Epcs presentation 2013
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Transcript of Epcs presentation 2013
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