Suprapannicular Incision Technique for Cesarean Delivery in obese patients

A case series published in September issue of the Journal of Obstetrics and Gynecology describes an alternative suprapannicular skin incision technique for cesarean delivery in obese patients. Lakhi et al. used this technique on 17 obese patients and observed no intraoperative complications or wound complications. The incision permitted easy access to the lower uterine segment thereby eliminating the need for a vertical hysterotomy.

In this technique, an assistant exerts caudal traction on the overhanging panniculus with Allis clamps, and a transverse skin incision was made below the umbilicus, at a point 3 cm below the line joining the anterosuperior iliac crests. Once opening the abdomen, retractors were used for easy access to the lower uterine segment and delivery of the baby.

courtesy:https://journals.lww.com 

With the rising global obesity rates, the obstetrician is increasingly faced with a decision to perform cesarean in obese and morbidly obese patients with large pannus.  However, the use of Pfannenstiel incision in obese patients with a moist region below the panniculus results in increased rate of surgical site infection, and it has been long debated.

Cases of fat necrosis of the abdominal pannus following cesarean section has been reported which may be secondary to pressure applied to the retracted pannus during surgery. Furthermore, this incision also limits access to the lower uterine segment due to overhanging pannus.

Obesity significantly increases the rate of cesarean section, and Weiss et al. report a cesarean section rate of 20.7% in a normal weight control group as compared to 33.8% in obese women, and 47.4% in morbidly obese women (BMI>35kg/m2).

A review of the literature showed that Tixier et al. have reported a case series of 18 patients using the suprapannicular infraumbilical transverse incision with no intraoperative or postoperative complications.

So far there are only case series and case reports about the alternative choice of the incision in obese patients. Currently, a randomized clinical trial comparing Wound Complication Rates Between Low Transverse, Midline Vertical, and High Transverse Skin Incisions in Women with a BMI of 40 or Above Undergoing a Cesarean Section for Delivery is underway at Albany Medical College, New York.

Prospective trials with enough power are needed before a recommendation is made regarding the choice of skin incision in obese and morbidly obese patients.

Abstract

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