Incisional small bowel strangulation after cesarean section

Abstract

Introduction and Aims of the study: Every surgical procedure has the possible risk for complications, caesarean section (CS) is no exception. We present a case of rare CS complication that led to re-laparotomy. Methods case presentation: A 25-year-old patient came to our hospital with twin pregnancy for labour induction. An urgent CS was performed through Pfannenstiel incision due to labour dystocia. Uterus was sutured using single layer continuous suture. Visceral peritoneum was sutured separately using continuous suture. Parietal peritoneum was left unsutured while rectus muscles were re-approximated with three interrupted stitches. On the third postoperative day patient complained about diffuse, spastic abdominal pain and vomiting. Abdominal CT scan revealed an infraumbilical abdominal wall defect with an eventration containing distal loops of ileum, occupying area of 12.3x6.9 cm. During urgent re-laparotomy, after disassembling aponeurotic suture, small bowel loops were noted to be strangulated in approximately 2 cm defect which had been left open when re-approximating abdominal muscles with interrupted sutures. Discussion: Re-laparotomy after CS in early postoperative period is extremely rare. According to guidelines, visceral, parietal peritoneum and rectus muscles should not be sutured as this reduces operating time, the need for postoperative analgesia and is not associated with more adhesion formation. However, there are conflicting results whether re-approximation of rectus muscles has a positive effect on the prevention of diastasis recti. In our case rectus muscles were closed separately from other layers with interrupted stitches while parietal peritoneum was left unsutured. It led to intestinal protrusion and strangulation in between two separate muscular sutures. Conclusions: Although there are discussions about CS technique, most guidelines recommend to not re-approximate rectus muscle. This case stands out as an example of a complication which most likely could have been avoided if rectus muscles were left unsutured.