Joel-Cohen or Pfannenstiel incision at cesarean delivery: does it make a difference? Can Joel-Cohen incision and single layer reconstruction reduce cesarean section morbidity? Modified Joel-Cohen technique for caesarean delivery. Pfannenstiel versus Maylard incision for cesarean delivery: A randomized controlled trial.
To evaluate whether the technique to open the abdomen might influence the operative time and the maternal and neonatal outcome.
                All consecutive women who underwent a cesarean section at a gestational age greater than or equal to 32 weeks were randomly allocated to have either the Joel-Cohen or the Pfannenstiel incision. Exclusion criteria were two or more previous cesarean sections and previous longitudinal abdominal incision. During the study period 366 patients underwent a cesarean delivery. Of these patients, 56 did not meet the inclusion criteria. The remaining patients were allocated to the Joel-Cohen (n = 152) group and to the Pfannenstiel (n = 158) group. Extraction time was defined as the time interval from skin incision to the clamping of the umbilical cord.
                The total operative time was similar in both groups [Joel-Cohen 32 min (12-60) vs. Pfannenstiel 33 min (18-70)]. The extraction time was shorter in the Joel-Cohen group than in the Pfannenstiel group [190 s (60-600) vs. 240 s (50-600), p = 0.05]. This remained statistically significant after adjustment for confounding variables (Hazard = 1.26, p = 0.05). No difference was found between groups in terms of intraoperative and postoperative complications. No difference was found in the neonatal neurodevelopmental assessment at 6 months of age in relation to the abdominal incision performed.
                The Joel-Cohen method of opening the abdomen at cesarean delivery is faster then the Pfannenstiel technique at delivering the fetus. However, considering the absence of benefits to the mother and the fetus there is no clear indication for performing a Joel-Cohen incision. To compare an innovative cesarean section based on Joel-Cohen incision with the traditional Pfannenstiel technique in terms of operative data and post-operative recovery.
                Out of 158 randomized patients, 83 patients underwent the innovative cesarean section (Joel-Cohen incision, one-layer locked uterine suture, no peritoneization) and 75 the traditional operative approach (Pfannenstiel incision, double layer closure of the uterus, visceral and parietal peritoneization). Operative data and post-operative morbidity were compared; sample size was calculated to detect a 13% difference in the occurrence of post-operative fever with a statistical power of 80%.
                Post-operative fever was not different in the two groups. Total operating time was shorter with the innovative technique: 31.6 +/-1.38 min vs. 44.4+/-1.44 (P=0.0001) and fewer sutures were used: 3.6+/-0.13 vs. 6+/-0.13 (P=0.001). Patients operated by the new technique began moving sooner and intestinal function restarted earlier.
                The proposed technique made for shorter operating times and faster recovery but no decrease in puerperal morbidity. To investigate whether a series of changes in the current caesarean section operative routine, based on new knowledge, would be beneficial.
                A prospective controlled trial.
                Labour ward with approximately 3000 deliveries annually in a suburban area of Gothenburg, Sweden.
                Seventy-two pregnant women scheduled for delivery by caesarean section were randomised to either modified Joel-Cohen technique (n = 36) or Pfannenstiel technique (n = 36).
                Blood loss during surgery and operating time.
                The median estimated intra-operative blood loss was 250 mL in the modified Joel-Cohen group and 400 mL in the Pfannenstiel group (P = 0.026). The proportion of women with > or = 300 mL was 16/36 in the modified Joel-Cohen group vs 28/36 in the Pfannenstiel group (OR 0.229, 95% CI 0.082-0.637). Median operating time was 20 min in the modified Joel-Cohen group compared with 28 min in the Pfannenstiel group (P < 0.001). The proportion of women with > or = 25 min was 1/36 in the modified Joel-Cohen group vs 33/36 in the Pfannenstiel group (OR 0.003, 95% CI 0.000-0.026).
                We conclude that the modified Joel-Cohen technique of caesarean delivery reduced intraoperative blood loss and operating time compared with the Pfannenstiel technique. To compare the Pfannenstiel incision with transverse muscle-cutting Maylard incision in women who had cesarean delivery.
                Patients were assigned randomly to a Pfannenstiel or Maylard incision. Postoperative treatment was similar for each group. Surgical characteristics, complications, postoperative pain (visual analog scale, analgesic use), and related quality of life (1- and 3-month self-administered questionnaires) were analyzed. Abdominal wall muscle recovery was compared objectively by dynamometer.
                Fifty-four women had a Pfannenstiel incision and 43 had the Maylard incision. There were no differences in intraoperative characteristics, postoperative morbidity, or pain. Women's responses to the Nottingham Health Profile questionnaire at 1 and 3 months postoperatively and clinical and isokinetic testing for abdominal wall strength were similar between the two groups.
                Transecting the rectus muscle was no more deleterious than the Pfannenstiel incision. There was no difference in objectively measured abdominal wall strength.
The Joel-Cohen incision has advantages compared with the Pfannenstiel incision. These are: less fever, pain and analgesic requirements; less blood loss; shorter duration of surgery and hospital stay. These advantages for the mother could be extrapolated to savings for the health system. However, these trials do not provide information on severe or long-term morbidity and mortality.