While pursuing my education at the Universities of Vienna and Tel Aviv, I observed that cesarean section (C-section) techniques vary not only from hospital to hospital but also among obstetricians working in the same department. Seeing how much these methods, including laparotomy vary, I realized that the deviations should be analyzed in order to find the optimal way to perform C-section, with regard to both execution and outcome of the operation.
As I believe in the importance of standardization of each surgical method in order to be able to compare and evaluate the outcome,1 I had been examining each step of the operation for 3 years and gradually my findings convinced other obstetricians in the hospital to use the method, although some employed certain modifications. The major challenge was to convince people to leave the peritoneum open,2 which was very unusual at the time. It took me some years to realize the value of this method, and when I was convinced, I began to present the method at national and international conferences and published a comparative study concerning individual steps.3 Word spread and I was invited to present this method at the XIV World Congress of FIGO in Montreal in 1994 and published the description in the conference proceedings.4 Thereafter, surgeons from all over the world started to visit our hospital in Jerusalem. Guests from the University of Uppsala, Sweden invited me for a workshop, published articles,5,6 and produced leaflets and a video that were circulated in over 100 countries. This operation method was first introduced in China in the 1990s and was accepted in some hospitals with enthusiasm.
I visited and operated in some Chinese hospitals. I was happy to observe excellent surgeons; however, in different centers many variations were done. The most common way I did observe was the use of the Pfannenstiel incision and abdominal packs, transverse opening of the uterus, and suturing the uterine wall with two layers without uterine exteriorizing. Two layers of the peritoneum were sutured, and after the closure of the fascia some subcuticular sutures were done, and the skin was closed with single sutures, intradermal, or glue.
The aim of this article is to share the method with our Chinese colleagues, to explain the different steps and the underpinning logic behind them. Moving beyond traditions and adopting new practices is often a challenge; however, I hope that explanations outlined here will convince you to adopt the method for the well-being of mothers and that China will join other countries in accepting it for universal use.
The method has been developed at the Misgav Ladach Hospital in Jerusalem between 1981 and 1984, and is now internationally known as “Stark cesarean” or “Misgav Ladach.”
Position of the parturient
The parturient should be placed on the operation table with closed legs in order to avoid tension on the fascia during suturing. Trendelenburg position before the start of the operation allows for easier access to the lower segment of the uterus.
Where should the surgeon stand?
Right-handed surgeons should stand on the right side of the parturient. Since the right hand is more sensitive, it allows reducing the extension of the uterine wall when delivering the baby, which results in less bleeding. While suturing the uterus, the tip of the needle goes away from the bladder, minimizing the risk of perforation of the bladder.
Left-handed surgeons should stand on the left side of the parturient for the same reasons.
Surgeons who have adopted the Misgav Ladach method following many years practicing different positions have extolled the change, with particular regard to the ease and comfort of using the right hand for delivering.
It is hard to believe that even today in some places general anesthesia is routinely used for C-section. Epidural, spinal, or the combinations of both are the optimal ways to perform the operation. Not only are they safer options with obvious benefits for potential top-ups, but they also allow mothers to be aware of the delivery.
Traditionally, either longitudinal or transverse incisions were used while performing C-section. The transverse incisions are usually performed in Pfannenstiel technique, which was invented in 1897 and first appeared in publication in 1900.7 There are aesthetic benefits to this method; however, there are higher rates of febrile morbidity and pain as a result of the need to separate the muscle from the fascia. Surgeons modify the Pfannenstiel incision and I have seen many variations of the shape of the incision (straight or curved), the timing and the ways of hemostasis, the ways to cut the fascia (with scalpel or scissors), and perhaps even more important, the method of closure (continuous or single stitches on the fascia, suturing subcutis or not, closing skin with single stitches or intradermally).
In 1972, I met Prof. Sidney Joel-Cohen in the University of Vienna. He was a South-African surgeon.8 I had already heard about him and about his innovative method of hysterectomy. As he became the Chair of the Gynecological department at the Beilinson Hospital at the University of Tel Aviv, I asked for a position in his department where we became and remained friends for many years. When I was appointed the Director of the Misgav Ladach Hospital, the retired Prof. Joel-Cohen joined me working at Misgav Ladach hospital as a mentor and a consultant. I adapted his incision that was designed for abdominal hysterectomy with some modifications for the C-section. It was easy to prove that C-section performed using the modified Joel-Cohen incision results in significantly lower febrile morbidity.3
The following description of the abdominal incision is meant for the right-handed surgeon who stands on the right side of the parturient. The length of the incision should be individually planned according to the estimated weight of the baby, taking into account the structure of the abdomen and the weight of the parturient. A smaller incision is required in case of multiple births as the weight of each baby is smaller than in singleton.
The first incision should be made within the transverse skin lines. To make them visible, the surgeons pull the skin toward the left spina iliaca with their left thumb. Thereafter, the planned incision can be marked by painting or marking with the surgical forceps. The incision, which is very superficial cutting only through the cutis, is made from the side of the assistant toward the surgeon in a straight line about 3 cm below an imaginary line connecting both spinae iliacae anterior superior. If the cutis incision is made in this way following the transverse lines, minimal bleeding if any at all occurs and the scars tend to disappear over time.
The deepening of the incision is done only in the central part of the incision in cutis. In the midline, there are no significant blood vessels and therefore usually hemostasis is not needed. When the fascia is exposed, a transverse incision of about 4–5 mm is made. Straight scissors with round tips are used now to open the fascia as lateral as needed. One blade is placed above the fascia in the hole that was created with the scalpel and the other one below. The tips of the scissors should not be open more than 4 mm in order to not to damage blood vessels, which usually move away from the round tips. The scissors are pushed first to the left and then to the right in order to open the fascia. The opening of the fascia is done below the subcutaneous tissue and above the straight muscles.
Now, the surgeon inserts two index fingers between the straight muscles and pulls the fascia up and down in order to create space for the assistant to put their index and middle fingers of the right hand below the straight muscle. Both the surgeon and the assistant pull the muscles laterally, including the fat tissue and blood vessels, as much as needed. In case of repeated operations or an extremely overweight woman, more force is needed. In this case, both the surgeon and assistant can use their index and middle fingers of both hands, pulling the muscles with four fingers overlapping two hands. The index fingers should never be placed next to each other but rather two fingers of the left hand over the fingers of the right hand (in case both hands are pulling while the index fingers are next to each other, there is a tendency to separate hands, thus stretching the blood vessels along their long axis and as the blood vessels have lateral sway but no longitudinal elasticity, they might tear and cause bleeding). This process should be done slowly in order to enable the tissues to adjust to the stretching force. Imagine that the longitudinal structures of the abdomen are similar to a stringed musical instrument. The strings can be pulled away from the center, as they have a lateral sway and similarly one does not have to cut straight blood vessels or muscles but rather to pull them laterally.
Opening of the peritoneum
The optimal way to open the peritoneum without risk of damaging any abdominal structure is by repeated stretching above the bladder until a small opening appears.9 The peritoneum opens transversely if two index fingers are used to pull the resulting hole up and down. Now, it is time to insert a hand speculum in order to facilitate the operation.
Handling the plica
Although the uterus and the cervix comprise one organ, and according to Mueller develops together,10 their structure and function are completely different. In the upper part of the uterus, a higher percentage of muscle tissue is found.11 It is important to open the uterus in the part with as little muscle tissue as possible and more fibrous tissue. Therefore, it is important to open the plica and push the bladder down in order to expose the lower segment of the uterus. The plica is opened about 1 cm above the visceral peritoneum with a transverse incision using a scalpel cutting only superficially but deep enough to show that the plica moves down. Thereafter, the plica is pushed down with the index finger of the right hand. In case of adhesions resulting from previous operations, an abdominal swab can be used.
Opening the uterine wall
The middle part of the lower segment of the uterus is cut transversely but superficially 4 cm wide. It should not be opened completely to avoid cutting of the presenting part of the baby; instead, the uterine wall is penetrated with the index finger of the right hand. Thereafter, the right thumb extends the opening of uterus to the left while the left index finger pulls to the right toward the surgeon.
Delivering the baby
If the amniotic sack is not ruptured, it should be perforated either with a tip of the finger or scalpel. The hand speculum is removed at this stage. The surgeon inserts the right hand in the uterus encircling the presenting part and lifting it, while the surgeon or the assistant push the fundus down.
The umbilical cord is clamped, blood sample is taken and the baby is given to the midwife.
Delivering the placenta
The optimal way is the detachment of the placenta spontaneously. Should spontaneous detachment not happen, it can be removed manually; however, such extraction of placenta is associated with more bleeding.12 After the placenta is removed, the uterus should be exteriorized while being contracted by two hands in order to stop possible bleeding. Do not forget to observe both ovaries for pathological findings such as dermoid cyst, which can be removed during the same operation.
Closing the uterine wall
Usually, if the uterus is opened using the described technique, there is minimal bleeding or no bleeding at all. After inserting the speculum back, the central part of the lower layer of the opened uterus should be grasped with designed forceps. The uterus should be sutured in one layer with a big needle of >80 mm. The sutures should be locked to achieve immediate hemostasis. There is no risk for necrosis of the trapped tissues because the uterus starts involution immediately after delivery and the blood supply is not restricted. The less the suture material used, the lesser the reaction to the foreign body, with less pain and irritation to the bladder. Occasionally, extra single sutures are needed to secure hemostasis.
Abdominal towels should be avoided as they might cause adhesions.13 Remove blood clots from behind the uterus in the Douglas pouch or in front of the bladder. Do not remove liquid blood as it will anyhow be absorbed from the intraperitoneal space within hours. At this stage, the exteriorized uterus should be placed back to the abdominal cavity.
Closing the abdominal wall
Following Harold Ellis's experimental work concerning the peritoneum layers showing that the peritoneum regenerates shortly after the operation with fewer adhesions,14 we started to leave the peritoneum open in all vaginal, endoscopic, and abdominal surgeries, including C-section, both the parietal and visceral peritoneum.15 Therefore, just the fascia and skin layers should be sutured, without knots in the subcutaneous layer, in order to prevent unnecessary pain and occasional granulation tissue.
As the fascia was opened above the plica arcuata, on its lateral aspects, two layers of fascia can be seen. It is important to include them on both sides of the incision in order to avoid possible hernias. Therefore, the surgeon places two straight artery forceps on both ends of the incision, grasping both layers together. Two additional artery forceps are placed on the upper and lower aspects of the fascia at the third quarter of its length toward the assistant. The assistant holds these two forceps and lifts them to facilitate the work of the surgeon who is suturing continuously toward the assistant. The two instruments should be held by the assistant not too far away from each other in order to prevent unnecessary tension on the suture material and not too close to each other in order to enable the surgeon to see the layers below.
Start suturing the fascia by penetrating both layers of the upper part of it from the inside toward the outside; and then penetrating both layers of the lower part of the fascia from the outside to the inside so that the knot will be done underneath the fascia. This avoids irritation in the subcutaneous tissue. The surgeon continues to suture toward the assistant until the third quarter of the cut is reached. The assistant removes the upper and lower forceps from the fascia and lifts the forceps next to their side while with their fingers pushing away the fat tissue in order to show the surgeon the exact layer. After knotting at the end of the layer, the subcutaneous tissue should be observed for possible bleeding, which usually is not the case.
The skin should be closed with as few sutures as possible, usually, by one midline Donati suture with a big needle taking also the subcutaneous tissue. This should be followed by two other similar stitches between the midline and the lateral edge of the skin cut. The open spaces between the sutures, in case there are any, can be adapted to each other by Allis clamps for 5 minutes. Certainly, more skin sutures can be placed if optimal adaptation is not reached. The less the stitches done, the better the drainage, and indeed some hours after the surgery, the bandage can be removed and a new one placed.
Recently, a modified method of closing the skin was described, also in China, using adhesives. Studies are currently being carried out to compare it to our described method.
This is beyond the scope of this article, however early hydration is recommended.16,17 Top-ups to the epidural can be given, and the mother should be encouraged to move as soon as possible and start taking care of her baby.
There are scores of articles concerning this technique from countries in different continents. All of them show advantages of the method, although different parameters are evaluated. They report less postoperative adhesion,18 shorter delivery and operation time,19 lower febrile morbidity,3 and lower need for painkillers.20
In another study, surgical time, bleeding, postoperative pain, quick recovery, and shorter hospital stays with less infection were shown with this method compared to the traditional one.21
In a study comparing the late outcome of the described method to the traditional one, five and more years after the operation, better long-term postoperative results in the women who were operated with the Stark method were shown. The results proved better outcome concerning pain, presence of neuropathic and chronic pain, and the satisfaction about the appearance of the scar.22
If the technique is not standardized as suggested here, it will be very difficult to compare among surgeons and institutions.1 Therefore, I suggest this method as a standardized universal method in China. All the details described in this text are evidence based. It is highly suggested that in all future comparisons between this surgical method and other techniques that will be done in China, this one should be performed exactly as described, and needless to say that the method it will be compared to should also be standardized without variations.
Basically, only 10 items of instruments should be used: scalpel, straight scissors with round tips, Doyen/Fritsch retractor uterine clamp, four straight clamps, surgical forceps, uterine forceps, and needle holder. Occasionally, two or three Allis clamps can be used for adaptation of the skin at the end of the operation.
Unfortunately, these days C-section is overused. In the 1930s, the rate of C-section in Europe was about 2%,23 while today it exceeds 30% in some hospitals. I work as a consultant at ELSAN hospital group in France comprising 123 clinics, where we have significantly reduced the rate of C-section by introducing an obligatory requirement for a documented second opinion for each non-emergency operation. It is my hope that the ease of the described technique will not be a reason for its overuse.
The described method is evidence based and follows the principle of “nothing missing and nothing superfluous.”
It is important to perform a C-section in the most efficient way in order to ensure that the outcome will be as favorable as possible.
I highly recommend this method as a Chinese standard C-section.
Conflicts of Interest
. Stark M, Gerli S, Di Renzo GC. The importance of analyzing and standardizing surgical methods. J Minim Invasive Gynecol 2009;16(2):122–125. doi: 10.1016/j.jmig.2008.11.005.
. Stark M. Clinical evidence that suturing the peritoneum after laparotomy is unnecessary for healing. World J Surg 1993;17(3):419.
. Stark M, Finkel AR. Comparison between the Joel-Cohen and Pfannenstiel incisions in cesarean section. Eur J Obstet Gynecol Reprod Biol 1994;53(2):121–122. doi: 10.5152/jtgga.2013.07.
. Stark M. Popkin DR, Peddle LJ. Technique of cesarean section: Misgav Ladach method. Women's Health Today. Perspectives on Current Research and Clinical Practice. Proceedings of the XIV World Congress of Gyneacology and Obstetrics, Montreal, September 1994, New York: Parthenon Publishing Group; 1994,81–85.
. Holmgren G, Sjöholm L, Stark M. The Misgav Ladach method for cesarean section: method description. Acta Obstet Gynecol Scand 1999;78(7):615–621.
. Darj E, Nordström ML. The Misgav Ladach method for cesarean section compared to the Pfannenstiel method. Acta Obstet Gynecol Scand 1999;78(1):37–41.
. Pfannenstiel. Uber die Vortheile des suprasymphysären Fascienquerschnitts für die gynäkologischen Köliotomien, zugleich ein Beitrag zu der Indikationsstellung der Operationswege. Sammlung Klinischer Vorträge, Gynäkologie (Leipzig) 1900;97:1735–1756.
. Stark M. The man behind the name Joel: a personal encounter. Acta Obstet Gynecol Scand 2015;94(6):669. doi: 10.1111/aogs.12631.
. Stark M. In the era of ’non-closure of the peritoneum’, how to open it? (Not every simple method is optimal, but every optimal method is simple). Acta Obstet Gynecol Scand 2009;88(1):119. doi: 10.1111/aogs.12631.
. Crosby WM, Hill EC. Embryology of the Mullerian duct system: review of present-day theory. Obstet Gynecol 1962;20:507–515.
. Rorie DK, Newton M. Histologic and chemical studies of the smooth muscle in the human cervix and uterus. Am J Obstet Gynecol 1967;99(4):466–469.
. Hidar S, Jennane TM, Bouguizane S, et al. The effect of placental removal method at cesarean delivery on perioperative hemorrhage: a randomized clinical trial ISRCTN 49779257. Eur J Obstet Gynecol Reprod Biol 2004;117(2):179–182. doi:10.1016/j.ejogrb.2004.03.014.
. Down RH, Whitehead R, Watts JM. Do surgical packs cause peritoneal adhesions? Aust N Z J Surg 1979;49(3):379–382.
. Ellis H. Internal overhealing: the problem of intraperitoneal adhesions. World J Surg 1980;4(3):303–306.
. Malvasi A, Tinelli A, Guido M, et al. Should the visceral peritoneum at the bladder flap closed at cesarean sections? A post-partum sonographic and clinical assessment. J Matern Fetal Neonatal Med 2010;23(7):662–669. doi: 10.3109/14767050903358363.
. Guedj P, Eldor J, Stark M. Immediate postoperative oral hydration after caesarean section. Asia Oceania J Obstet Gynaecol 1991;17(2):125–129.
. Tan PC, Alzergany MM, Adlan AS, et al. Immediate compared with on-demand maternal full feeding after planned caesarean delivery: a randomised trial. BJOG 2017;124(1):123–131. doi: 10.1111/1471-0528.14211.
. Nabhan AF. Long-term outcomes of two different surgical techniques for cesarean. Int J Gynaecol Obstet 2008;100(1):69–75. doi:10.1016/j.ijgo.2007.07.011.
. Messalli EM, Cobellis L, Pierno G. Cesarean section according to Stark. [in Italian]Minerva Ginecol 2001;53(5):367–371.
. Hudić I, Bujold E, Fatušić Z, et al. The Misgav-Ladach method of cesarean section: a step forward in operative technique in obstetrics. Arch Gynecol Obstet 2012;286(5):1141–1146. doi: 10.1007/s00404-012-2448-6.
. Cardona-Osuna ME, Avila-Vergara MA, Peraza-Garay F. Comparison of pregnancy outcomes caesarean techniques: modified Misgav-Ladach, Pfannenstiel-Kerr and Kerr-half infraumbilical. [in Spanish]Ginecol Obstet Mex 2016;84(8):514–522.
. Belci D, Di Renzo GC, Stark M, et al. Morbidity and chronic pain following different techniques of caesarean section: a comparative study. J Obstet Gynaecol 2015;35(5):442–446. doi: 10.3109/01443615.2014.968114.
. Stark L. Auswertung von 1000 Anstaltsgeburten. Monatsschr Geburtshilfe Gynäkol 1931;89:161.