Evaluation of the effect of cesarean suture techniques on isthmocele formation

Objective: This thesis study aims to investigate whether single layer locked continuous suturing, double layer locked continuous suturing and transverse locked continuous suturing techniques used for uterine incision repair in cesarean section operation affect postoperative formation of isthmocele. Materials and Methods: This is a review of 90 pregnant women who had cesarean delivery at the obstetrics and gynecology department of Afyonkarahisar Health Sciences University Medical Faculty between 10 November 2022 and 10 August 2023. The women who were aged between 18 and 45 years, the women who had singleton pregnancy and the women who had primary or recurrent cesarean delivery were included. The women who were aged younger than 18 years, the women who were aged older than 45 years, the women who had multiple pregnancies, the women who had cesarean delivery during active labor and the women who refused to participate were excluded. Uterus was repaired by single locked suturing in 30 patients while double locked suturing was performed to repair uterus in 30 patients and transverse locked suturing was done in the remaining 30 patients. Each patient underwent transvaginal ultrasonography to evaluate any persisting isthmocele and measure residual myometrial thickness as well as isthmocele width and depth at third and sixth postoperative month. Results: The patients who received double layer locked suturing were significantly younger than the patients who received single layer and transverse locked suturing techniques (p=0.029). The patients who received transverse locked suturing technique had significantly lower cesarean deliveries than the patients who received single and double layer locked suturing techniques (p=0.005). The rates of single and double layer locked suturing techniques were significantly higher in women who had at least two cesarean deliveries than the women who had only one cesarean delivery (p=0.027). The rate of previous cesarean delivery was significantly higher in women who received transverse locked suturing than the women who received single and double layer locked suturing (p=0.014). The women who received single layer, double layer and transverse locked suturing were statistically similar with respect to both preoperative and postoperative hemoglobin values (p=0.389 and p=0.489 respectively). Single layer, double layer and transverse locked suturing techniques were statistically similar in aspect of residual myometrial thickness, isthmocele depth and width recorded at postoperative third month (p=0.549, p=0.174 and p=0.379 respectively). Additionally, single layer, double layer and transverse locked suturing techniques were statistically similar in aspect of residual myometrial thickness, isthmocele depth and width recorded at postoperative sixth month (p=0.522, p=0.147 and p=0.280 respectively). İsthmocele developed in 46 out of 90 patients (51.1%) while there was no isthmocele in 44 patients (48.9%). The patients who developed isthmocele had significantly higher gravidity and cesarean delivery numbers than the patients in whom there was no isthmocele (p=0.008 and p==0.001 respectively). The istmocele development risk increased significantly with increasing number of cesarean delivery (p=0.001). Single layer, double layer and transverse locked suturing techniques were found to be statistically similar with respect to isthmocele development risk (χ2 =0.356, p=0.837). Conclusion: In this thesis study, double layer locked, single layer locked and transverse locked suturing techniques were found to be statistically similar with respect to isthmocele development. Moreover, isthmocele development rate was statistically similar in aspect of uterine suturing techniques. Residual myometrium thickness, isthmocele depth and width values measured at third and sixth postoperative months did not differ significantly with respect to suturing techniques. The cesarean delivery rate and related isthmocele rate both increase steadily due to the current alterations in economical and sociocultural conditions. To overcome this steady increase, surgical repair techniques used for cesarean deliveries should be standardized and necessary measures should be undertaken. Additionally more research should be carried out and more scientific evidence should be gathered about the identification of risk factors related with isthmocele formation. Keywords: cesarean section, isthmocele, sutures, uterus