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The small details that influence postoperative pain

Stark, Michael; Mynbaev, Ospan; Tinelli, Andrea; Malvasi, Antonio

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European Journal of Anaesthesiology: February 2017 - Volume 34 - Issue 2 - p 110-111
doi: 10.1097/EJA.0000000000000575
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Congratulations to Adesope et al.1 on the recent comprehensive article, ‘Local anaesthetic wound infiltration for postcesarean section analgesia: a systematic review and meta-analysis’. The authors mentioned the shortcomings of their review; however, there are other limitations that repeat themselves in different studies concerning the outcome of caesarean section. One of the main shortcomings of meta-analysis concerning caesarean section is the lack of standardisation of the surgical method, as only studies using a standardised method enable comparison of outcomes among different surgeons and institutions.2

About 25 years ago, we described a modified caesarean section, the so-called Misgav Ladach method.3 The benefit of this method over traditional techniques was shown in several studies, and specifically a reduced need for analgesics was proven.4–6

It is agreed that local anaesthetic wound infiltration reduces the use of opioids with minimal effect on the pain scores; however, we look constantly for other ways to reduce postoperative pain. In the Misgav Ladach method, the opening of the abdomen using the modified Joel-Cohen method seems to cause reduced trauma as the fascia is not separated from the muscle like in the Pfannenstiel incision. Leaving the peritoneum unsutured is also a pain-reducing factor.7 Suturing the uterus is mainly for immediate haemostasis, as the uterus contracts anyway immediately after caesarean section and the suture material cannot contract with the uterus. It seems therefore that the more suture material left behind, the more foreign body reaction there will be, which might cause pain. For many years, we sutured the uterus with a one-layer continuous locking stitch, using an 80-mm-sized needle. Using a big needle enables stitching further away from the incision line and results in excellent haemostasis with minimal steps and less suture material, rarely needing extra haemostatic sutures. This should become a topic of study, comparing the outcome concerning pain with a smaller or bigger needle. Obviously, the surgical technique itself is not under the control of the anaesthesiologist, but close cooperation and exchange of information, as exemplified by the authors, might result in better outcome and reduced postoperative pain.

Acknowledgements related to this article

Assistance with the letter: none.

Financial support and sponsorship: none.

Conflicts of interest: none.


1. Adesope O, Ituk U, Habib AS. Local anaesthetic wound infiltration for postcaesarean section analgesia: a systematic review and meta-analysis. Eur J Anaesthesiol 2016; 33:731–742.
2. Stark M, Gerli S, Di Renzo GC. The importance of analyzing and standardizing surgical methods. J Minim Invasive Gynecol 2009; 16:122–125.
3. Holmgren G, Sjöholm L, Stark M. The Misgav Ladach method for cesarean section: method description. Acta Obstet Gynecol Scand 1999; 78:615–621.
4. Darj E, Nordström ML. The Misgav Ladach method for cesarean section compared to the Pfannenstiel method. Acta Obstet Gynecol Scand 1999; 78:37–41.
5. Federici D, Lancelli B, Muggiasca L, et al. Cesarean section using the Misgav Ladach method. Int J Gynaecol Obstet 1997; 57:273–279.
6. Ansaloni L, Brundisini R, Morino G, et al. Prospective, randomized, comparative study of Misgav Ladach versus traditional ceasarean section at Nazareth Hospital, Kenya. World J Surg 2001; 25:1164–1172.
7. Barmigboye AA, Hofmeyr GJ. Closure versus nonclosure of the peritoneum at caesarean section: short- and long-term outcomes. Cochrane Database Syst Rev 2014; 11:CD000163.
© 2017 European Society of Anaesthesiology