ajog.

org

Letters to the Editors

REFERENCE

2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.

2015.03.010

1. Tarnow-Mordi WO, Duley L, Field D, et al. Timing of cord clamping in

very preterm infants: more evidence is needed. Am J Obstet Gynecol
2014;211:118-23.

Single- vs double-layer and locking vs nonlocking

closure of uterus: missing woods for the trees?
TO THE EDITORS: Roberge et al1 present an important
and welcome review with a practically useful conclusion
that single-layer and locked rst-layer closure during cesarean are associated with thinner myometrial thickness.
Randomized controlled trials (RCTs) are of paramount
importance in guiding/changing opinion, but could be
rationally used to make wider practice recommendations
rather than strictly limited narrow interpretations. Roberge
et al1 have also highlighted many limitations of their
metaanalysis and the studies included in it. Apart from
being highly resource intensive (expensive), the RCTs of
surgical procedures have particular limitations (compared to,
say, pharmacological interventions) because of the wide
spectrum of subset variation in surgical technique and skill
involved; and are often less than conclusive. Another limitation of RCTs is the propensity and compulsion to study what
is conveniently or objectively quantiableeeg, single-/doublelayer closure of uterusecreating a awed impression that this
must be the main/nal arbitrator of the strength of uterine
scar.2 In reality, these are only imperfect surrogates for the
underlying surgical principles inuencing the healing of
uterine incision. A 2-layer closure would be ideal/preferable as
it allows better approximation of thick myometrial edges. But
this could be accomplished judiciously with adequate hemostasis without devascularization, or injudiciously with excessively tight locking sutures with strangulation of tissues.2 The
common imitative practice in the United Kingdom of
including wide bites of surrounding smooth uncut myometrium in the second layer with tight locking sutures could lead
to ischemic necrosis of intervening myometrium leaving an
area of poorly healed myometrium.2 Thus, the locking of
second layer of sutures may be equally or more disadvantageous than locking the rst layer, even if this has not been the
subject of available studies. On the other hand, operative time
saving of 6 minutes (with single-layer closure)1 is clinically
irrelevant or unimportant and should not normally enter
decision-making equation.
Thus, the thick myometrial edges are best sutured in 2
layers avoiding locking of both layers of sutures. Evidencebased surgical practice should be founded on knowledge
from studies/RCTs but also supplemented by a more
comprehensive process of observation, learning, and pragmatic expertise.3 Sir Austin Bradford Hill whose landmark
work (RCTs) on streptomycin in tuberculosis ushered in the
era of evidence-based medicine remarked, Any belief that

the controlled trial is the only way would mean not that the
pendulum had swung too far, but that it had come right off
its hook.4 Good surgical principles (gentle tissue handling,
minimizing tissue trauma, adequate hemostasis without
devascularization, good anatomical reconstruction/approximation) are not easily amenable to evaluation by RCTs. But,
their discussion (although unfashionable and somewhat
unglamorous) should be included in all reviews/articles on
cesarean delivery techniques avoiding the imbalance of sole
emphasis on RCTs. This should promote more inclusive and
pragmatic decision making and training in surgical
techniques.
Shashikant L. Sholapurkar, MD, DNB, MRCOG
Department of Obstetrics and Gynecology
Princess Anne Wing
Royal United Hospital Bath National Health Service Foundation Trust
Bath, United Kingdom
s.sholapurkar@nhs.net
The author reports no conict of interest.

REFERENCES
1. Roberge S, Demers S, Berghella V, Chaillet N, Moore L, Bujold E.
Impact of single- vs double-layer closure on adverse outcomes and
uterine scar defect: a systematic review and metaanalysis. Am J Obstet
Gynecol 2014;211:453-60.
2. Sholapurkar SL. Increased incidence of placenta previa and accreta
with previous caesareansea hypothesis for causation. J Obstet Gynaecol
2013;33:806-9.
3. Greenhalgh T, Howick J, Maskrey N; Evidence-based Medicine Renaissance Group. Evidence-based medicine: a movement in crisis? BMJ
2014;348:g3725.
4. Hill AB. Heberden oration, 1965: reections on the controlled trial. Ann
Rheum Dis 1966;25:107-13.
2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.
2015.01.006

REPLY
We agree with Dr Sholapurkar about the fact that: (1) good
surgical principles should remain at the basis of the recommendations regarding uterus closure; and (2) randomized
controlled trials are usually designed to answer very specic
questions that do not include important variables such as, in
our case, the locking of the sutures and the inclusion of the
endometrium into the scar. Observational studies suggest that

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