Extraperitoneal caesarean advantages: Less pain, faster recovery, no formation of intraperitoneal adhesions and future prevention against new antibiotic-resistant bacterial strains?
Authors: Bacic Boris , Barčot Ognjen , Sabljić Jelena , Dumančić Stipe , Markoski Blagoja , Leskur Mateo 
Published: March 2023

Purpose
The main advantage of extraperitoneal (EXP) caesarean section is not only less pain, faster recovery, and less potential for infection but also a possible lack of intraperitoneal adhesions.
Methods
In a 3-year period from 2019 to 2022, 88 EXP caesarean sections were performed. From 88 EXP caesarean arm 11 patients were exclude because opening of peritoneum during procedure. Three women were below 37 weeks gestation and were excluded. A comparison was made with 90 patients who underwent standard transperitoneal (TPC) caesarean section. For both groups, the inclusion criterion was uterine inertia as an indication for caesarean section. Only pregnant woment from 37 to 42 weeks were included. After this, 51 patients remained in the EXP arm, and 49 remained in the TPC arm.
Results
No difference was found in gestational weeks, newborn weight, or Apgar score between the EXP and TPC groups. Standard blood tests, such as erythrocyte (Er), haemoglobin (Hgb) and haematocrit (Htc) tests, were not significantly different in EXP and TPC groups. In the TPC group, body mass index (BMI) was significantly higher (p = 0,04). The operative times between the groups were just above statistical significance (p = 0,06). Leukocytes, C-reactive protein (CRP) and postoperative infection were statistically higher (p = 0,005, p = 0,002, p = 0,04 retrospectively) in the TPC group. The bilirubin value and incidence of newborn febrility were not significantly different between the EXP and TPC groups. The use of Tramadol + Metamizol at 3 hours (p = 0,009), 6 hours (p = 0,01), and 9 hours (p = 0,01) and the use of diclofenac at 6 hours (p = 0,001), 12 hours (p = 0,009), and 18 hours (p = 0,01) after surgery were statistically significantly in the TPC group. Additionally, the first bowel movement at 24, 48, and 72 hours after surgery was statistically significantly earlier in the EXP group (p = 0,02 to p = 0,005). In small group of patients who underwent a TPC section after an EXP caesarean section, intraperitoneal adhesions were not found; in another group of patients who underwent an TPC caesarean section and then again TPC section, adhesions were found in 12 patients (p = 0,04).
Conclusion
Similar to other studies EXP caesarean have, less pain, a faster first bowel movement and faster recovery with no difference in Apgar score were found in our study. The small group of women who underwent a TPC section after an EXP caesarean section showed no intraperitoneal adhesions (p = 0,04). This study analysed only C-sections in patients with uterine inertia who were predisposed to infection, and more infections were observed in the TPC group. Protective effect EXP caesarean for infection is proven in era before usage of antibiotics and could be very important in new era of antibiotic-resistant bacterial strains. EXP caesarean sections could be a good solution in the fight against adhesions and infection in women who undergo second, third or even fourth caesarean sections.