AJOG REVIEWS

Nonclosure of peritoneum: A reappraisal

Togas Tulandi, MD, and Dania Al-Jaroudi, MD
Montreal, Quebec, Canada
In our specialty, the practice of closing or not closing the peritoneum is still being debated. Our purpose was to
review the literature on the subject, to evaluate the advantages and disadvantages of the procedure, and to
provide clinical opinions. Closure of the peritoneum either parietal or visceral peritoneum is unnecessary, it is
associated with a slightly longer operating time and more postoperative pain, and there are some suggestions
that it might cause more adhesion formation. There are more advantages than disadvantages to not closing
the peritoneum. We encourage clinicians not to close both parietal and visceral peritoneum. (Am J Obstet
Gynecol 2003;189:609-12.)

Key words: Peritoneal closure, peritoneal nonclosure, adhesion, bowel obstruction

In a recent international meeting in the United States,

we were surprised to learn that some gynecologists still
consider closing the peritoneum to be a necessity and to
fail to do so is a poor surgical technique. They stated that
younger gynecologists do not respect the traditional
technique of abdominal closure, which includes closure
of both visceral and parietal peritoneum. These gynecologists argued that peritoneal closure restores the
normal anatomy, closes the peritoneal defect, reduces the
risks of infection and herniation, and decreases adhesion
formation. We hereby re-examine the current evidence
whether visceral or parietal peritoneum should or should
not be closed.
Peritoneal healing in an animal model
The peritoneum is the serous membrane that covers
the abdominal wall (parietal peritoneum) and the viscera
(visceral peritoneum). As early as 1919, it was noted that,
unlike the healing of a skin defect that gradually heals
from the wound edges, the peritoneal defect restores
simultaneously by regeneration.1 It heals rapidly, and the
duration of repair is independent on the size of the
peritoneal defect.2
Most animal studies compared closure and nonclosure of the parietal peritoneum.3-5 In a rabbit model,
From the Department of Obstetrics and Gynecology, McGill University.
Received for publication November 19, 2002; revised January 31, 2003;
accepted February 24, 2003.
Reprint requests: Togas Tulandi, MD, Department of Obstetrics and
Gynecology, McGill University, 687 Pine Ave W, Montreal, Quebec,
Canada, H3A 1A1. E-mail: togas.tulandi@mcgill.ca
2003, Mosby, Inc. All rights reserved.
0002-9378/2003 $30.00 + 0
doi:10.1067/S0002-9378(03)00299-0

peritoneal healing occurred in 5 days; however, when

the peritoneum was sutured, it occurred in 2 to 3 weeks.
The presence of sutures promotes intense inflammatory
foreign body reaction and tissue necrosis that might
predispose to adhesion formation.6 Indeed, several
animal studies have demonstrated that the closure of
the parietal peritoneum, either by sutures or staples, is
associated with more adhesion formation than leaving it
open to heal by secondary intention.3-6 For example, in
a horse model, the closure of the parietal peritoneum is
associated with a 50% adhesion rate. This was higher
than the rate without peritoneal closure (27%).3
Other investigators reported similar findings.7 It
appears that leaving the peritoneum to heal by secondary
intention does not predispose to wound dehiscence or
incisional hernia and is associated with less adhesion
formation.8,9
What we can learn from general surgery
Our colleagues in general surgery have long realized
that the closure of parietal peritoneum is unnecessary and
that they have abandoned this practice.8,10-12
Parietal peritoneum. In 1977, Ellis and Heddle8 first
reported the results of a randomized study that compared
closure and nonclosure of parietal peritoneum with
a vertical laparotomy incision. They found no difference
in the incidence of wound dehiscence or hernia between
the closure (2.5% and 4.3%, respectively) and the
nonclosure group (3.0% and 4.3%, respectively). They
concluded that peritoneal closure plays no role in the
healing of the laparotomy wound.
Two decades later, Dorfman et al13 randomly assigned
129 patients who underwent cholecystectomy with Kocher
609

610 Tulandi and Al-Jaroudi

incision into closure and nonclosure of parietal peritoneum. They also found that there were no differences in
the overall wound complications, wound dehiscence, and
incisional hernia in the two groups of patients. Similar
findings were reported in another randomized trial after
a laparotomy with lateral paramedian incision12 and with
vertical incision.11
Visceral peritoneum. An observational study in 1952
revealed that, of 18 patients who had undergone
reperitonealization after abdominoperineal resection, 4
patients had intestinal obstruction.14 No bowel obstruction was found in those patients with no closure of the
visceral peritoneum. It seems that the bowel obstruction
was due to incarceration of the intestine in the newly
reconstructed pelvic floor.15
Gynecologic operations
Parietal peritoneum. In 1988, by means of a secondlook laparoscopy, we first reported that there was no
difference in the adhesion formation after laparotomy
with peritoneal closure (22.2%) and without peritoneal
closure (16%).16 We did not encounter wound dehiscence or hernia in either closure or nonclosure groups.
The incidence of wound infection was 3.6% and 2.4%,
respectively. In a nonrandomized study, Palazzetti et al17
reported that the incidence of ileus after abdominal
hysterectomy was significantly higher in women with
peritoneal closure (40%) than in women without peritoneal closure (21%, P = .003).
Visceral peritoneum. Lipscomb et al18 compared the
clinical outcome of 106 women who underwent vaginal
hysterectomy with or without peritoneal closure. There
was no difference in postoperative complications between
the two groups of patients. However, the authors
acknowledged that the power of their study was only 20%.
In women with ovarian cancer, the closure of pelvic
and periaortic peritoneum is associated with more
adhesion formation than in women with no closure.19,20
There was also no difference in the duration of
postoperative ileus and in the hospital stay between the
closure group (3.6 and 8.6 days, respectively) and the
nonclosure group (3.8 and 9.3 days, respectively).19 In
1999, we evaluated 262 women who were admitted to the
hospital for small bowel obstruction.21 We found that
the most common cause of small bowel obstruction was
intra-abdominal adhesions. Furthermore, adhesions that
involved the site of closure of the pelvic peritoneum
were responsible for bowel obstruction in 85% of cases,
with adhesions to the anterior abdominal wall occurring
in another 15% of cases. This is in agreement with the
findings after closure of visceral peritoneum during
abdominoperineal resection.15
Parietal and visceral peritoneum. Franchi et al22
randomly assigned 120 patients who underwent radical
hysterectomy and node dissection to closure and non-

August 2003
Am J Obstet Gynecol

closure of both parietal and visceral peritoneum. They

found that the amount of drainage in the nonclosure
group was less than in the closure group (340 mL and 740
mL, respectively; P < .005). They attributed it to the
escape of lymph fluid into the abdominal cavity in the
nonclosure group; the fluid was then absorbed. No
difference was found in the operating time and in the
incidence of lymphocyst formation, infection, and bowel
obstruction between the two groups.
In another randomized trial, Gupta et al23 studied 144
patients who underwent a hysterectomy with and without
peritoneal closure. The postoperative pain between the
two groups was similar. The mean estimated blood loss in
the closure group was more than in the nonclosure group
(258 and 213 mL, P = .03), and the mean operating time
in the closure group was 10 minutes longer (49.1 and 39.1
minutes, respectively, P < .001).
These findings suggest that, even among oncologic
patients, the closing of the peritoneum is unnecessary and
might increase adhesion formation. The results of
randomized trials on peritoneal closure versus nonclosure
among women who underwent gynecologic operations
and cesarean deliveries are depicted in Table I.*
Cesarean delivery
There have been many studies that compare the effects
of nonclosing the peritoneum at the time of cesarean
delivery. Most investigators compared the closing and
nonclosing of both parietal and visceral peritoneum; the
peritoneal suturing was done with polyglactin.
Parietal peritoneum. Closure of the parietal peritoneum was compared with peritoneal nonclosure at the
time of cesarean delivery through a Pfannenstiel incision
in 248 women.24 The mean duration of surgery in the
nonclosure group (48.1 1.2 minutes) was shorter than
in the closure group (53.2 1.4 minutes, P < .005). There
was no difference in the amount of blood loss, ileus, and
dehiscence between the two groups. The mean hospital
stay was 4.5 days in the closure group and 4.8 days in the
nonclosure group; the incidence of wound infection was
1.0% and 0.9%, respectively. In a small series, Hojberg
et al25 reported that the use of postoperative analgesics
was lower if the parietal peritoneum was left open. The
duration of hospital stay was 7.1 0.4 days in the closure
group and 6.3 0.3 days in the nonclosure group. Febrile
morbidity was encountered only in two patients in the
closure group.
Visceral peritoneum. Nagele et al26 conducted the
largest randomized trial that compared closure and
nonclosure of visceral peritoneum among 549 women.
The operating time was significantly longer in the
closure group (56.9 17.9 minutes) than in the non-

*References 8,11,12,18,19,22,23.

Tulandi and Al-Jaroudi 611

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Am J Obstet Gynecol

Table I. Randomized trials of peritoneal closure or nonclosure in general surgery and gynecology
Ellis and
Heddle8

Franchi et al22

Gupta e et al23

Vertical,
Lateral
Midline
Pelvic and
Vaginal
Radical
median, or
paramedian
incision for
paraaortic
hysterectomy
hysterectomy
paramedian
incision for
general
lymphadand node
incision for
general
surgical
enectomy for
dissection
general surgical
surgical
cases
ovarian
cases
cases
cancer
Parietal
Parietal
Parietal
Visceral
Visceral
Parietal and
visceral
C
NC
C
NC
C
NC
C
NC
C
NC
C
NC
162
164
77
75
87
92
50
52
49
57
59
61
8.0
12.2
NA
NA
NA
NA
28.0
26.9
NA
NA
3.4
1.6

Hysterectomy,
transverse,
or left
paramedian
incisions

Authors
Procedure/
incision

Peritoneum

C vs NC
Patients
Febrile (%)
morbidity
Wound
NA
infection (%)

NA

Gilbert et al12

9.1

12.0

Hugh et al11

2.3

3.3

Kadanah et al19 Lipscomb et al18

8.0

5.8

2.0

1.8

10.2

18.0

Parietal and
visceral
C
NC
76
68
16.2
15.2
6.8

C, Closure; NC, nonclosure.

Table II. Randomized trials of closure or nonclosure of parietal and visceral peritoneum at the time of cesarean delivery
Parameter
Patients (No.)
Mean operating time (min)
Mean hospital stay (d)
Febrile morbidity (%)
Wound infection (%)

Hull and
Varner27
C
59
57.9
4.2
13.5
8.5

NC
54
50.0
4.0
16.6
5.6

Irion
et al28
C
143
53.2
6.8
8
NA

NC
137
47.3
6.5
8
NA

Ohel
et al29
C
100
44
NA
10
3.0

NC
100
32
NA
10
4.0

Grundsell
et al30
C
182
41.3
6.4
19.2
3.2

NC
179
33.4
5.3
7.8
2.2

Rafique
et al31
C
50
38.8
NA
NA
2.0

NC
50
32.8
NA
NA
2.0

Ho
et al32
C
94
40.4
4.4
NA
NA

NC
96
38.8
4.6
NA
NA

C, Closure; NC, nonclosure; NA, not applicable.

closure group (50.6 16.8 minutes). The incidence of

febrile morbidity was significantly higher when the
peritoneum was closed (15.7% vs 8.4% in the nonclosure group, P = .009). The incidence of cystitis was
also higher in the closure group (7.7% vs 3.1% in the
nonclosure group, P = .01). The incidence of wound
infection and endometritis was 4.9% and 5.1% in the
closure group and 1.9% and 3.9% in the nonclosure
group. Patients in the closure group also required more
postoperative narcotics (P < .001). Hospital stay was
significantly longer in the closure group (7.9 1.8 days
vs 7.2 1.6 days, P < .001). The authors concluded that
the routine closure of the visceral peritoneum should be
abandoned in women who undergo cesarean delivery.
Parietal and visceral peritoneum. Table II shows the
results of randomized trials that compared closure and
nonclosure of peritoneum at the time of cesarean delivery
that involved 1284 women.27-32 The results show that
there are no disadvantages of not closing the peritoneum.
Hull and Varner27 found that there was no difference in
the postoperative morbidity between the two groups of
patients. The number of oral analgesics and the operating
time, however, were significantly higher in the closure
group. Among 361 patients, Grundsell et al30 found that
the incidence of febrile morbidity and wound infection
was lower among the women with closure of visceral and

parietal peritoneum. The operating time in the nonclosure group was shorter (P < .01) and the average
hospital stay was 1 day less (P < .01).
In another study, postoperative pain was found to be
less if the visceral and parietal peritoneum were not
sutured.31 Irion et al28 found that the return of bowel
function occurred faster in patients whose peritoneum
was left open. Adhesion formation at repeat cesarean
delivery has been evaluated also.33,34 Confirming previous
clinical and animal studies, the results suggest that
peritoneal nonclosure does not promote, and might even
decrease, adhesion formation.
Clearly, these studies demonstrate that closing the
peritoneum is not only unnecessary but also associated
with a longer operating time and more postoperative
pain. In a systematic review, Wilkinson and Enkin35
concluded that there is a consistent trend for improved
immediate postoperative outcome if the peritoneum is
not closed.
Comment
Evidence of the safety of not closing the peritoneum is
overwhelming. Most studies show that this practice not
only reduces the operating time but also that the
postoperative recovery is similar or even better than in
those with peritoneal closure. This is applicable to both

612 Tulandi and Al-Jaroudi

parietal and visceral peritoneum and to both cesarean and

gynecological operations. The fewer requirements of
analgesics and the shorter hospital stay are economical.
We may ask why nonclosure of the peritoneum has not
gained much general acceptance among the obstetricians
and gynecologists.36 The answers might be that it is
difficult to change the traditional dogma of peritoneal
closure or that this topic has not received sufficient
attention from our colleagues.
In our specialty, there have been more randomized
trials on peritoneal nonclosure than in general surgery.
The results show that closing either the parietal or visceral
peritoneum is unnecessary and is associated with a slightly
longer operating time and more postoperative pain; there
is a suggestion that it might cause more adhesion
formation. In a recent article, Ellis37 acknowledged that
there have been increasing medicolegal claims that arise
from adhesion-related complications. He stated that
peritoneal defects and the pelvic floor should be left
open since they rapidly reperitonealized.
We encourage obstetricians and gynecologists to omit
peritoneal closure. As shown in the randomized trials,
there are more advantages than disadvantages of not
closing the peritoneum.
REFERENCES
1. Hertzler AR. The peritoneum. Vol 1. St. Louis: Mosby; 1919.
2. Ellis H, Harrison W, Hugh TB. The healing of peritoneum under
normal and pathological conditions. Br J Surg 1965;52:471-6.
3. Swanwick RA, Stockdale PH, Milne FJ. Healing of parietal peritoneum in the horse. Br Vet J 1963;129:29-35.
4. McDonald MN, Elkins TE, Wortham GF, Stovall TG, Ling FW,
McNeeley SG, Jr. Adhesion formation and prevention after peritoneal injury and repair in the rabbit. J Reprod Med 1988;33:436-9.
5. Ling FW, Stovall TG, Meyer NL, Elkins TE, Muram D. Adhesion formation associated with the use of absorbable staples in comparison to
other types of peritoneal injury. Int J Gynaecol Obstet 1989;30:361-6.
6. Elkins TE, Stovall TG, Warren J, Ling FW, Meyer NL. A histological
evaluation of peritoneal injury and repair: implications for adhesion
formation. Obstet Gynecol 1987;70:225-8.
7. Kyzer S, Bayer I, Turani H, Chaimoff C. The influence of peritoneal
closure on formation of intraperitoneal adhesions: an experimental
study. Int J Tissue React 1986;8:355-9.
8. Ellis H, Heddle R. Does the peritoneum need to be closed at
laparotomy? Br J Surg 1977;64:733-7.
9. Kapur B, Danewar A, Chopra P. Evaluation of peritoneal closure at
laparotomy. Am J Surg 1979;137:650-2.
10. McFadden PM, Peacock EE. Preperitoneal abdominal wound repair:
incidence of dehiscence. Am J Surg 1983;145:213-4.
11. Hugh TB, Nankivell C, Meagher AP. Is closure of the peritoneal layer
necessary in the repair of midline surgical abdominal wounds? World
J Surg 1990;14:231-3.
12. Gilbert JM, Ellis H, Foweraker S. Peritoneal closure after lateral
paramedian incision. Br J Surg 1987;74:113-5.
13. Dorfman S, Rincon A, Short H. Cholecystectomy via Kocher incision
without peritoneal closure. Invest Clin 1997;38:3-7.
14. Trimpi HD, Bacon HE. Clinical and experimental study of denuded
surfaces in extensive surgery of the colon and rectum. Am J Surg
1952;34:596-602.

August 2003
Am J Obstet Gynecol

15. Ulfelder H, Quinby WC Jr. Small bowel obstruction following combined abdominoperineal resection of the rectum. Surg 1951;30:174-7.
16. Tulandi T, Hum HS, Gelfand MM. Closure of laparotomy incisions
with or without peritoneal suturing and second-look laparoscopy. Am
J Obstet Gynecol 1988;158:536-7.
17. Palazzetti PL, Cipriano L, Pachi A. Is peritoneal closure necessary
after abdominal hysterectomy? Int J Gynecol Obstet 2000;71:255-6.
18. Lipscomb GH, Ling FW, Stovall TG, Summitt RL Jr. Peritoneal
closure at vaginal hysterectomy: a reassessment. Obstet Gynecol
1996;87:40-3.
19. Kadanah S, Erten O, Kucukozkan T. Pelvic and periaortic peritoneal
closure or non-closure at lymphadenectomy in ovarian cancer: effects
on morbidity and adhesion formation. Eur J Surg Oncol 1996;22:
282-5.
20. Than GN, Arany AA, Schunk E, Vizer M, Krommer KF. Closure or
non-closure of visceral peritoneums after abdominal hysterectomies
and Wertheim-Meigs radical abdominal hysterectomies. Acta Chir
Hung 1994;34:79-86.
21. Al-Took S, Platt R, Tulandi T. Adhesion-related small bowel obstruction after gynecologic operations. Am J Obstet Gynecol 1999;180:
313-5.
22. Franchi M, Ghezzi F, Zanaboni F, Scarabelli C, Beretta P, Donadello
N. Nonclosure of peritoneum at radical abdominal hysterectomy and
pelvic node dissection: a randomized study. Obstet Gynecol
1997;90:622-7.
23. Gupta JK, Dinas K, Khan KS. To peritonealize or not to peritonealize?
A randomized trial at abdominal hysterectomy. Am J Obstet Gynecol
1998;178:796-800.
24. Pietrantoni M, Parsons MT, OBrien WF, Collins E, Knuppel RA,
Spellacy WN. Peritoneal closure or non-closure at cesarean. Obstet
Gynecol 1991;77:293-6.
25. Hojberg KE, Aagard J, Laursen H, Diab L, Secher NJ. Closure versus
non-closure of peritoneum at cesarean section: evaluation of pain.
Acta Obstet Gynecol Scand 1998;77:741-5.
26. Nagele F, Karas H, Spitzer D, Staudach A, Karasegh S, Beck A, et al.
Closure or nonclosure of the visceral peritoneum at cesarean
delivery. Am J Obstet Gynecol 1996;174:1366-70.
27. Hull DB, Varner MW. A randomized study of closure of the
peritoneum at cesarean delivery. Obstet Gynecol 1991;77:818-21.
28. Irion O, Luzuy F, Beguin F. Nonclosure of the visceral and parietal
peritoneum at cesarean section: a randomized controlled trial. Br J
Obstet Gynaecol 1996;103:690-4.
29. Ohel G, Younis JS, Lang N, Levit A. Double-layer closure of uterine
incision with visceral and parietal peritoneal closure: are they
obligatory steps of routine cesarean sections? J Matern Fetal Med
1996;5:366-9.
30. Grundsell HS, Rizk DE, Kumar RM. Randomized study of nonclosure of peritoneum in lower segment cesarean section. Acta
Obstet Gynecol Scand 1998;77:110-5.
31. Rafique Z, Shibli KU, Russell IF, Lindow SW. A randomised
controlled trial of the closure or non-closure of peritoneum at
caesarean section: effect on postoperative pain. Br J Obstet Gynaecol
2002;109:694-8.
32. Ho WP, NorAzlin MI, Patrick CFW, Nasri NM, Adeeb N. Peritoneal
closure at caesarean section. Acta Obstet Gynecol Scand 1997;76:
30-4.
33. Stark M, Chavkin Y, Kupfersztain C, Guedj P, Finkel AR. Evaluation of
combinations of procedures in cesarean section. Int J Obstet Gynecol
1995;48:273-6.
34. Joura EA, Nather A, Hohlagschwandtner M, Husslein P. Peritoneal
closure and adhesions. Hum Reprod 2002;17:249-50.
35. Wilkinson CS, Enkin MW. Peritoneal non-closure at caesarean
section (Cochrane Review). In: Cochrane Library, issue 3. Oxford:
Update Software; 2002.
36. Duffy DM, diZerega GS. Is peritoneal closure necessary? Obstet
Gynecol Surv 1994;49:817-22.
37. Ellis H. Medicolegal consequences of postoperative intra-abdominal
adhesions. J R Soc Med 2001;94:331-2.