INTRODUCTION
Increasing rates of cesarean delivery (CD) in the world mean that a
growing number of women are experiencing related
complications.1 While short-term problems associated
with the procedure include bleeding, and infection, there are also
serious long-term issues, such as placenta adhesion anomalies, CD scar
defects, uterine rupture, dehiscence, and caesarean delivery scar
pregnancies. Further, many patients complain of postmenstrual spotting,
dysmenorrhea, and pelvic pain, which may also be associated with these
complications.2,3
There is no clear consensus on the best uterine closure technique for
preventing cesarean scar defects. However, it is known that both the
surgical suture technique and mechanical stresses affecting the surgical
scar are the most important factors related to incision
integrity.4 Several different techniques are used to
close the uterus after cesarean, including single- and double-layer
closures with/without locking and either passing through or avoiding the
decidua. A variety of different suture materials are also available.
Here, the main focus is on the uterine closure technique, especially for
minimizing postoperative uterus rupture/dehiscence and caesarean
delivery scar defects. Further, these techniques are modifiable
parameters, with many recent studies having attempted to determine a
standard.5 Nevertheless, no such standard has been
established. For instance, while the Misgav Ladach single-layer
continuous uterine closure with locking is prevalent throughout the
world,6 studies have reported different
results.7-10 A meta-analysis also showed a fourfold
risk of uterine rupture in future pregnancies among patients whose uteri
were closed using a single-layer locking technique when compared to
those who were treated with a double-layer
technique.11 Further, Stegwee et al. (2019) found that
patients whose uterine incisions were closed by double-layer following
cesarean section (CS) experienced greater advantages in terms of
residual myometrium thickness (RMT), healing ratio (residual myometrium
thickness/adjacent myometrium thickness), and
dysmenorrhea.2 However, another meta-analysis
conducted by Di Spiezio Sardo et al. (2017) found no significant
differences between single- and double-layer closures in terms of niche
development, uterine dehiscence, or rupture.10 As
such, there is no current consensus about the specific uterine closure
technique that best minimizes the risk of uterine rupture and/or
caesarean delivery scar defect. This study therefore investigated the
effects of single- and double-layer closures of the uterus in regard to
niche development and residual myometrium thickness at 6-9 months after
CS.