Impact of Hysterotomy Closure Technique on Subsequent Cesarean Scar Defects Formation: A Systematic Review

INTRODUCTION

The uterine caesarean scar defect, also known as uterine niche or isthmocele, is an irregularity in the anterior uterine wall at the site of a previous cesarean section scar. It is associated with obstetrical complications such as caesarean scar, ectopic pregnancy, uterine rupture, and the placenta accreta spectrum. Women with cesarean scar defects are frequently asymptomatic but may also experience abnormal vaginal bleeding, chronic pelvic pain, and infertility.

METHODS

This systematic review aims to determine the best hysterotomy closure technique to prevent subsequent development of uterine scar defects. An electronic search in Medline, Embase, Cochrane Database of Systematic Reviews, ClinicalTrials.gov was performed from January 2001 until December 2020 for studies evaluating hysterotomy closure techniques.

RESULTS

Our systematic search strategy identified 1,781 titles. Six studies fulfilled inclusion criteria and were included in the final analysis. The results supported the superiority of the double-layer closure over the single-layer closure.

CONCLUSIONS

Hysterotomy closure with continuous running sutures in two layers represents a suitable option to prevent cesarean scar defect formation. Particularly, the first layer should include the decidua and the second layer should overlap the first.

Clinical application of single-layer annular vaginal flap in transvaginal repair for vesicovaginal fistula

PURPOSE

To compare the first-time success rate and prognosis of repairing vesicovaginal fistula (VVF) by transvaginal and transvesical approaches, and to highlight a modified transvaginal repair technique which only require single layer closure of an annular vaginal flap.

METHODS

Retrospective analysis of 57 consecutive patients who underwent VVF repair between 2007 and 2021. Fistula characteristics, operative factors, post-surgical complications and outcomes were analyzed.

RESULTS

A total of 57 women with a median age of 50.4 (27-75) years were included. The history ranged from 7 days to 8 years, with an average of 20 months. 56 cases (98.2%) of VVFs were caused by pelvic surgery, and only one resulted from difficult labour. 11 cases (19.3%) had a history of surgical repair failure. All 57 cases of surgery were smoothly completed. Among them, 17 patients underwent transvaginal repair, whereas 40 (70.2%) women had transvesical repair. Transvaginal approach had a significantly shorter operative time, less intraoperative blood loss, reduced postoperative hospital stay, less hospitalization cost and lower minor complication rates than transvesical group (p < 0.05). No serious complications occurred in the two groups. No cystostomy was performed in the transvaginal group, but 12 cases (30%) in the transvesical group. The average follow-up time was 18.5 (3-48) months. The first-time success rates of transvaginal and transvesical techniques were 82.3 and 75%, respectively.

CONCLUSION

VVF repair with single layer closure of an annular vaginal flap is a technically feasible, simple and successful approach with significantly better operative parameters and lower complications rates.

Endoscopic management of congenital nasal meningoencephaloceles: a short series of 15 paediatric cases

PURPOSE

To retrospectively analyse surgical management of clinico-radiologically proven nasal meningoencephalocele amongst children and results of repair with single-layer septo-mucosal flap at a tertiary skull base surgery centre in north India.

METHODS

Fifteen children with clinic-radiological nasal meningoencephaloceles with or without CSF rhinorrhoea were included. Radiological scans included CT scans and MRI scans for all cases to delineate soft tissue and bony architecture. All children underwent endoscopic excision of encephaloceles and repair of the skull base defect.

RESULTS

The authors were successful in fourteen cases. Successful cases included 4 children less than 6 months of age who underwent single-layer rotated septo-mucosal flaps, thereby avoiding donor site morbidity.

CONCLUSION

As endoscopic excision of nasal encephalocele is an established management approach, the authors take the concept of minimally invasive surgery a step further by successfully managing these lesions with single-layer repair. Vascularized septo-mucosal flap seems to be the only determining factor for a successful repair for congenital meningoencephalocele. However, a prospective study comprising a larger subset of patients would substantiate the assumption.

Efficacy of single layered intestinal anastomosis over double layered intestinal anastomosis-an open labelled, randomized controlled trial

AIMS & OBJECTIVES

The hand-sewn method of bowel anastomosis is the most common because of its affordability, familiarity and easy availability of materials. It can be done in single or double layers, with different surgeons preferring one technique over the other. Double layer intestinal anastomosis (DLIA) is time-consuming, challenging to perform, and carries possibly a higher risk of devascularisation, infection, and necrosis. Studies conducted so far do not show a significant difference between the two, but have concluded that more studies are required to determine this definitively. This study attempted to see whether the single layer intestinal anastomosis (SLIA) is non-inferior to DLIA in terms of incidence of anastomotic leak. It also compared mortality, morbidity, and length of hospitalization (LOH) between the two groups.

MATERIALS AND METHODS

This was a parallel arm, open labelled, non-inferiority randomized controlled trial conducted in the department of surgery in a tertiary care centre between October 2016 and March 2018. Patients who fulfilled the inclusion criteria were randomly allotted to two groups: Patients undergoing SLIA and patients undergoing DLIA. After the procedure, all patients were assessed for anastomotic leak, morbidity, mortality and LOH in the postoperative period. A 3-month follow-up period was observed for complications.

RESULTS

A total of 106 patients were randomised, 52 in SLIA and 54 in DLIA. Baseline demographic and clinicopathological characteristics between the two groups were comparable. The most common indication for intestinal anastomosis was ostomy closure in both groups. There was no significant difference between the two groups in terms of anastomotic leak, other complications, mortality and LOH.

CONCLUSION

SLIA was comparable to DLIA with respect to incidence of anastomotic leak, morbidity, mortality, and the length of hospitalization, and can be considered as a safe and feasible alternative, in elective and emergency settings.

A study on the efficacy of single layer full thickness duct to mucosa pancreatojejunostomy following pancreatoduodenectomy

Pancreatoduodenectomy is the procedure of choice for treating periampullary and pancreatic head malignancy. The procedure has been standardized and the mortality has reduced considerably to fewer than 5% in high volume centers specializing in pancreatic surgeries. Unfortunately, the morbidity still hovers around 40%. The Achiles heal of pancreatoduodenectomy is the pancreatoenteric anastamosis, the failure of which leads to significant morbidity. Literature is flooded with a plethora of techniques of reconstruction, and the results are variable. In this present study, we have analyzed a technique in which we used a single layer full thickness duct to mucosa pancreatojejunostomy. Among the 25 subjects in this study, there was only one case of one mortality due to drug-induced cardiac arrhythmia, and no mortality secondary to pancreas-specific complications were reported. The present study was a pilot study compared with historical controls, where these results were comparable to the historical data reported earlier as well as our own historical data of two-layered anastamosis. The results of this pilot study supported our concept of single layer full thickness duct to mucosa anastamosis being least traumatic to the pancreas and having an equal efficacy to that other conventional techniques.

Large-Area Growth of Uniform Single-Layer MoS2 Thin Films by Chemical Vapor Deposition

We report the largest-size thin films of uniform single-layer MoS2 on sapphire substrates grown by chemical vapor deposition based on the reaction of gaseous MoO3 and S evaporated from solid sources. The as-grown thin films of single-layer MoS2 were continuous and uniform in thickness for more than 4 cm without the existence of triangular-shaped MoS2 clusters. Compared to mechanically exfoliated crystals, the as-grown single-layer MoS2 thin films possessed consistent chemical valence states and crystal structure along with strong photoluminescence emission and optical absorbance at high energy. These results demonstrate that it is possible to scale up the growth of uniform single-layer MoS2 thin films, providing potentially important implications on realizing high-performance MoS2 devices.