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Re-laparotomy after cesarean section: Operative complications in surgical

delivery

Article  in  Archives of Gynecology and Obstetrics · March 2008

DOI: 10.1007/s00404-008-0604-9 · Source: PubMed

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Arch Gynecol Obstet (2008) 278:419–425
DOI 10.1007/s00404-008-0604-9

O R I G I N A L A R T I CL E

Re-laparotomy after cesarean section: operative

complications in surgical delivery
Ali Gedikbasi · Alpaslan Akyol · Emel Asar ·
Banu Bingol · Remzi Uncu · Akif Sargin · Yavuz Ceylan

Received: 18 November 2007 / Accepted: 12 February 2008 / Published online: 15 March 2008
© Springer-Verlag 2008

Abstract due to infection and abscess formation (n = 8). Two cases

Objective To determine the risk factors causing re-lapa- required admission into the intensive care unit. We had one
rotomy and the indications, management and outcomes of case with maternal mortality. Majority of the complications
re-laparotomy after a cesarean section. were revealed at an early period and these were hemor-
Methods We had, during the study period of January 2002 rhagic cases mostly.
to January 2007, 28,799 cesarean sections and 35 cases Conclusion Although the rate of re-laparotomy after
with re-laparotomy. We studied the patients’ age, parity, cesarean section is low, several actions must be undertaken
indications for cesarean section and indications for re-lapa- to decrease the need for re-laparotomy. In particular, cases
rotomy, time interval after cesarean section to reopening of with placental abruption and previous cesarean ¸3 are with
the abdomen, type of surgery, need for blood transfusion higher risk for re-laparotomy and have a 15-fold risk for re-
and span of hospital stay. laparotomy after cesarean section.
Results The incidence of re-laparotomy was 0.12%.
Cases with placental abruption and previous cesarean ¸3 Keywords Re-laparotomy after cesarean section ·
had a higher risk for re-laparotomy. Procedures that were Placental abruption · Previous cesarean ¸3
performed at re-laparotomy were drainage and resuturing
of hematomas (n = 8), resuturing of uterus and securing
hemostasis with stitches (n = 10), bladder repair (n = 1), Introduction
herniation repair (n = 1), total abdominal hysterectomy
(n = 2), subtotal abdominal hysterectomy (n = 5), and Delivery by cesarean section (CS) has become one of the
draining and resuturing of broad ligament, parametrium, most common procedures in obstetrics and the rate of CS is
abdominal wound, and cutaneus and subcutaneous tissue increasing worldwide [1]. The obstetric and medical indica-
tions for performing CSs, with or without legitimacy, are
expanding, due to patient requests [2]. The rate of compli-
cations associated with cesarean delivery is known to be
several-fold that of vaginal delivery [3, 4]. This may be in
A. Gedikbasi · A. Akyol · E. Asar · R. Uncu · A. Sargin · Y. Ceylan
Department of Obstetrics and Gynecology, part due to the pathology underlying the indication or the
Istanbul Bakirkoy Maternity and Children quality of the surgery.
Diseases Hospital, Istanbul, Turkey In spite of the huge appeal for this operation, patients
who undergo CS are exposed to a signiWcant rate of short-
B. Bingol
Department of Obstetrics and Gynecology, and long-term complications [5]. One of the important
Istanbul Metropolitan Florence Nightingale Hospital, complications is re-laparotomy after cesarean section (R-
Istanbul, Turkey LACS). R-LACS in the early postoperative period is one of
the rarest types of short-term complications; consequently,
A. Gedikbasi (&)
Atakoy 11. Kisim, Lale Apt. D.40, 34710 Istanbul, Turkey there are only three studies pertaining to R-LACS in the
e-mail: alged_1971@yahoo.com obstetric literature [6–8].

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420 Arch Gynecol Obstet (2008) 278:419–425

The objective of this study was to determine the inci- In general, the standard preoperative care for a CS
dence, indications, management and outcomes of re-lapa- included intravenous antibiotics given prophylactically dur-
rotomy procedures in an attempt to avert even a few of the ing surgery, removal of the urinary catheter, encourage-
avoidable procedures, improve the quality of care in the ment of early ambulation (12 h after the operation),
peri- and postoperative period, and reduce maternal mor- resumption of oral intake when bowel sounds were present
bidity and mortality. and discharge from the hospital on the 3rd postoperative
day after defecation.
The inclusion criterion for the study was a re-laparot-
Patients and methods omy after CS, deWned as a reoperation, within the puer-
perium (6 weeks) or related to the CS, within 3 months.
This was a retrospective study based on CSs performed at The medical records of women who met the inclusion
Bakirkoy Maternity and Children Diseases Hospital in criterion were reviewed by an experienced abstractor.
Istanbul, a tertiary care center for obstetrics and gynecology We had 35 patients who underwent R-LACS during the
and pediatrics. The total vaginal and cesarean deliveries study period. Data were obtained from the records at the
and CS rates between January 2002 and December 2006 are operating theater, patient Wles at the documentation unit
shown in Table 1. Referrals were made from other hospi- and computer records. The following data were col-
tals, polyclinics and maternity homes in the city and the lected: age, parity, indications for CS and indications for
nearby regions. R-LACS, time after completion of the CS to reopening of
Routinely and throughout the study, a group of 20 obste- the abdomen, type of surgery, requirement of blood
tricians supervised all vaginal and cesarean deliveries and transfusion and duration of hospital stay. Patients were
took part all in surgical procedures. The most common divided into three groups based on the time of R-LACS
indications for CS and the related percentages during the as follows: (1) early period (within 24 h), (2) intermedi-
5-year study are shown in Table 2. In our department, one ate period (between 24 and 72 h) and (3) late period
senior obstetrician was always present in the labor room (beyond 72 h).
and gave the indication for and approved all CSs, and The diVerences in R-LACS were evaluated by the Stu-
another senior obstetrician was always present in surgery dent’s t test, and means were compared by the
2 test. Sta-
and accepted the patient and took part in the surgery. tistical signiWcance was deWned as P < 0.05.

Table 1 Cesarean rates in Bakirkoy Maternity and Children Diseases Hospital between 2002 and 2006
2002 2003 2004 2005 2006 Total birth rates Mean rates (2002–2006)

Cesarean delivery 5.732 5.813 6.458 5.540 5.256 28.799 5.7598

Vaginal delivery 13.342 14.930 14.786 10.590 9.762 63.410 12.682
Total birth 19.074 20.743 21.244 16.130 15.018 92.209 18.4418
Cesarean rate (%) 30.05 28.02 30.39 34.35 35.13 31.23 31.23

Table 2 Indication types and

Indications Percentage (%) n (n = 35) P OR CI 95%
rates of 28,799 cesarean deliver-
ies in our hospital during 2002– Previous cesarean 29.0
2006 and related incidences of
35 cases of R-LACS performed ·2 28.6 9 0.845 0.86 0.40–1.84
¸3 0.4 2 0.0003 14.96 3.54–63.12
Fetal distress 18.5 7 0.839 1.19 0.52–2.74
Malpresentation 11.3 –
Cephalopelvic disproportion 10.2 1 0.247 0.25 0.03–1.89
Abnormal labor progress 7.5 2 0.934 0.74 0.17–3.11
Multiple pregnancies (twin, triplet...) 4.8 3 0.518 1.85 0.56–6.07
On request 4.4 1 0.973 0.63 0.08–4.66
Bolded values are signiWcant Macrosomy (¸ 4500 gr) 3.7 –
data (statistical signiWcant) Placenta previa 2.2 1 0.791 1.3 0.17–9.56
a
Previous uterine operation, Placental abruption 1.9 8 0.0001 15.28 6.91–33.8
cord presentation, preeclampsia/ a
Others 6.5 1 0.595 0.42 0.05–3.09
HELLP, etc

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Arch Gynecol Obstet (2008) 278:419–425 421

Results these interventions fail, uterine or hypogastric artery liga-

tion is performed before proceeding to hysterectomy, in an
During the 5-year period, there were 28,799 cesarean deliv- eVort to conserve future fertility. If all attempts fail, a hys-
eries and a total of 92,239 deliveries, yielding a mean CS terectomy is performed. Obstetricians prefer to perform a
rate of 31.23% (Table 1). The CS rate increased almost subtotal rather than a total hysterectomy, if possible. Total
every year from 30.05% in 2002 to 35.13% in 2006. hysterectomy was performed in cases of existing cervical
The main indications for CS in our hospital are shown in hemorrhagic pathology. Two total hysterectomies were per-
Table 2. A total of 35 patients (0.12%) underwent R-LACS. formed, because of complete placenta previa and hemor-
Table 2 also shows the indications for CS in these 35 cases rhage from the placental bed (one patient) and massive
with R-LACS, the associated statistical signiWcance and the bleeding into the abdominal cavity (one patient). We
odds ratio (OR) for re-laparotomy. Previous cesarean deliv- performed a subtotal hysterectomy in Wve cases for the
ery ¸3 and placental abruption were signiWcant with ORs following indications: atonic bleeding (three patients),
of 14.96 and 15.28, respectively. intraabdominal hemorrhage (one patient), and bleeding
The indications for re-laparotomy are shown in Table 3. from the placental bed that revealed an insertion abnormal-
The mean patient age was 28.14 years (range, 20–43 years) ity in the case of a placenta previa (one patient).
and the mean parity was 1.63 (range, 1–8). One maternal The time interval between CS and re-laparotomy was
mortality due to CS and postoperative infection occurred. reviewed and categorized into three types as follows: early
Procedures that were performed at re-laparotomy, period (within 24 h), intermediate period (24–72 h) and late
included drainage and resuturing of hematomas (eight period (beyond 72 h). Re-laparotomy occurring during the
patients), resuturing of the uterus and securing hemostasis early period had a mean of 6 h in our study. The majority of
with stitches (ten patients), bladder repair (one patient), the complications were manifest in the early period, of
hernia repair (two patients), total abdominal hysterectomy which hemorrhage was the most common indication.
(two patients), subtotal abdominal hysterectomy (Wve Table 4 summarizes the complications and outcomes of the
patients), and draining and resuturing of the broad liga- re-laparotomies diagnosed during the early period.
ment, parametrium, abdominal wound and cutaneus and One R-LACS was performed during the intermediate
subcutaneous tissues due to infection and abscess formation period. The patient had a CS because of a twin pregnancy
(seven patients). and severe preeclampsia. She had an R-LACS 28 h follow-
The indications for R-LACS are listed in Table 3. The ing the CS, because of a pelvic hematoma. Laparotomy and
indications included bleeding into the abdomen (12 drainage was performed and she recovered after receiving
patients), postoperative abdominal mass or hematoma (8 four units of packed red blood cells.
patients), infection or abscess formation (7 patients), atonic The late period spanned 3–78 days with a mean of
uterus (3 patients), complete placenta previa or bleeding 19.7 days. In the late period, infection of the incision or
from the placental bed (2 patients), evisceration (1 patient), abscess formation was the most commonly encountered
bladder injury (1 patient) and herniation of the omentum process. Table 5 summarizes the complications, which
due to drainage (1 patient). occurred during the late period.
In cases of hemorrhage presenting as bleeding into the The only fatality involved a 26-year-old gravida 2 para
abdomen, atonic uterus, and hemorrhage due to complete 1, who had a CS in our hospital because of a prior CS. She
placenta previa, obstetricians who are staV at our teaching was referred back to our hospital 5 days later with an infec-
hospital manage hemorrhage by securing hemostasis with tion and pelvic pain. Intraabdominal and wound infection
stitches, unipolar coagulation and compressions. Should were conWrmed; the tissue adjacent to the wound was

Table 3 Indications/main rea-

Indications n Percentage Time to laparotomy
sons for re-laparotomy and time
interval until surgery Bleeding into abdomen 12 34.2 445 m (90–720 m) 7.4 h
Postoperative abdominal mass/hematoma 8 22.8 390.4 h (2 h–78 d) 390.4 h
Infection, abscess 7 20.0 16.4 d (5–69 d) 392.6 h
a
Atony 3 8.6 420 m (240–600 m) 7h
Placenta previa totalis, hemorrhage 2 5.7 180 m (120–240 m) 3h
Evisceration 1 2.9 7d 168 h
a
Case 4 of Table 5 was exclud- Bladder injury 1 2.9 360 m 6h
ed because of extraordinary
Herniation of omentum due to drainage 1 2.9 6d 144 h
conditions
Total 35 100.0 179.8 h
m minutes, h hours, d days

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 422

123
Table 4 Overview of 21 cases in the early period
Case Cesarean indication Time interval Indication for laparotomy Operation technique Operation Postoperative Postoperative complication
for laparotomy time time in
(m = minutes) (m = minutes) hospital
(days)

1 Placental abruption 480 Bleeding into abdomen Laparotomy 200 20 ICU, re-re-laparotomy 4 days later and
hysterectomy, acute renal failure
2 Fetal distress 540 Bleeding into abdomen Laparotomy 45 3 –
3 Placental abruption 360 Bleeding into abdomen Laparotomy 165 13 Postoperative fever, transfusion
4 Twin, transverse presentation 600 Bleeding into abdomen Laparotomy 75 4 Postoperative fever, transfusion
5 Cephalopelvic disproportion 60 Bleeding into abdomen Laparotomy 120 8 Postoperative fever, transfusion
6 Fetal distress 720 Bleeding into abdomen hysterectomy 80 6 Transfusion
7 Placental abruption 480 Bleeding into abdomen Subtotal hysterectomy 100 6 Transfusion
8 Placental abruption 240 Bleeding into abdomen Laparotomy 120 4 Transfusion
9 Cephalopelvic disproportion 420 Bleeding into abdomen Laparotomy 100 5 Transfusion
10 Placental abruption 360 Bleeding into abdomen Laparotomy 120 5 Transfusion
11 ÃVF, on request 360 Bleeding into abdomen Laparotomy 90 4 –
12 Previous cesarean (·2) 720 Bleeding into abdomen Laparotomy 90 4 Transfusion
13 Placental abruption 720 Hematoma Laparotomy , re-suture 60 15 ICU, postoperative fever
14 Twin 240 Hematoma Laparotomy, re-suture 90 5 Postoperative fever
15a Fetal distress 300 Hematoma Laparotomy, re-suture 60 5 Postoperative fever, transfusion,
re-re-laparotomy 10 days later
16 Placental abruption 120 Hematoma Laparotomy, re-suture 150 5 Transfusion
17 Previous cesarean (·2) 120 Pp.totalis/hemorrhage Hysterectomy 90 5 –
18 Placenta previa 240 Pp.totalis/hemorrhage Subtotal hysterectomy 60 5 Transfusion
19 Previous cesarean (·2) 600 Atony Subtotal hysterectomy 90 7 Postoperative fever, transfusion
20 Previous cesarean (·2) 240 Atony Subtotal hysterectomy 100 6 Transfusion
21 Previous cesarean (·2) 360 Bladder injury Laparotomy, repair 75 5 Transfusion
394 m = 6.6 h 95 m 6.6 d
a
15 is the same patient of Table 5, case 3
ICU intensive care unit, Pp totalis placenta previa totalis
Arch Gynecol Obstet (2008) 278:419–425
 Table 5 Overview of 13 cases in the late period
Arch Gynecol Obstet (2008) 278:419–425

Case Cesarean indication Time interval Indication for laparotomy Operation technique Operation Postoperative Postoperative complication
for laparotomy time time in
(d = days) (m = minutes) hospital (days)

1 Previous cesarean (¸3) 78 d Intraabdominal mass/hematoma Laparotomy ,re-suture 100 6 –

2 Previous cesarean (¸3) 5d Intraabdominal mass/hematoma Laparotomy ,re-suture 65 14 Postoperative fever, transfusion
3a Fetal distress 15 d Hematoma Laparotomy ,re-suture 75 4 –
4 Placental abruption 30 d Atony Subtotal hysterectomy 100 6 Postoperative fever, transfusion
5 Fetal distress 12 d Abscess in right parametrium Draining and re-suture 50 6 –
6 Abnormal labor progress 6d Abscess in left broad ligament Draining and re-suture 80 8 –
7 Fetal distress 9d Abscess in anterior abdominal wall Draining and re-suture 40 20 Postoperative fever, transfusion
8 Previous cesarean (·2) 9d Abscess in anterior abdominal wall Draining and re-suture 35 12 Postoperative fever
9 Previous cesarean (·2) 69 d Abscess in anterior abdominal wall Draining and re-suture 45 4 –
10 Previous cesarean (·2) 5d Abscess in anterior abdominal wall Draining and re-suture 90 12 Postoperative fever
11 Previous cesarean (·2) 5d Peritonitis, suspicious abscess formation Draining and re-suture 60 10 Exitus
12 Preeclampsia 6d Herniation of omentum due to drainage Laparotomy and repair 50 10 Postoperative fever
13 Fetal distress 7d Evisceration Laparotomy and repair 120 9 Postoperative fever, ileus
19.7 d 63 m 9.3 d
a
3 is the same patient of Table 4, case 15

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423
424 Arch Gynecol Obstet (2008) 278:419–425

edematous, erythematous and the exudate was serosanguin- a VBAC plateaued between 1989 (18.9%) and 1996
ous. She had signs of peritonitis, but ultrasonography did (28.3%). The loss of enthusiasm for VBAC has been attrib-
not detect any obvious intraabdominal pathologic process. uted to the increasing number of reports of uterine ruptures
Extensive debridement of the cutaneus, subcutaneous and [13, 15]. In response to these reports, the VBAC trial rate
necrotic areas of the anterior abdominal fascia was per- decreased to 9.2% in 2004 [15]. Although the trial of labor
formed and antibiotics were given. Microbiologic survey of rate of VBAC attempts has decreased over the past several
the exudate revealed a Clostridium perfringens infection. years, new well-designed studies support the safety of
On the 3rd day (8th day postoperatively), she developed VBAC for many women with prior CSs [16].
preshock and was transferred to the intensive care unit, but For a safe CS, securing hemostasis is essential. Obstetri-
died secondary to sepsis. cians should use blunt dissection of subcutaneous tissue
There were two maternal intensive care unit admissions. and unipolar coagulation can be applied after the delivery
In Table 4, cases 1 and 13 were admitted to the intensive of the infant. Bleeding into the abdomen (12 patients), post-
care unit because of hypovolemic shock and acute renal operative hematoma in the abdomen or abdominal wall
failure, and postoperative fever and suspicion of sepsis, (9 patients), atony (3 patients), and hemorrhage due to
respectively. complete placenta previa (2 patients) constituted 74.3% of
Two repeat re-laparotomies were performed. The Wrst all cases. This rate was between 66 and 83% in prior studies
case (Table 4, case 1) had CS because of placental abrup- [7, 8]. Other recent studies [17, 18] about rehospitalization
tion. The indication for R-LACS was abdominal hemor- and puerperal complications reported similar circum-
rhage. Although hemostasis was achieved, there was stances, but diVerent rates. Bleeding secondary to atony or
bleeding and a hysterectomy was performed 4 days later. placenta previa bleeding are unpreventable situations, but
The second case had a CS because of fetal distress, after complications of bleeding into the abdomen or hematoma
which a hematoma formed. The hematoma was drained and formation, depend, in part on the surgeon, surgical tech-
resuturing was performed. Fifteen days later, she sought niques [7] and tissue factors. Ceydali et al. [19] in a recent
evaluation for pelvic pain. On ultrasound, another hema- evidence-based analysis for best abdominal closure in
toma was visible over the rectus muscle and a repeat re-lap- diVerent general surgical procedures concluded that the
arotomy was performed. best possible closure technique includes the following: a
mass closure (compared to a layer closure), a simple run-
ning suturing technique, use of absorbable monoWlament
Discussion suture material and a suture length-to-wound length ratio of
4:1. DiVerent techniques of fascial closure have not been
The incidence of R-LACS in this study was 0.12%, which speciWcally studied in any trial of CS [20].
is lower than the incidences in previously published studies Incidental bladder lacerations may occur during CS,
(0.39–0.73%; 6–8). The current study was a descriptive sur- despite preoperative Foley catheter drainage. Incidental
vey of the incidence, indications, management and out- bladder lacerations may result from adhesions from prior
comes of R-LACS in a tertiary teaching hospital in Istanbul abdominal procedures, inferior extension of the uterine
over a 60-month period. incision or an inadvertent dissection. Postrepair integrity
The indications for CS at our hospital were similar to should be assessed with retrograde Wlling by methelene
previously published studies [6–8]. Unfortunately, we had a blue and a Foley catheter should remain in situ 5–7 days to
very high rate for previous CS of 29.0%, which contributed facilitate complete healing [21]. Herniation of the omentum
to the high CS rate of 31.23% in our hospital. CS on during drainage is a unique and underestimated complica-
demand has become an increasingly common option for tion.
patients in the past decade. Nevertheless, physicians should Post-CS surgical site infections were the main indica-
regard and apprise the patient about the complications, tions for R-LACS, especially during the late period (20% of
mortality and morbidity rates associated with cesarean all cases) in our series. Opøien et al. [22] stated diVerent
delivery in comparison to vaginal delivery. Indications risk factors, such as surgical time exceeding 38 min and a
should be provided for appropriate and necessary cases. It body mass index of >30. These factors are unpreventable
has been suggested, and we concur, that the indications for and are mainly patient dependent. Unfortunately, the only
CS are often for social or inappropriate reasons [9–13]. The fatal case in our series was puerperal Clostridium perfrin-
World Health Organization (WHO) recommends that the gens sepsis, which is a rare condition in obstetrical practice.
CS rate should be no higher than 15% [14]. Another factor We found only three case reports in the English literature
that would decrease the rate of CS is encouragement of over the last 10 years, based on our search in MEDLÃNE
vaginal birth after a previous cesarean section (VBAC). Of [23–25]. However, this rare anaerobic infection continues
note, the increase in patients undergoing a trial of labor for to occur in modern obstetric practice and knowledge about

123
Arch Gynecol Obstet (2008) 278:419–425 425

clinical signs may help in accurate diagnosis and treatment 10. Ribeiro VS, Figueiredo FP, Silva AA, Bettiol H, Batista RF,
may perhaps be life saving. Coimbra LC, Lamy ZC, Barbieri MA (2007) Why are the rates of
cesarean section in Brazil higher in more developed cities than in
The most important factors in our study leading to CS less developed ones? Braz J Med Biol Res 40:1211–1220
and R-LACS were placental abruption and previous 11. Abenhaim HA, Benjamin A, Koby RD, Kinch RA, Kramer MS
CS ¸ 3. We found only one study by Alchalabi et al. [26], (2007) Comparison of obstetric outcomes between on-call and
which stated a 14-fold increase in the risk of cesarean hys- patients’ own obstetricians. CMAJ 177:352–6
12. Leung GM, Ho LM, Tin KY, Schooling CM, Lam TH (2007)
terectomy in patients with previous CS ¸ 3. Surgical risk Health care consequences of cesarean birth during the Wrst
of adhesions following previous abdominal surgeries and 18 months of life. Epidemiology 18:479–484
homeostasis and related hematological changes and con- 13. Lehmann S, Børdahl PE, Rasmussen SA, Irgens LM (2007) Nor-
ditions in cases of placental abruption may be the causes wegian midwives and doctors have increased cesarean section
rates. Acta Obstet Gynecol Scand 86:1087–1089
of R-LACS. We had ten cases (two cases because of pre- 14. Anonymous (1985) Appropiate technology for birth. Lancet
vious CS ¸ 3 and eight cases because of placental abrup- 2:436–437
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