Peritoneal closure—to close or not to close

Ying-Ching Cheong, Nitu Bajekal and Tin-Chiu Li1,

The Jessop Hospital for Women, Leavygreave Road, Sheffield S3 7RE, UK

Abstract

Peritoneal closure is a controversial issue among obstetricians and gynaecologists. This article reappraises the issue of peritoneal closure. We conducted a thorough literature search using Medline, Pubmed and Embase as well as a hand-search for all references quoted in the relevant papers. The routine non-closure of the peritoneum reduces operation time by an average of 6 min. Most studies showed no difference in the other outcome measures including infection/febrile episodes, analgesic/anaesthetics requirement, bowel function restoration, post-operative stay and adhesion formation. There are insufficient data concerning adhesion formation. In conclusion, apart from a slightly shorter operation time associated with non-closure of the peritoneum, many studies showed no difference in short-term morbidity in the closure and the non-closure group. More studies are needed to examine the long-term morbidity associated with the closure or the non-closure of the peritoneum.

Key words: Peritoneal closure/non-closure/outcome measures/morbidity

Introduction

In considering peritoneal closure, the United Kingdom's Royal College of Obstetricians and Gynaecologists (RCOG) green-top guidelines suggested that `non-closure appears to have few associated risks and may be recommended in many obstetric and gynaecological operations' (RCOG, 1998Go). Despite this recommendation 2 years ago, the issue of closure of the peritoneum versus non-closure remains controversial among many obstetricians and gynaecologists. We recently conducted a survey in The Jessop Hospital for Women, Sheffield to examine the individual practice among consultant obstetricians and gynaecologists in a teaching hospital on closure or non-closure of the peritoneum. We found that 50% of the consultants in this hospital have continued to perform routine closure of the peritoneum after surgery whereas the other 50% do not.

Traditionally, closure of the peritoneum was thought to possibly allow for (i) restoration of anatomy and approximation of tissues for healing; (ii) re-establishment of the peritoneal barrier to reduce the risk of infection; (iii) reduction of the risk of wound herniation or dehiscence; and (iv) minimizing adhesion formation (Duffy and diZerega, 1994Go). When consultants who continued to perform routine peritoneal closure were asked why they continued to do so despite the recommendation of the RCOG green-top guidelines, the most common answer was that there was no strong evidence to support the recommendation.

Consequently, we decided to reappraise this issue and attempted to re-analyse objectively the literature data in order to determine whether or not there is good evidence to support routine non-closure of the peritoneum. We conducted a thorough literature search using Medline, Pubmed and Embase as well as a hand-search for all references quoted in the relevant papers.

General considerations

Many previous studies examined the advantages and disadvantages of peritoneal closure versus non-closure ( Gilbert et al.1987Go; Tulandi et al.1988Go; Hull and Varner, 1991Go; Pietrantoni et al.1991Go; Irion et al.1996Go; Lipscomb et al.1996Go; Nagele et al.1996Go; Grundsell et al.1998Go). Various aspects of the outcome were examined including the intra-operative factors such as operating time and blood loss, post-operative factors such as pain, length of hospital stay, rates of infection, haematoma formation and wound healing. Outcomes in the longer term included adhesion formation/reformation and hernias. The Cochrane database examined the issue of peritoneal closure versus non-closure in Caesarean section. The conclusions were `no significant difference in short term morbidity from non-closure of the peritoneum in Caesarean section' (Wilkinson and Enkin, 1997Go). It is, however, important to appreciate that the conclusions drawn from Caesarean section may not be applicable to general gynaecological surgery due to the obvious differences in the nature of the two surgery types.

Many of these studies represented retrospective analysis of relatively small numbers of patients. There was only one properly randomized controlled study ( Irion et al.1996Go). Among the other randomized controlled trials, for various reasons Nagele et al. (1996) allocated women by the days of the week ( Nagele et al.1996Go), whilst Pietrantoni et al. (1991) and Hull and Varner (1991) allocated women by the last digit of their hospital number (Hull and Varner, 1991Go; Pietrantoni et al.1991Go), all of which could have introduced some degree of bias into their respective studies.

In this review, we compared the results of closure versus non-closure under separate outcome measures including operation time, infection/febrile episodes, bowel function post-surgery, analgesic/anaesthetic requirement, post-operative stay and post-operative adhesions formation.

Operating time

Seven studies compared the operating time between the closure and non-closure groups (Table IGo). Among the seven studies, six showed that, as expected, non-closure of the peritoneum reduced the total operating time by up to 10 min compared with closure. Most surgeons would agree that shortening an obstetric or a gynaecological procedure by 5–10 min does not significantly influence the outcome or post-operative recovery.


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Table I. Operating time of closure versus non-closure of the peritoneum
 
Infection/febrile episodes

Thirteen studies compared the infection/febrile episodes between the closure and non-closure groups (Table IIGo). Of the 13 studies, the majority (n = 11 ) showed that there was no difference in the infection and febrile episodes between the two groups, with the exception of two studies which showed a significantly higher incidence of infection/febrile episodes in the closure group compared with the non-closure group ( Nagele et al.1996Go; Grundsell et al.1998Go). These two studies were performed in women who had undergone Caesarean section. Nagele et al. (1996) showed that 15.7% of women in the closure group had fever for >2 days post-operatively compared with 8.4% of women in the non-closure group. They also found that 7.7 versus 3.1% of the closure and non-closure group respectively had cystitis. However, they failed to find a difference between the two groups in terms of wound infection ( Nagele et al.1996Go). If closure of the peritoneum is likely to lead to `sub-peritoneal pockets' of infection, as speculated by the authors, the number of patients having wound infection would be expected to be significantly higher in the closure compared with the non-closure group. None of the studies performed on gynaecological surgery (n = 8 ) detected any difference in the infection/febrile episodes in the closure versus the non-closure group.


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Table II. Studies examining infection/febrile morbidity in closure versus non-closure of the peritoneum
 
Analgesic/anaesthetic requirement

Of the six studies examining analgesic requirement between the closure and non-closure groups (Table IIIGo), all but one ( Nagele et al.1996Go) found no difference between the two groups. In that study, 549 women undergoing Caesarean section were examined prospectively. It was found that women in the non-closure group required more post-operative narcotics (oral or parenteral) than the closure group. However, a significantly (P < 0.03 ) higher proportion of women in the non-closure group (25.9%) had spinal anaesthetics compared with the closure group (14.6%). It is likely that the use of spinal analgesia rather than general anaesthetics could have altered the need for narcotic analgesia in the immediate post- operative period.


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Table III. Analgesia/anaesthetics requirement post-operatively for patients who had closure of the peritoneum versus non-closure
 
Bowel function

Nine studies compared the time taken to restore bowel function after surgery between the closure and non-closure groups (Table IVGo). Among the nine studies, six did not detect a difference between the two groups. One study ( Irion et al.1996Go) found that bowel function took a slightly longer time to return to normal after closure of the peritoneum compared with non-closure. In that study, it was found that the mean time to positive auscultation of bowel sounds was 1.3 days (SD 0.6) in the non-closure group compared with 1.5 days (SD 0.5) in the closure group. Almost all women had return of their bowel sounds by the second day post-operation. It is unlikely that the observed difference between the two groups is of any clinical significance. Whilst Hull and Varner (1991) found no difference in the episodes of ileus or patial ileus in the closure or non-closure group, they observed that bowel stimulants were more frequently used in the closure group compared with the non-closure group (Hull and Varner, 1991Go). However, as they randomized the patients based on the last digit of the patients' medical record, the study could have suffered randomization bias. It is also unclear why patients with ileus/partial ileus were treated with bowel stimulants, which is not the standard practice in England.


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Table IV. Assessment of bowel function after closure of the peritoneum compared with non-closure
 
Post-operative stay

Six studies compared the length of post-operative stay between the closure and non-closure groups (Table VGo). Among the six studies, the majority (four studies) showed no difference in the length of hospital stay. Two studies showed that closure of the peritoneum leads to a longer hospital stay of no more than 1 day.


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Table V. Length of hospital stay in patients with closure versus non-closure of the peritoneum after surgery
 
Scar dehiscence

Four studies compared the incidence of scar dehiscence between the closure and non-closure groups. Among these four studies (Ellis and Heddle, 1977; Gilbert et al.1987Go; Pietrantoni et al.1991Go; Grundsell et al.1998Go), none showed any significant difference in the incidence of scar dehiscence between the closure and non-closure groups.

Adhesions

The long term benefits and hazards of non-closure of the peritoneum are unknown. Post-operative adhesion development has been reported to occur in 55–100% of patients after surgery ( Pitttaway et al.1985Go; Trimbos-Kemper et al.1985Go). Intestinal obstruction is encountered after 0.3% of benign adnexal gynaecological surgeries, 3% of hysterectomies, 5% of radical hysterectomies and 1% of general surgical laparotomies (Menzies and Ellis, 1990Go). Moreover, the presence of adhesions during surgery may result in longer operating time and increased intra-operative complications, including damage to the bowel, bladder, ureters, and bleeding.

The treatment of pelvic adhesions and their associated morbidity contributes to a significant portion of health care expenditure. In the USA, hospital admissions related to adhesion-associated morbidity and surgical treatment of adhesions accounted for US$1.33 billion of the health care expenditure in 1994 ( Ray et al.1998Go). In Sweden, a postal study to all surgeons found that the annual cost for treating adhesions in the country was US$4.1 million (Holmdahl and Risberg, 1997Go).

A recent study reiterated the importance of adhesion-related morbidity ( Lower et al.2000Go). The authors used the Scottish National Health Service linked database to follow-up patients who had operations in 1986 for a 10-year period. The end-point of this epidemiological study was to determine the morbidity related to adhesions denoted by the number of hospital re-admissions directly or indirectly related to adhesions. There were 5.7% of the patients re-admitted due to complications directly related to adhesions. However, one-third of patients were, on average, re-admitted twice over the 10-year period, due to adhesion-related problems. In addition, adhesion-related morbidity was shown to increase steadily over the 10-year study period.

Among the various outcome measures concerning long-term morbidity, adhesion formation/reformation is probably one of the most important ones. There were only two studies that compared the incidence of adhesion formation between peritoneal closure and non-closure. The first study ( Kadanali et al.1996Go) examined the difference in adhesion formation of the pelvic sidewall between patients who had closure and non-closure of the peritoneum after pelvic/peri-aortic lymphadenectomy, and radical hysterectomy. All the patients had second-look via laparotomy after a course of chemotherapy. A substantial proportion of these (48%) had persistent cancer. It was found that the adhesion formation rate of the pelvic sidewall in the closure group was significantly (P < 0.01 ) higher than the non-closure group. However, the data should be interpreted with caution. Adhesions were increased in the group with closure compared with non-closure of the pelvic and para-aotic peritoneum. We must be cautious in interpreting these results for two main reasons. Firstly, para-aortic and pelvic lymphadenectomy involves the dissection into the retro-peritoneal space, a procedure not commonly performed in non-oncology-related general surgery or gynaecology. The patho-physiology of cancer includes, in part, an extensive remodelling of connective tissue ( Slawomir et al.1997Go). Healing in cancer patients is known to be different ( Lotti et al.1998Go) and thus patients with cancer should be examined separately with regard to peritoneal adhesion formation/reformation. Secondly, the study examined closure or non-closure of the pelvic sidewall, not the anterior parietal peritoneum which is the subject of surgery in the other studies.

The second study (Tulandi et al., 1988Go) was a retrospective, non-randomized cohort study. A total of 333 women who were undergoing laparotomy in a reproductive unit in Canada were analysed, of which 165 had non-closure and 163 had closure of the peritoneum. After 6 months, a subgroup of these two groups were offered a second-look laparoscopy if they had failed to achieve pregnancy. They found no difference in the incidence of adhesion formation in the two groups. There were some deficiencies in this study. Firstly, the small sample size had insufficient power to detect a difference in adhesion formation between the groups. Secondly, performing a second-look laparoscopy on a subgroup of women may introduce bias. Thirdly, the study was not prospectively randomized. Nonetheless, this is the only study available in the literature data examining this important outcome in routine/general gynaecological practice.

Conclusion

What we do know is that routine non-closure of the peritoneum reduces operation time by an average of 6 min. Most studies showed no difference in the other outcome measures including infection/febrile episodes, analgesic/anaesthetics requirement, bowel function restoration, post-operative stay and adhesion formation. The data in relation to adhesion formation is preliminary and requires further carefully planned prospective study to verify the outcome. At present, one can conclude that, apart from a slightly shorter operation time associated with non-closure of the peritoneum, many studies showed no difference in short-term morbidity between the closure and non-closure groups. One cannot claim that non-closure is better than closure, or vice versa. In this respect, we agree with the conclusion from the Cochrane database (Wilkinson and Enkin, 1997Go) that there is no significant difference in short-term morbidity from non-closure of the peritoneum at Caesarean section. However, it may not be justified to extrapolate the data relating to Caesarean section to other gynaecological surgery. Most importantly, we have identified a lack of literature data on long-term morbidity relating to adhesion formation between closure and non-closure of the peritoneum. Carefully planned prospective studies in the future will be necessary to verify if indeed closure of the peritoneum (in humans) is better than, the same as, or worse than non-closure.

Notes

1 To whom correspondence should be addressed. Email: yingcheong{at}hotmail.com Back

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