Modifications to the Misgav Ladach technique for cesarean section ‐ and reply

Sir, Holmgren and colleagues’ detailed and clear description of the Misgav Ladach technique for cesarean section (1) is greatly welcomed and long awaited. We are great enthusiasts of the main aspects of this technique, such as manual opening of the abdomen, single-layer suture of the uterus and non-closure of the visceral and parietal peritoneum, as they seem to have welldemonstrated benefits. The method was introduced in our department nearly two years ago and its acceptation among obstetricians, specially of the younger generation, has been remarkable. Over these two years, however, we have adopted some modifications to the technique that we believe have made it more acceptable to all involved. Some of these have arisen because of emerging evidence in favor of alternative procedures, some due to older routines which we felt there was no need to change, some are probably due to specific characteristics of our population, and some are simply because we were unable to obtain a truly detailed description of the technique before. 1. The side of the patient from which the surgeon stands was never felt to be sufficiently important to change an old habit, so we have maintained the contrary stand from that proposed by the Jerusalem group, without any apparent negative implications. 2. Perhaps the main divergence from the technique described in the paper (1) is that we maintain the Pfannenstiel skin incision, exclusively for aesthetic reasons. Our pregnant women have not reacted well to the proposal of the higher Joel Cohen incision, maybe because of the popularity of small beachwear in our country. An incision performed underneath the upper border of the pubic hairline remains aesthetically more acceptable. Nevertheless, the remaining steps of the Joel Cohen technique for opening the abdominal wall can usually be performed if the midline subcutaneous incision is directed upwards, so as to reach the rectus sheath above the insertion of the pyramidalis muscles. If opening of the rectus sheath does not occur above the pyramidalis muscle, a single cut with the scissors in the midline to separate the pyramidalis from their rectus sheath insertion is sufficient to gain access to the underlying spaces and create a sufficient large operating field for the remaining steps of the procedure. 3. We have found that the lateral extension of the rectus sheath incision can usually be performed manually (at least in our population), even when previous cesarean scars are present. This still gives a good control of the extension of the incision and leaves very clear borders for suturing at the end. 4. We do not extend the midline uterine peritoneum incision with the scalpel laterally, or push the bladder down with fingers or swab. A 2–3 cm transverse midline knife incision through both peritoneum and uterine fibres with lateral manual exten-