li M49 2008 Chinese 140 JCPV 23 4 0Fan Y50 2008 Chinese 198 PF PV 35 5.9 0Desari D51 2009 English 1000 PF PV 12 2 0Zhao R52 2010 Chinese 148 PF PV 51 5 0Zhang X53 2010 Chinese 225 PF PV 38.6 4 0Li Y54 2011 Chinese 234 PF PV 23 7.1 0Zhang H55 2010 Chinese 178 PF PV 40 9 0Li R56 2010 Chinese 120 JCPV 28 9.2 0

Chinese 100 PF PV 42 16 0Yang H57 2011 Chinese 151 PF PV 14.2 0

Author Date Language

## CDa Approachb OTc IDd Bladder Injury %

Pf JC Para Supra

8

Table 1. Operative Data

Author Date Language

## CDa Approachb OTc IDd Bladder Injury %

Pf JC Para SupraIrwin7 1940 English 32 PF PV 45 12.5Stearns8 1943 English 16 SV 18.7Waters9 1944 English 250 PF/V SV 36 1.6

English 180 PF/V PVNorton10 1946 English 160 PF/V SV 5.6Ricci11 1946 English 175 V PV 45 3.4Caccierelli12 1948 English 100 PF SV 30 0Anz,Ward13 1950 English 32 PF PV 3.3Bourgeois14 1950 English 41 V SV 4.2Gilbert15 1953 English 57 PV SV 0Paternite16 1954 English 91 V PV 35 10 2Marr JP17 1958 English 125 V PV 45 5.7Durfee R18 1960 English 100 PF SV 40 11 0Wu C19 1972 English 170 PF PV 35 10 1Joschko20 1974 English 254 PF PV 36.2 7.2 3.5Hanson21 1978 English 45 PF PV 29 6.9 2Perkins22 1978 English 50 PF PV 35 10 0Morozov23 1981 Czech 560 PF PV 47 6.6 0Chemukha24 1982 Russian 300 PF PV 40 7.8 0.6Wallace25 1983 English 91 PF PV 38 9 2Hanson26 1983 English 345 PF PV 21 6.5 0.3

English 16 PF PV 20 3.5 0English 31 PF PV 22 6 0English 61 PF PV 24 5 0

Liu Z27 1988 Chinese1342 PF PV 34 16 0Duvenaishki281991 Bulgaria

n151 PF PV 40 4 0

Li Yalin29 1996 Chinese 578 PF PV 40 2Qiu X30 1997 Chinese 800 PF PV 29 2.2 0

Chinese 80 PF SV 40 2 7.5Wang M31 1998 Chinese 249 PF PV 33 7 0Rao R32 1999 English 3628 PF PV 30 10 0.1Kang R33 2000 Chinese 100 PF SV 28 4 0Yang X34 2000 Chinese 150 PF PV 38 12.5 0Liu H35 2000 Chinese 237 PF PV 46 9 0Li X36 2000 Chinese 364 PF PV 29 11 0Lu Y37 2000 Chinese 165 PF PV 30 5 0Li D38 2001 Chinese 200 PF PV 40 13 0Meng J39 2002 Chinese 380 JCPV 24 7 0

Chinese 151 PF SV 40 15 0Liang H40 2002 Chinese 126 PF SV 36 16 0Zeng Y41 2002 Chinese 105 PF PV 38 10Yin G42 2002 Chinese2436 PF PV 33 0Wei Y43 2002 Chinese 155 PF PV 55 13.6 0

2002 Chinese 181 Vert PV 44 8 0Hzu Y44 2004 Chinese 398 PF PV 35 0Yang W45 2004 Chinese 130 PF PV 30 5 0

Chinese 110 JCPV 41 9.7 0Ruan Y46 2004 Chinese 464 PF PV 23 5.9 0Xie R47 2005 Chinese 140 PF PV 35 6 0Li Y48 2006 Chinese 206 PF PV 44 13.5 0Li M49 2008 Chinese 140 JCPV 23 4 0Fan Y50 2008 Chinese 198 PF PV 35 5.9 0Desari D51 2009 English 1000 PF PV 12 2 0Zhao R52 2010 Chinese 148 PF PV 51 5 0Zhang X53 2010 Chinese 225 PF PV 38.6 4 0Li Y54 2011 Chinese 234 PF PV 23 7.1 0Zhang H55 2010 Chinese 178 PF PV 40 9 0Li R56 2010 Chinese 120 JCPV 28 9.2 0

Chinese 100 PF PV 42 16 0Yang H57 2011 Chinese 151 PF PV 14.2 0

Author Date Language

## CDa Approachb OTc IDd Bladder Injury %

Pf JC Para Supra

11

Results

Sources 54 Articles

Operative Description Descriptive Narrative Found

CD Technique

ApproachDissection

LigamentsPeri-Uterine Fascia

Bladder Drainage

Pfannensteil Para-vesical Blunt Stretch Not

Necessary Empty Not Necessary

Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBluntSharp Stretc

hCut

No Yes Empty

Fill No Yes

Joel CohenSupravesical

Sharp Cut/Divide InciseFill & Empty

Drain

10

Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBluntSharp Stretc

hCut

No Yes Empty

Fill No Yes

Irwin7 PF PV + + + + +Stearns8 PF SV + + + + +Waters9 PF or V SV + + + + +

PV + + + + +Norton10 V PV + + + + +Ricci11 V SV + + + +Caccierelli12 V PV + + + +Anz,Ward13 V PV + + + + +Bourgeois14 V SV + + + +Gilbert15 PF SV + + + + +Paternite16 V PV + + + + +Marr JP17 V SV + + + +Durfee R18 PF PV + + +Wu C19 PF PV + + + + +Joschko20 PF PV + + + + +Hanson21 PF PV + + + + +Perkins22 PF PV + + + + +Morozov23 PF PV + + + + +Chemukha24 PF PV + + + + +Wallace25 PF PV + + + + +Hanson26 PF PV + + + + +

PF PV + + + + +PF PV + + + + +PF PV + + + + +

Liu Z27 PF PV + + + + +Duvenaishki28

PF PV + + + + +

Li Yalin29 PF PV + + + + +Qiu X30 PF PV + ++ + +

PF SV+ ++ + +Wang M31 PF PV + + + + +Rao R32 PF PV + + + + +Kang R33 PF SV ++ + + +Yang X34 PF PV + ++ + +Liu H35 PF PV + + + + +Li X36 PF PV + + + + +Lu Y37 PF PV + + + + +Li D38 PF PV + + + + +Meng J39 JC PV + + + + +

PF SV + + + + +Liang H40 PF SV+ + + + +Zeng Y41 PF PV + ++ + +Yin G42 PF PV + + + + +Wei Y43 PF PV + ++ + +

Vert PV + ++ + +Hzu Y44 PF PV + + + + +Yang W45 PF PV + + + + +

JC PV + + + + +Ruan Y46 PF PV + + + + +Xie R47 PF PV + + + + +Li Y48 PF PV + + + + +Li M49 JC PV + + + + +Fan Y50 PF PV + + + + +Desari D51 PF PV + + + + +Zhao R52 PF PV + + + + +Zhang X53 PF PV + + + + +Li Y54 PF PV + + + + +Zhang H55 PF PV + + + + +Li R56 JC PV + + + + +

PF PV + + + + +Yang H57 PF PV + + + + +

Table 2. Surgical Technique DataAuthor CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg

PF JC PV SupraBluntSharp Stretch

Cut

No Yes Empty

Fill No Yes

Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBluntSharp Stretc

hCut

No Yes Empty

Fill No Yes

Irwin7 PF PV + + + + +Stearns8 PF SV + + + + +Waters9 PF or V SV + + + + +

PV + + + + +Norton10 V PV + + + + +Ricci11 V SV + + + +Caccierelli12 V PV + + + +Anz,Ward13 V PV + + + + +Bourgeois14 V SV + + + +Gilbert15 PF SV + + + + +Paternite16 V PV + + + + +Marr JP17 V SV + + + +Durfee R18 PF PV + + +Wu C19 PF PV + + + + +Joschko20 PF PV + + + + +Hanson21 PF PV + + + + +Perkins22 PF PV + + + + +Morozov23 PF PV + + + + +Chemukha24 PF PV + + + + +Wallace25 PF PV + + + + +Hanson26 PF PV + + + + +

PF PV + + + + +PF PV + + + + +PF PV + + + + +

Liu Z27 PF PV + + + + +Duvenaishki28

PF PV + + + + +

Li Yalin29 PF PV + + + + +Qiu X30 PF PV + ++ + +

PF SV+ ++ + +Wang M31 PF PV + + + + +Rao R32 PF PV + + + + +Kang R33 PF SV ++ + + +Yang X34 PF PV + ++ + +Liu H35 PF PV + + + + +Li X36 PF PV + + + + +Lu Y37 PF PV + + + + +Li D38 PF PV + + + + +Meng J39 JC PV + + + + +

PF SV + + + + +Liang H40 PF SV+ + + + +Zeng Y41 PF PV + ++ + +Yin G42 PF PV + + + + +Wei Y43 PF PV + ++ + +

Vert PV + ++ + +Hzu Y44 PF PV + + + + +Yang W45 PF PV + + + + +

JC PV + + + + +Ruan Y46 PF PV + + + + +Xie R47 PF PV + + + + +Li Y48 PF PV + + + + +Li M49 JC PV + + + + +Fan Y50 PF PV + + + + +Desari D51 PF PV + + + + +Zhao R52 PF PV + + + + +Zhang X53 PF PV + + + + +Li Y54 PF PV + + + + +Zhang H55 PF PV + + + + +Li R56 JC PV + + + + +

PF PV + + + + +Yang H57 PF PV + + + + +

10

Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBluntSharp Stretc

hCut

No Yes Empty

Fill No Yes

Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBluntSharp Stretc

hCut

No Yes Empty

Fill No Yes

Irwin7 PF PV + + + + +Stearns8 PF SV + + + + +Waters9 PF or V SV + + + + +

PV + + + + +Norton10 V PV + + + + +Ricci11 V SV + + + +Caccierelli12 V PV + + + +Anz,Ward13 V PV + + + + +Bourgeois14 V SV + + + +Gilbert15 PF SV + + + + +Paternite16 V PV + + + + +Marr JP17 V SV + + + +Durfee R18 PF PV + + +Wu C19 PF PV + + + + +Joschko20 PF PV + + + + +Hanson21 PF PV + + + + +Perkins22 PF PV + + + + +Morozov23 PF PV + + + + +Chemukha24 PF PV + + + + +Wallace25 PF PV + + + + +Hanson26 PF PV + + + + +

PF PV + + + + +PF PV + + + + +PF PV + + + + +

Liu Z27 PF PV + + + + +Duvenaishki28

PF PV + + + + +

Li Yalin29 PF PV + + + + +Qiu X30 PF PV + ++ + +

PF SV+ ++ + +Wang M31 PF PV + + + + +Rao R32 PF PV + + + + +Kang R33 PF SV ++ + + +Yang X34 PF PV + ++ + +Liu H35 PF PV + + + + +Li X36 PF PV + + + + +Lu Y37 PF PV + + + + +Li D38 PF PV + + + + +Meng J39 JC PV + + + + +

PF SV + + + + +Liang H40 PF SV+ + + + +Zeng Y41 PF PV + ++ + +Yin G42 PF PV + + + + +Wei Y43 PF PV + ++ + +

Vert PV + ++ + +Hzu Y44 PF PV + + + + +Yang W45 PF PV + + + + +

JC PV + + + + +Ruan Y46 PF PV + + + + +Xie R47 PF PV + + + + +Li Y48 PF PV + + + + +Li M49 JC PV + + + + +Fan Y50 PF PV + + + + +Desari D51 PF PV + + + + +Zhao R52 PF PV + + + + +Zhang X53 PF PV + + + + +Li Y54 PF PV + + + + +Zhang H55 PF PV + + + + +Li R56 JC PV + + + + +

PF PV + + + + +Yang H57 PF PV + + + + +

10

Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg PF JC PV SupraBluntSharp Stretc

hCut

No Yes Empty

Fill No Yes

Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg

PF JC PV SupraBluntSharpStretch

Cut

No YesEmpty

Fill No Yes

Irwin7 PF PV + + + + +Stearns8 PF SV + + + + +Waters9 PF or V SV + + + + +

PV + + + + +Norton10 V PV + + + + +Ricci11 V SV + + + +Caccierelli12 V PV + + + +Anz,Ward13 V PV + + + + +Bourgeois14 V SV + + + +Gilbert15 PF SV + + + + +Paternite16 V PV + + + + +Marr JP17 V SV + + + +Durfee R18 PF PV + + +Wu C19 PF PV + + + + +Joschko20 PF PV + + + + +Hanson21 PF PV + + + + +Perkins22 PF PV + + + + +Morozov23 PF PV + + + + +Chemukha24 PF PV + + + + +Wallace25 PF PV + + + + +Hanson26 PF PV + + + + +

PF PV + + + + +PF PV + + + + +PF PV + + + + +

Liu Z27 PF PV + + + + +Duvenaishki28 PF PV + + + + +

Li Yalin29 PF PV + + + + +Qiu X30 PF PV + ++ + +

PF SV+ ++ + +Wang M31 PF PV + + + + +Rao R32 PF PV + + + + +Kang R33 PF SV ++ + + +Yang X34 PF PV + ++ + +Liu H35 PF PV + + + + +Li X36 PF PV + + + + +Lu Y37 PF PV + + + + +Li D38 PF PV + + + + +Meng J39 JC PV + + + + +

PF SV + + + + +Liang H40 PF SV+ + + + +Zeng Y41 PF PV + ++ + +Yin G42 PF PV + + + + +Wei Y43 PF PV + ++ + +

Vert PV + ++ + +Hzu Y44 PF PV + + + + +Yang W45 PF PV + + + + +

JC PV + + + + +Ruan Y46 PF PV + + + + +Xie R47 PF PV + + + + +Li Y48 PF PV + + + + +Li M49 JC PV + + + + +Fan Y50 PF PV + + + + +Desari D51 PF PV + + + + +Zhao R52 PF PV + + + + +Zhang X53 PF PV + + + + +Li Y54 PF PV + + + + +Zhang H55 PF PV + + + + +Li R56 JC PV + + + + +

PF PV + + + + +Yang H57 PF PV + + + + +

43

10

Author CDa Approachb Dissectionc Ligsd Fasciae Bladderf Drainsg

PF JC PV SupraBluntSharpStretch

Cut

No YesEmpty

Fill No Yes

4444

M. Fauck’s Extraperitoneal Cesarean Section

4545

Ambulatory Cesarean Section

46

Implications

47

Your have options!

48

Exit to Peritoneum

Remain in E

PS

49

You have choices!

5050

Exit to Peritoneum

Remain Extraperitoneal

You have choices!

Evidenced-Based Medicine

?

Live Births CD Rate % Cesarean Delivery

China 16,486,000 50 8,243,000 6.4 X

India 27,165,000 9 2,444,850 1.9 X

USA 4,301,000 30 1,290,300 1.0 X

Where are the CD being done?

53

EBM~Opening Peritoneum

RCS EBMUSA

EBMChina

Transperitoneal

None

Comparative Studies Favor

Extraperitoneal Cesarean Delivery

Extraperitoneal

54

EBM~Technique for EPCS

RCS EBMUSA

EBMChina

Blunt Minimalism (Joel-Cohen)

None

ComparativeStudies Favor

Blunt Minimalism (Joel-Cohen )

Extraperitoneal CDSharp Invasive(Pfannenstiel )

55

Is being studies elsewhere

Like two worlds

1988-2012 1940-1983

58

Finis