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For some time now, an alleged new technique of cesarean section, called extraperitoneal cesarean section, made talk about her. the Prof. Philippe Deruelle, gynecologist and Obstetrics General Secretary of the CNGOF, the National College of French Obstetrician Gynecologists, answers our questions.
At the same time, Dr Bénédicte Simon, who performs extra-peritoneal cesarean section in Versailles (Yvelines), gives us his point of view and his experience.
A not so recent technique
« When we do a cesarean in the classic way, we will open the belly through a low incision, then separate the muscles, then access the uterus by opening the peritoneum, passing through the belly », Summarizes Professor Deruelle, recalling that the peritoneum is the thin membrane that covers and contains all the organs of the abdominal cavity, whether they are reproductive, urinary or digestive.
This widely proven approach has its drawbacks and detractors, as the resumption of transit can be a bit slow and the incision of the peritoneum can sometimes lead to adhesions at the level of scars, and therefore more pain.
From the twentieth century, another technique, called extra-peritoneal cesarean section, was born. It consists of use different anatomical planes, on the side, so as not to have to open the abdominal cavity, the peritoneum.
« In this approach, we will go through another place, between the bladder and the uterus, a place where we are not in the abdominal cavity, where we can access the uterus without incising the peritoneum. », Explains Professor Deruelle.
Extra-peritoneal cesarean section: fewer post-operative complications?
« It was true thirty or forty years ago, estime le Pr Deruelle, when we did not know the Cohen Stark technique, or Cesarean section called Misgav Ladach (named after the hospital where it was developed), which allows relatively simple post-operative treatment. »
The extra-peritoneal cesarean section generates, by its technique, fewer surgical complications and faster recovery compared to older caesarean techniques, where the stomach muscles were severed.
But today, the most widely practiced caesarean section, called Cohen Stark, ” revolutionized the care of pregnant women “And” halves operative time and recovery time “, Assures Professor Deruelle, who indicates that he has patients who, even after a classic cesarean, can eat the same evening and are up the next day.
The major difference between the extraperitoneal cesarean section technique and the Cohen Stark technique, currently promoted by the College of Obstetrician Gynecologists, is the opening of the peritoneum. If it is performed well, the Cohen Stark Caesarean does not require cutting the abdominal muscles, which are simply spread apart, on the other hand, the peritoneum is necessarily severed.
What is the scientific evidence for its benefits?
Certainly, the extra-peritoneal cesarean section, because it does not cut the muscles and it does not cut the peritoneum, seems to be the least invasive and painless cesarean section. Note that if the first incision of the skin is horizontal, the second incision, that of the aponeurosis, membrane which envelops the muscles, is vertical (whereas it is horizontal in the technique of Cohen Stark). Difference that would change everything at the level of postoperative mobility according to the gynecologists who promote this technique, but which has not been scientifically evaluated, notes Professor Deruelle. It has not been proven that the vertical or horizontal opening of the fascia changes anything in terms of recovery.
On this point, obstetrician-gynecologist Bénédicte Simon does not entirely agree. This recalls thata scientific study is underway in Israel and France, and that the different techniques developed by Doctor Denis Fauck for extra-peritoneal cesarean section are borrowed from other surgeries, which have been proven. The extraperitoneal incision is thus borrowed from the urologic surgery, while the vertical incision of the fascia is a technique borrowed from the vascular surgery. ” It is easy to understand that changing from deep (intraperitoneal) surgery to superficial (extraperitoneal) surgery is less painful for patients:The operating shock is shallower, the comfort is much better », Argues Dr Simon, assuring that his patients can often be up in the hour following the cesarean section.
« Cesarean section is the most common surgical operation, and the only intervention that requires mobility and post-operative comfort to take care of the baby. When a woman has an operation for anything, she usually does not have to take care of her children who are usually looked after by the family or the dad. Many efforts are being made to develop outpatient surgery in all areas, except for cesarean section », Regrets Dr Simon.
Despite everything, it is accepted by all that the extra-peritoneal cesarean section is technically more complicated and requires a real apprenticeship with initiated gynecologists.
« There is a lack of data on the repetition of this type of cesarean section, where we approach areas of the body not so easy to access. To my knowledge, there are no scientific studies that have compared this cesarean section to other cesarean techniques. “, Such as that of Cohen Stark, further underlines Professor Deruelle, who advises caution.
According to the gynecologist, Obstetrics General Secretary of the CNGOF, the extra-peritoneal cesarean “ has not been studied enough to be extensively promoted as something miraculous. “
Could the fad for this surgical technique result in part from the well-conducted communication of certain private clinics which have made extra-peritoneal cesarean section their specialty?
Dr Simon refutes this idea, because this one asks only to train the other gynecologists, who seem reluctant because do not always see the interest for women. Apprehension on the part of obstetricians who are not surgeons? Lack of curiosity, habit? Dr. Simon, who also trains doctors abroad – in Tunisia, Israel or even Lithuania -, however, asks only to provide his knowledge in France …
As for the current craze, it would rather be due, for Dr. Simon, to the enthusiasm of the women themselves, who spread the word and testify of their very positive experience to whoever wants to hear them.
The delicate question of operating time
Whatever one says about the Cohen Stark cesarean, it allows a very short operating time, since the uterus is easily accessible once the peritoneum is divided. Conversely, ” extraperitoneal cesarean section lengthens operating time and requires specific training, where the Cohen Stark technique is quite simple and shortens the operating time », Assures Professor Deruelle.
We quickly understand the concerns: if the extra-peritoneal cesarean does not pose a problem during a scheduled cesarean, it will be all the more delicate to carry out in case of emergency cesarean section, where every minute counts to save the life of the mother and / or the baby.
While for life-threatening emergencies, Dr. Simon recognizes that extraperitoneal cesarean section is not recommended, she believes that the lengthening of the operating time, of only ten minutes, is a false problem during an elective cesarean section, performed for medical reasons or convenience. “ What is ten minutes of surgery in addition to the benefits for the patient? She says.
A cesarean section that allows you to be an actor of her childbirth
The craze for extraperitoneal cesarean section can also be explained by everything that surrounds it and which attracts any future mother eager tobe an actress during childbirth by cesarean section.
Because the extra-peritoneal cesarean, the idea of which is to approach as close as possible to a physiological childbirth, is often accompanied by a small plastic tip (called a “Guillarme blower” or “winner flow” ®) in which the pregnant woman goes. blow to expel the baby through the belly thanks to the contraction of the abs. Immediately after the baby is released, the skin to skin is also offered, for all the virtues that we know: mother-child bond, warmth of the skin …
But it is a mistake to think that these more natural approaches to childbirth are only performed in the context of an extra-peritoneal cesarean. ” The blower nozzle and the skin to skin can be perfectly integrated into a “classic” Caesarean section, by Cohen Stark », Assures us Professor Deruelle. The only thing that is specific to extraperitoneal cesarean section is the incision technique. All the support around this technique can to be carried out in other cesarean sections.
Unfortunately, it must be admitted that this support is not always offered to women during cesarean sections and conventional deliveries, hence their enthusiasm for birthing centers and other “natural” delivery rooms, where their birth plans seem more fulfilled and respected.
In short, extraperitoneal cesarean section seems to divide obstetrician-gynecologists for the time being: few of them practice it, some are skeptical, others do not see its interest in the face of the classic technique … It is up to each one to form her opinion and to choose according to her conception of childbirth, her geographical possibilities, her budget, her apprehension …
Remember that for the time being, this technique remains very little practiced in France, in private clinics which are quite popular and few in number. A situation deplored by Dr. Simon, who says he is nevertheless ready to disseminate his technique to whoever wants to hear it, and who does not understand the lack of interest of French gynecologists and obstetricians for this new approach.
However, we can think that, if studies come to validate the advantages of this type of cesarean section, and that women make more and more demand for it, the reluctance of obstetricians will eventually diminish to the point that the extraperitoneal cesarean comes. not supplant the Cohen-Stark Caesarean, but complete the surgical arsenal of obstetricians.
Finally, remember that the cesarean section remains a surgical intervention which should only be performed in the event of medical necessity, in the face of pathological situations, because the risk of complications is greater than during vaginal delivery. The rate of caesarean sections performed in France is around 20% of deliveries, knowing that the World Health Organization (WHO) recommends a rate between 10 and 15%.