Full text of DOI:10.1007/BF03215866

World J. Surg. 25, 1164–1172, 2001
DOI: 10.1007/s00268-001-0100-x
WOR LD
Journal of
SURGERY
© 2001 by the Socie´te´
Internationale de Chirurgie
Surgical Globetrotting
Prospective, Randomized, Comparative Study of Misgav Ladach versus
Traditional Cesarean Section at Nazareth Hospital, Kenya
Luca Ansaloni, M.D.,1,2 Roberto Brundisini, M.D.,1 Gianfranco Morino, M.D.,1 Andrew Kiura, M.D.1,3
1Nazareth Hospital, PO Box 49682, Nairobi, Kenya
2Department of General Surgery, Ospedale Civile di Lugo, Viale Masi 3, 48011, Lugo, Ravenna, Italy
3Kenya Medical Research Institute, PO Box 5840, Nairobi, Kenya
Abstract. Cesarean section (CS) is the commonest major operation car-
ried out in many low income countries. A new technique for CS, called the
Misgav Ladach procedure, was evaluated in a randomized trial in Naz-
areth Hospital (Kiambu District, Kenya). A total of 160 patients were
assigned to the Misgav Ladach procedure (n ؍ 80) or to the traditional
CS as performed in most rural hospitals in low income countries (n ؍ 80).
The two groups were analyzed by operating time, presence of infection and
febrile morbidity, grade of postoperative pain, starting of fluid and solid
alimentation, and development of incisional hernia and hypertrophic
scar. The operating time of the Misgav Ladach procedure was signifi-
cantly shorter. 20.4 (SD 6.1) minutes versus 30.4 (SD 6.1) minutes (p <
0.001). A total of 5 wound infections (6.2%) were seen with the Misgav
Ladach procedure versus 16 (20.0%) in the control group (p ؍ 0.01). The
number of analgesic doses required during the postoperative period were
significantly less in the Misgav Ladach group: 1.3 (SD 0.6) versus 1.9 (SD
0.7) ampuls of pethidine (p < 0.001) and 15.1 (SD 2.0) versus 16.4 (SD
1.8) tablets of ibuprofen (p < 0.001). Incisional pain was significantly less
in the Misgav Ladach group: Visual Analogue Scale score 3.0 (SD 1.5)
versus 4.9 (SD 2.0), p < 0.01. The patients in the Misgav Ladach group
began drinking fluids voluntarily [19.1 (SD 4.5) hours versus 20.6 (SD
4.0) hours; p ؍ 0.01] and eating solid food [41.2 (SD 9.3) hours versus
46.1 (SD 9.0) hours; p < 0.01] significantly before than those in the
control group. At the 6-week follow-up, the presence of hypertrophic scar
was significantly associated with the traditional procedure (2.1% vs.
48.8%; p < 0.001). We conclude that the Misgav Ladach operation should
become the standard method for performing CS in low income countries,
particularly in rural hospitals.
of all layers (visceral and parietal peritoneum, fascia, subcutane-
ous, skin) to close the abdomen.
During the last decade, Stark and colleagues developed in
Misgav Ladach Hospital in Jerusalem a new CS technique [1] in
which the abdomen is opened using the transverse cut of the
Joel-Cohen method [2]. Other distinctive features of the Misgav
Ladach method include single-layer closure of the uterus and
nonclosure of the peritoneal layers. Although none of these de-
tails is common practice for CS as it is actually practiced, they
were demonstrated to be safe and efficacious in many studies
[3–9]. Moreover, in preliminary reports from high income coun-
tries the Misgav Ladach method has been compared with the
traditional Pfannenstiel method [10, 11], showing some advan-
tages, such as less bleeding [1, 11], shorter operative duration
saving theater and staff time [3, 11], less postoperative pain [10,
11], fewer postoperative infections and less febrile morbidity [10],
early bowel function resumption [12], and less danger of perito-
neal adhesions [1, 10, 13]. There are other advantages associated
with the Misgav Ladach method for CS as well. It is easy to learn
and to perform (even by nonsurgeon or nonobstetrician doctors),
the strong scar wound reduces the risk of incisional hernia (major
disability in women with heavy workloads), and fewer theater
materials (i.e., sutures and instruments) are used. Moreover, there
is early ambulation (with reduced risk of thrombosis and early
start on breast-feeding), early discharge home, and a lower inci-
dence of hypertrophic scar or keloids [14].
These advantages are important, particularly in low income
countries. CS is the most common major operation carried out in
eastern Africa. It has been estimated that 20 to 30 CSs are
currently performed annually in a population of 100,000, although
there is actually a need for 200 to 250 annually [15, 16]. The
problem of this unmet need in the population living in rural areas
of developing countries is due to the facts that in these areas
doctors are scarce, distances between hospitals are large, and
transport is rarely readily available. These considerations explain
the fact that many obstetric and gynecologic conditions in rural
settings are managed by non-specialist doctors (in particular gen-
eral surgeons, when available) [17] and has motivated the health
ministries of some countries to delegate CS performance to staff
Cesarean section (CS) is a common operation performed as an
elective or an emergency procedure. Countless variations of the
procedure have been introduced since the first CS was carried out.
Some have concerned seemingly small details of the operation,
whereas others have presented major breakthroughs, (e.g., the
incision proposed by Pfannenstiel at the turn of the century that
has become the standard in Western countries). In contrast, in
many hospitals of low income countries CS is still traditionally
performed with a longitudinal, subumbilical, midline laparotomy,
with double layers of sutures on the uterine wall and with suturing
Correspondence to: L. Ansaloni, M.D., Divisione Chirurgica, Ospedale
Civile di Lugo, Viale Masi 3, 48011, Lugo, Ravenna, Italy, e-mail:
so10790@iperbole.bologna.it

Ansaloni et al.: Misgav Ladach Cesarean Section
1165
not formally trained as medical doctors [18]. Thus any improve-
Concerning the marital status the patients were defined as
ment in CS should produce benefits to the reproductive health of single (when not married, divorced, or widowed) or married. The
the communities of low income countries, where the incidence of educational level was defined as “low” for patients who were
operative deliveries is high and sometimes delegated to nonmed- illiterate or had a primary school diploma and “high” for those
ical staff.
who had a secondary school diploma or more education.
For these reasons we carried out a prospective, randomized
Gestational age was calculated considering the last menstrual
study to compare the Misgav Ladach technique for CS with the period (according to the patient) and the upper uterine level by
traditional procedure as done in low income countries, mostly in palpation. The status was defined as an emergency when CS
the hospitals of rural areas. The aim of the study is to determine became immediately necessary because of maternal or fetal com-
the safety of the technique by observing any complications arising promise, even if it was not considered life-threatening to the
intraoperatively and postoperatively and to evaluate its efficacy in mother or the fetus. Elective CS was that performed at a time
comparison with the traditional method by noting the operating convenient to the patient and the medical and midwifery staff.
time, the presence of infection and febrile morbidity, the degree
Indications for CS were formulated by the obstetrician in the
of postoperative pain, the time of starting fluid and solid alimen- ward and were grouped in the following categories: (1) fetal
tation, the development of incisional hernia, and the outgrowth of distress; (2) cephalopelvic disproportion (CPD) and one PCS with
hypertrophic scar and keloids.
CPD; (3) more than one PCS; (4) maternal complications (pla-
centa praevia, severe preeclampsia, eclampsia); (5) fetal malpre-
sentations and cord prolapse; (6) failure of induction.
Patients and Methods
Study Site (Geographic) and Participating Surgeons
Randomization and Record Keeping
The study was performed in Nazareth Hospital (Kiambu District,
Kenya), a 200-bed rural hospital sited 30 km from Nairobi, with a
good standards of diagnostic and therapeutic facilities and a busy
maternity ward. The study was carried out with the participation
of two surgeons who agreed to standardize the two procedures.
One of them (L.A.), who was already familiar with the Misgav
Ladach technique, during a teaching/pilot phase taught the other
surgeon (R.B.) this procedure until he was satisfied the latter
could carry out the operation well. Both surgeons were already
well familiar and expert with the traditional method of carrying
out CS. Patients operated on during the teaching/pilot phase were
not included in the study, but the data collected were used to
calculate the sample size. This phase consisted of 50 patients and
lasted 40 days.
Randomization was obtained through an alternate assignment to
the two procedures, closely following the inclusion/exclusion cri-
teria. After completion of surgery, all details were recorded on a
paper form kept with the patient’s notes and later stored in a
computer database.
Preoperative Management
The same antibiotic prophylaxis was given to all patients in the
Misgav Ladach and traditional groups. They received a single
dose of ampicillin 3 g plus metronidazole 500 mg intravenously
immediately before operation. Ampicillin was chosen for its low
cost, broad spectrum, sufficient half-life, and high wound concen-
tration and metronidazole for its anaerobic activity and long
half-life [19, 20]. No antibiotic prophylaxis was given after oper-
ation. This regimen has been proved effective for reducing the
infectious morbidity rate in rural hospitals in developing countries
[21].
The type of anesthesia, either general or spinal anesthesia (2%,
hyperbaric lignocaine 2 ml) was chosen by the anesthetist inde-
pendently of the surgeon’s preference. All the patients were op-
erated on in the supine position with a wedge placed under the
right buttock to prevent the supine hypotensive syndrome. The
instrument sets were the same for both procedures: one scalpel,
two pairs of scissors (one straight, one curved), one Doyen mobile
retractor, four artery forceps, three Green Armytage forceps, one
needle-holder, two Durante dissecting forceps.
Study Population and Preoperative Protocol
All patients who underwent CS performed by the two surgeons
(emergency or elective, with any indication) from March 17, 1997
to July 27, 1997 were included in the study to attain the 160 CSs
established by the sample size calculation. The exclusion criteria
were uterine rupture with prolonged obstructed labor (Ͼ 24
hours) or with fetal death or the need for a cesarean hysterec-
tomy.
The patients were informed about the nature and purposes of
the trial, and informed consent to participate to the randomiza-
tion was obtained. They were free to withdraw from the study
whenever they wished without any obligation. No incentives were
given to the patients regarding participation in the study or the
follow-up. All the medical information obtained from the patients
was kept confidentially among the research scientists conducting
the study.
Surgical Procedures
Misgav Ladach Procedure. The principal elements of the Misgav
Certain data were collected preoperatively, such as age, weight, Ladach CS are the following: (1) the Joel-Cohen method for
marital status, education, gestational age (in weeks), gravidity, opening the abdomen; (2) suturing the lower uterine segment
parity, number of abortions, previous cesarean section (PCS), incision in one layer of catgut chromic no. 2 in continued locked
rupture of membranes (in hours), degree of cervical opening (in suture; and (3) nonclosure of both the visceral and parietal peri-
centimters), number of cervical examination(s) performed prior toneal layers. The technical details and operative steps used for
to the operation, emergency procedure (versus elective), and the Misgav Ladach technique are exactly those described by
indication for CS.
Stark [1].

1166
World J. Surg. Vol. 25, No. 9, September 2001
Traditional Procedure. The usual CS procedure in developing Parameters
countries, mostly in rural hospitals, consists of subumbilical lon-
The following indicators were chosen to compare the postopera-
tive outcome between the two procedures.
gitudinal laparotomy, closing the uterus in two layers of catgut
chromic no. 2 in continued locked suture, and closing both peri-
toneal layers with continued sutures of plain catgut no. 2/0. The
other technical details were common to the two procedures.
Duration of operation, complications during the operation,
gender and weight of the baby, and the Apgar score (at 1 and 5
minutes) were collected as intraoperative data and recorded on
the trial form. Operating time was measured from the first skin
incision to the last skin suture placement for both techniques. A
stillbirth was defined as any infant delivered after the 28th week of
pregnancy who does not breathe or show any sign of life. Perinatal
death was defined as a stillbirth or neonatal death during the first
week of life.
1. Febrile morbidity (defined as body temperature over 38°C on 2
days, excluding the first 24 hours.)
2. Eventual need and use of postoperative antibiotics.
3. Presence and grade of a wound infection. Using the definitions
of Cruse [27], surgical wounds are considered “uninfected” if
they heal per primum without discharge; “definitely infected” if
pus is discharged, even if organisms are not cultured from the
purulent material; and “possibly infected” if they are inflamed
without discharge or draining of culture-positive serous fluid.
Wound infections were also graded according to the classifica-
tion of Karl et al. [28]: grade 1, superficial infection (cellulitis
with minimal purulent exudate); grade 2, deep infection (cel-
lulitis with moderate purulent infection); grade 3, infection
throughout the wound with or without dehiscence.
4. Doses of analgesics required (number).
Postoperative Management
5. Evaluation of the pain grade at the 30th postoperative hour
(Ϯ6 hours) with a Visual Analogue Scale (VAS) graduated
from 0 to 10.
6. Postoperative day on which the patients spontaneously began
to drink fluids (from the first postoperative day on) and to eat
solid food (from the 18th postoperative hour on).
During the immediate postoperative period the vital signs were
monitored by the recovery room nurse until the patient was fully
awake and stable; blood pressure and pulse were then monitored
in the ward hourly for 6 hours and then on a daily basis. Body
temperature was recorded twice a day (6 a.m. and 2 p.m., and
further in case of need). The urinary catheter was removed when
the patient was fully awake and stable.
Postoperative analgesia was given at the discretion of the pa-
tient. During the first postoperative day (24 hours) pethidine 100
mg IM 8 hourly was administered only if the dose was requested
by the patient; beginning on the second day oral analgesia (ibu-
profen 400 mg three times a day) was given only on the patient’s
request.
Saline 0.9% alternating with 5% dextrose, for a total of 3000 ml
of intravenous fluids over 24 hours, were given until the patient
requested them to be discontinued. She was then allowed to take
oral fluids (even during the first postoperative day). Solid diet was
allowed from the 18th postoperative hour at the patient’s request.
The advantages of starting alimentation with fluid and solid food
early after CS are well documented in the literature [22–24].
Early mobilization of the patient was practiced 12 hours after
surgery in the case of general anesthesia and 24 hours after
surgery if spinal anesthesia was given. The supine position for the
first 24 hours after spinal anesthesia was maintained to avoid a
postdural puncture headache (PDPH). Although the efficacy of
this measure as prophylaxis of PDPH is under debate [25], we did
not want change a practice already established in our hospital.
The surgical wound was exposed on the third postoperative day
and painted with gentian violet 1% solution. Gentian violet was
chosen because is inexpensive and easily available in Kenya; it
leaves a dry film on the wound, and it does not stain the skin of
black patients. The daily dressing was continued only for infected
7. Postoperative day on which the patients were discharged (from
the 7th day on).
8. Presence of any complications (particularly incisional hernia
and hypertrophic scar or keloids) at the 6-week follow-up.
Hypertrophic scar, which usually appears within weeks of the
causative injury and in colored peoples precedes keloid forma-
tion, was defined as raised lesions in the surgical scar that stay
within the boundaries of the wound (keloids, by contrast, are
defined as scars in the skin that grow beyond the confines of the
original wound) [29].
Points 1, 2, and 3 were used to compare the infectious morbidity
in the two groups, points 4 and 5 the postoperative pain, point 6
the paralytic ileus, point 7 the presence of early postoperative
complications, and point 8 the presence of late complications.
Approval and Ethical Consideration
This study was conducted under a protocol approved by the
Scientific and Ethical Committee of Kenya Medical Research
Institute (KEMRI no. 461–1997). In a series of studies already
conducted on the Misgav Ladach procedure, although only in high
income countries, the new method was shown to be safe and more
efficacious than the Pfannenstiel procedure [1, 3, 10, 11].
Analysis
wounds. Alternate stitches were removed on the sixth postopera- The sample size of 80 patients for each group has been calculated
tive day and the remainder on the seventh day when the patients by Epitable of Epi Info, Version 6.02 software package (Centers
were discharged if no complications arose [26].
for Disease Control and Prevention, Atlanta, GA, USA, 1994) to
A surgical review after 6 weeks (or earlier, in case of need) in reach a confidence level of 95% with a power of 80%, through a
the outpatient department was proposed and planned for each pilot study with 50 nonrandomized patients, described before, that
patient who participated to the study. This length of time for the has demonstrated the percentage of some of the outcomes that
follow-up was chosen to coincide with immunization of the new- were under study. The statistical analysis was carried out using Epi
born.
Info Analysis. Differences between proportions were tested using

Ansaloni et al.: Misgav Ladach Cesarean Section
1167
Table 1. Baseline features of the randomized patients.
Misgav Ladach
CS (n ϭ 80)
Traditional
CS (n ϭ 80)
Parameter
p
Surgeon: L.A./R.B.
46/34
48/32
0.74*
Age (years), mean [SD]
27.6 [4.2]
72.6 [13.8]
2/78
27.0 [4.3]
69.8 [13.1]
6/74
0.26***
0.25***
0.27**
0.72*
Weight (kg), mean [SD]
Marital status: single/married
Education: low/high
24/56
22/58
Gestational age (weeks), mean [SD]
Gravidity, mean [SD]
38.4 [1.7]
2.5 [1.1]
1.3 [1.1]
15/65
38.0 [1.8]
2.8 [1.9]
1.3 [1.5]
18/62
0.26***
0.99***
0.60***
0.55*
Parity, mean [SD]
Previous abortion, yes/no
Presence of PCS, yes/no
Labor length (hours), mean [SD]
Membrane rupture (hours), mean [SD]
Cervical dilatation (cm), mean [SD]
Cervical examinations (no.), mean [SD]
Emergency/elective CS
Indications for CS
Fetal distress
CPD and one PCS with CPD
More than one PCS
Maternal complications
41/39
38/42
0.63*
5.4 [8.0]
2.6 [4.8]
1.7 [2.8]
1.2 [1.8]
42/38
4.3 [6.8]
2.2 [4.6]
1.3 [2.3]
0.8 [1.3]
42/38
0.60***
0.74***
0.65***
0.46***
0.87*
12
16
25
22
13
11
0.96*
8
9
Fetal malpresentation and cord prolapse
Failed induction
14
14
8
8
General/spinal anesthesia
Single/twin pregnancy
55/25
78/2
32/46
3.2 [0.6]
63/17
74/6
37/37
3.1 [0.6]
0.15*
0.27**
0.26*
Newborn gender,a female/male
Newborn weight (kg),a mean [SD]
0.62***
PCS: previous cesarean section; CPD: cephalopelvic disproportion.
aSingle pregnancies only.
*Chi-square; **Fisher exact test, ***Mann-Whitney U-test.
the chi-square or Fisher’s exact test (where appropriate) and layer because of excessive bleeding in two patients and uterine
differences between means using the Mann-Whitney U-test.
rupture with an alive newborn in the other.
The data for the indicators used to compare the postoperative
outcome between the two procedures are reported in Table 2. The
traditional CS procedure took significantly longer than the Misgav
Results
During the study period (March 17, 1997 to July 27, 1997) at Ladach procedure. There were three stillbirths among the 168
Nazareth Hospital we managed 1024 deliveries (mean 9.9 deliv- babies (1.8%) delivered during the 160 CSs under study: two were
eries daily). Among them, 242 (23.6%) were cesarean deliveries, in single pregnancies in the Misgav Ladach CS group due to fetal
161 of which were performed by the two surgeons (L.A. and R.B.) asphyxia and one in a twin pregnancy in the traditional CS pro-
carrying out the study. All but one of CSs performed by the two cedure group due to an anencephalic baby. During the perinatal
surgeons were included in the study. The reason for exclusion in period (the first week) there were four deaths among the 165
that case was the need for cesarean hysterectomy due to an remaining newborns (2.4%): one in the Misgav Ladach group and
unrepairable right lateral laceration of the lower uterine segment three in the traditional procedure group, all due to prematurity.
in a multipara with a fibromatous uterus during a CS performed
Regarding the infectious morbidity, it must be pointed out that
with the traditional procedure. Hence 160 eligible patients were although there were no significant differences in febrile morbidity
randomized. There were no statistically significant differences or use of postoperative antibiotics in the two groups wound
between the groups (Table 1).
infections complicated the postoperative course of 16 (20.0%)
The intraoperative complications are as follows. Strong adhe- patients in the group with the traditional procedure versus 5
sions due to PCS were found during the operation in three (6.2%) with the Misgav Ladach procedure (p ϭ 0.01). According
patients (3.8%) with the Misgav Ladach procedure and in three to the classification of Karl et al. [28], among the 16 infected
patients who underwent the traditional procedure. Extra stitches wounds in the group operated with the traditional method eight
were needed owing to continuous bleeding from any of the cor- were grade 1 and eight grade 2. In the Misgav Ladach group there
ners of the uterine incision in four cases (5.0%) using the tradi- were four of grade 1 and one of grade 2. None in either group was
tional CS and in two (2.5%) with the Misgav Ladach CS. During grade 3. Concerning the use of postoperative antibiotic treatment,
another two Misgav Ladach procedures some extra stitches were it must be clarified that in eight patients (four in each CS group)
added to the single layer uterine suture because of bleeding from the antibiotic was a continuation of a therapy started before the
the edges of the uterine incision. In three other Misgav Ladach operation for various reasons (respiratory tract infection in two,
cases, closure of the uterine incision was performed with two membrane leak in four, skin infection and cervicitis in one each).
locked continuous sutures and suture of the visceral peritoneal Thus the antibiotic treatment was started after the operation in

1168
World J. Surg. Vol. 25, No. 9, September 2001
Table 2. Comparative intraoperative, postoperative, and 6-week follow-up data for all patients randomized to Misgav Ladach or traditional
cesarean section.
Misgav Ladach CS
(n ϭ 80)
Traditional CS
(n ϭ 80)
Parameter
p
Operating time (minutes), mean [SD]
Apgar score at 1 minute,a mean [SD]
Apgar score at 5 minutes,a mean [SD]
Stillbirth/born alive
20.4 [6.1]
8.3 [1.7]
9.0 [1.9]
2/80
30.4 [6.1]
8.5 [0.9]
9.2 [1.5]
1/85
Ͻ0.001*
0.58*
0.70*
0.48**
0.52**
0.44**
0.44***
0.01***
Ͻ0.001*
Ͻ0.001*
Ͻ0.01*
0.01*
Perinatal death/discharged alive
3/79
4/82
Presence of febrile morbidity, yes/no
Use of postoperative antibiotics, yes/no
Presence of wound infection, yes/no
Analgesic doses (pethidine), mean [SD]
Analgesic doses (ibuprufen), mean [SD]
Pain grade (Visual Analogue Scale), mean [SD]
Time to first fluid feed (hours), mean [SD]
Time to first solid feed (hours), mean [SD]
Incisional hernia, yes/no
2/78
5/75
7/73
10/70
5/75
16/64
1.3 [0.6]
15.1 [2.0]
3.0 [1.5]
19.1 [4.5]
41.2 [9.3]
0/48b
1.9 [0.7]
16.4 [1.8]
4.9 [2.0]
20.6 [4.0]
46.1 [9.0]
2/41c
Ͻ0.01*
0.22**
Ͻ0.01***
Presence of hypertrophic scar, yes/no
1/47b
21/22c
aSingle pregnancies only.
bAmong 48 procedures.
cAmong 43 procedures.
*Mann-Whitney U-test; **Fisher’s exact test; ***chi-square test.
three patients in the Misgav Ladach group (one each for wound uterus and nonclosure of the peritoneal layers [1, 10]. These
infection, respiratory tract infection, and urinary tract infection) surgical details are not common practice for CSs performed in
and in six in the traditional group (two each for wound infection, Kenya and other low income countries, where this operation is
respiratory tract infection, and persistent unexplained fever).
still generally done with midline subumbilical laparotomy, double-
The number of analgesic (pethidine or ipubrofen) doses re- layer closure of the uterus, and closure of visceral and parietal
quired by the patients during the postoperative period were sig- peritoneal layers. The other details of the Misgav Ladach CS,
nificantly less in the Misgav Ladach group. Even the evaluation of including exteriorization of the uterus and manual extraction of
incisional pain grade during the immediate postoperative period the placenta, are instead common practice.
showed significantly less pain in the group with the Misgav Ladach
Stark and colleagues based the introduction of changes in an
procedure. Furthermore, the patients of the Misgav Ladach group already well standardized operation on some important philo-
began voluntary fluid and solid food intake significantly before sophical surgical considerations. First is the idea of surgical mini-
those operated on with the traditional procedure.
malism. Only those surgical maneuvers that are shown to be
Discharge was later than 7 days postoperatively for three pa- necessary are used; and wherever possible, the alternative is cho-
tients (3.8%) in the Misgav Ladach group and for four (5.0%) in sen that least disrupts the tissue. Thus suturing the peritoneal
the traditional group. The causes for the late discharge were two layers and the double-layer closure of the uterus is avoided. The
renal failures in eclampsia and one urinary infection in the Misgav second principle is that of operating in harmony with physiologic
Ladach CS group and one malaria, one renal failure in eclampsia, and anatomic considerations. Using the Joel-Cohen method for
and two wound infections in the traditional CS group.
opening the abdomen, the level of skin incision and the level of
Altogether 48 patients (60.0%) in the Misgav Ladach group and separation of the recti muscles are well away from muscle inser-
43 (53.8%) in the traditional procedure group appeared for the tion sites. In this way little force is needed at separation, reducing
6-week follow-up; the difference between groups was not signifi- disruption of blood vessels and nerves, which are vulnerable near
cant (p ϭ 0.4, chi-square test). Two incisional hernias were found the site of muscle fixation [1, 3, 10].
in the patients operated with the traditional procedure and none
The Joel-Cohen skin incision is a distinctive feature of the
in the Misgav Ladach group, but the difference was not significant. Misgav Ladach CS [2]. The choice of abdominal incision for CS
The presence of a hypertrophic scar was significantly associated must be determined by desire to achieve quick, adequate expo-
with the traditional procedure.
sure, which is especially important in emergency situations, and to
avoid postoperative complications, such as wound disruption and
incisional hernia. Although it has been found that the lag time
from incision to delivery is significantly shorter through a low
Discussion
At the Misgav Ladach Hospital in Jerusalem, Stark and col- midline abdominal incision than with a Pfannenstiel incision [30],
leagues, based on Joel-Cohen’s time and motion studies in gyne- it must be pointed out that Stark demonstrated a significant
cologic surgery, evolved an improved method for CS [1, 3]. This reduction in operative duration with the Joel-Cohen incision com-
Misgav Ladach procedure, although incorporating the method of pared with the Pfannenstiel incision [3]. On the other hand, it has
opening the abdomen developed by Joel-Cohen for hysterectomy been found in general and gynecologic surgery that a transverse
operations, goes well beyond, bringing together ideas from vari- laparotomy heals better than a midline vertical incision, reducing
ous sources, both surgical and gynecologic. Other distinctive fea- the risk of wound dehiscence and incisional hernia [31–36]. In our
tures of the Misgav Ladach CS include single-layer closure of the experience with the limited time of only a 6-week follow-up, we

Ansaloni et al.: Misgav Ladach Cesarean Section
1169
found 4.7% incidence of incisional hernia in the group of women tion of plasmin by the tissue plasminogen activator system [46].
operated on with the traditional procedure in contrast to none in Within 3 days the peritoneal defects are covered by new mesothe-
the Misgav Ladach group. This finding, although not statistically lial cells recruited by cytokines and other macrophage-secreted
significant, encourages us to use the Misgav Ladach CS to prevent mediators. After 5 to 8 days the peritorieal surface is completely
incisional hernia. This consideration is important because wound repaired [6, 45, 47, 48]. Experimental studies have shown that the
hernia is a major disability in women with a heavy workload, such reduction in peritoneal plasminogen activating activity that occurs
as those living in low income countries. Another advantage of after injury, inflammation, and ischemia plays a key role in adhe-
transverse incisions, such as the Joel-Cohen incision, versus low sion formation, [49–51]. Suturing peritoneal surfaces produces
midline laparotomy is the fact that the skin components of this ischemic necrosis in adjacent tissue and thus promotes adhesion
incision, following the well established lines of Langer, are not formation, probably because the peritoneum is damaged and not
under tension. It is not surprising then, that as is showed by our able to absorb the fibrin gel matrix owing to the reduced fibrino-
study the risk of hypertrophic scar formation, a particular hazard lytic activity [52–55]. Based on these experimental studies, many
in Africa [29] is significantly reduced. Furthermore, it must be authors have demonstrated clinically that nonclosure of perito-
pointed out that the Joel-Cohen incision, being higher than the neum during CS reduces infectious morbidity and postoperative
Pfannenstiel incision, is easier to perform, results in less bleeding pain, provides less troublesome bowel function, and saves oper-
[3], and allows better operative exposure, as was shown in a ating time [5, 6, 8, 9]. Studies contemplating a second look, either
comparison between the Pfannenstiel and Maylard laparotomy, at laparoscopy or at laparotomy, in CS patients have shown a
the latter making use of the same skin incision as the Joel-Cohen reduction (in one case significant) in adhesion formation in the
[37]. It can be objected that because the abdominal scar of the group with peritoneal nonclosure [13, 56].
Joel-Cohen incision is higher than that of the Pfannenstiel some
The other technical details in our study were similar for the two
women do not like it because they wish to hide the scar. This is still procedures, in particular manual extraction of the placenta, uterus
not a factor in low income countries; and the fact that the method exteriorization, and removal of easily accessible blood clots,
is becoming popular in Israel, Italy, and Sweden, which are high avoiding the mopping up of spilled amniotic fluid and liquid
income countries, makes this unlikely to be a major disadvantage blood, and the decreased use of towels in the peritoneal cavity.
[11].
Although manual extraction of the placenta seems in some studies
Regarding closure of the transverse lower uterine segment to increase the infectious morbidity rate [57–59] and operative
incision, the need for the second layer of imbricating suture in the blood loss [57, 60], we followed the advice of Stark [1] regarding
traditional two-layer method of repair has been recently ques- this step because we believed that manual removal makes the
tioned by several studies. These studies have reported decreased third stage of the delivery much quicker. Extraabdominal uterine
operating time, with no increased need of additional uterine exteriorization was always performed, as advised by Stark [1],
hemostatic sutures and no increased risk of endometritis or scar because in our experience it makes it easier to suture the uterus,
rupture during subsequent labor with the use of continuous, preventing damage to abdominal organs when stitching, facilitates
locked, single-layer repair when compared with the two-layer manual contraction of the uterus, and can contribute to dimin-
repair [38–40]. Closure in a single layer not only saves time, it ished blood loss [61]. Our data do not support the view of others
causes less ischemia and provides better healing with less saccu- [58, 62] who think that uterine exteriorization carries some risk of
lation. Although some have proposed a single-layer continuous infectious morbidity. Finally, removal of blood clots without pack-
nonlocking repair [41] or a single-layer interrupted suture for ing the peritoneal cavity with towels has the aim of decreasing the
closing the uterine wound [42], to avoid ischemia, we believe that risk of adhesion formation [63] and avoiding reducing the bacte-
a locked suture is not associated with local ischemia, as retraction riostatic effect of amniotic fluid [64, 65].
of the uterus reduces tissue volume and thus releases any tension
Our study demonstrated that the women who underwent the
around the stitch.
Misgav Ladach procedure compared with the women who under-
Another feature of the Misgav Ladach method is leaving the went the traditional CS procedure done in low income countries
visceral and parietal peritoneum unstitched, bringing down the showed some significant differences in outcomes. In particular,
omentum to cover the previously repaired uterine wall. Omitting there was less operating time, less wound infection, less postop-
suturing of the peritoneal layers has long been practiced by ab- erative pain, and less postoperative paralytic ileus. Furthermore,
dominal surgeons with good results, especially because it has been the Misgav Ladach procedure was not burdened by the presence
shown that closing the peritoneum as a separate layer does not of intraoperative and early and late postoperative complications.
play a significant role in laparotomy wound healing [43]. In addi- Although these advantages are important anywhere, they are
tion, suturing peritoneal layers seems to increase adhesion forma- particularly important in low income countries. Being faster than
tion; and as surgeons we are concerned with limiting adhesions, as the traditional CS method, the Misgav Ladach procedure helps
they may lead to intestinal obstruction and infertility [44]. Skin save theater and staff time and decreases the amount of anesthetic
and mucosal surfaces, being of ectodermal origin, heal by approx- needed. Even the suture materials used for the Misgav Ladach
imation of wound edges, unlike the peritoneum, which, being of method are less. In addition, causing fewer wound infections, the
mesodermal origin, heals by mesothelial migration from the un- Misgav Ladach CS reduces the need for antibiotics and dressings.
derlying tissues to multiple sites of repair [7]. Large peritoneal Moreover, the reduction in postoperative pain and paralytic ileus
defects heal nearly as rapidly as small ones [45]. Following sur- not only lessens the need for postoperative analgesia, it allows
gery, after initial production of an inflammatory exudate contain- earlier ambulation, thereby reducing complications such as
ing first a large number of polymorphonuclear neutrophils and thrombosis. It also allows earlier breast-feeding and nursing care
later macrophages and a fibrin gel matrix, degradation of the of the baby by the mother and earlier alimentation, avoiding the
fibrin gel matrix into fibrin split products occurs through activa- need for postoperative starvation and intravenous fluids. Lastly, it

1170
World J. Surg. Vol. 25, No. 9, September 2001
allows earlier discharge from hospital, freeing beds for others. hypertrophique dans le groupe de c´esarienne classique (2.1%
Taking into account all these considerations, the Misgav Ladach versus 48.8%, p Ͻ 0.001). Nous concluons que le proce´d´e de
procedure could reduce the financial burden that afflicts many «Misgav Ladach» devrait ˆetre la m´ethode de r´ef´erence pour
rural hospital in low income countries.
c´esarienne dans les pays `a revenue bas, surtout dans les hoˆpitaux
As we have already pointed out, the Misgav Ladach technique ruraux.
is the result of reexamining every step of the traditional CS to
evaluate its necessity and efficacy in achieving its purpose. Be-
Resumen
cause some of the conventional steps of the traditional CS appear
to be superfluous and sometimes dangerous, the time reduction
La operacio´n de ces´area (CS) es la intervencio´n m´as frecuente en
derived from suturing the uterus in one layer and nonclosure of
the peritoneal layers is an added benefit. Certainly a second added
benefit due to fewer steps being performed is that the method is
easier to learn and easier to use. In our experience, the only
difficulty with learning and teaching the Misgav Ladach technique
is mastering the Joel-Cohen incision, as the midline laparotomy is
a more common and more well known method for opening the
abdomen. This is an undoubted advantage for hospitals in rural
settings where CS is performed by nonspecialist doctors and even
by nonmedical staff.
paises subdesarrollados. Con objeto evaluar una nueva te´cnica de
CS, denominada Misgaw Ladach, se efectuo´ un estudio
randomizado en el Hospital de Nazareth (distrito de Kiambu,
Kenya). Se recopilaron 160 pacientes en las que se realizo´ la
t´ecnica de Misgaw Ladach (n ϭ 80) o la CS convencional, como
se realiza en la mayoria de los hospitales rurales en los paises en
vias de desarrollo (n ϭ 80). Ambos grupos se analizaron para
valorar el tiempo operatorio, la infeccio´n y la morbilidad febril, el
grado de dolor postoperatorio, el momento en que se comenzo´ la
ingesta liquida y so´lida, el desarrollo de eventraciones y de
cicatrizacio´n queloidea. El tiempo operatorio con la te´cnica de
Misgaw Ladach es significativamente m´as corto: 20.4 (SD ϭ 6.1)
vs 30.4 (SD ϭ 6.1) minutos (p Ͻ 0.001). Con la te´cnica de Misgaw
Ladach se observaron 5 infecciones de la herida operatoria
(6.2%) frente a 16 (20%) en el grupo control (p ϭ 0.01). El
nu´mero de dosis analg´esicas requeridas por las operadas con la
t´ecnica de Misgaw Ladach fue significativamente menor: 1.3
(SD ϭ 0.6) vs 1.9 (SD ϭ 0.7) ampollas de petidina (p Ͻ 0.001) y
15.1 (SD ϭ 2.0) vs 16.4 (SD ϭ 1.8) apo´sitos de Ibuprofen (p Ͻ
0.001). El dolor de la herida operatoria fue significativamente
menor con la te´cnica de Misgaw Ladach: En la escala analo´gica
visual alcanzo´ un grado de 3.0 (SD ϭ 1.5) vs 4.9 (SD ϭ 2.0), (p Ͻ
0.01). Adem´as, las pacientes operadas con la te´cnica de Misgaw
Ladach empezaron voluntariamente a beber (19.1, SD ϭ 4.5 vs
20.6 SD ϭ 4.0 horas, p ϭ 0.01) y a ingerir alimentos so´lidos (41.2
SD ϭ 9.3 vs 46.1 SD ϭ 9.0 horas, p Ͻ 0.01), mucho antes que las
del grupo control. Tras un seguimiento de 6 semanas se
observaron cicatrices queloideas en el 2.1% de las intervenciones
realizadas con la t´ecnica de Misgaw Ladach frente a un 48.8% de
las operadas de ces´area con la t´ecnica tradicional (p Ͻ 0.001).
Concluimos sen˜alando que la t´ecnica de Misgaw Ladach CS debe
convertirse en el m´etodo est´andar para la realizacio´n de una
ces´area en pueblos econo´micamente d´ebiles y, especialmente en
los hospitales rurales.
Conclusions
We are aware that until the Misgav Ladach method is widely
accepted there might be some confusion related to introducing a
new method. We believe, however, that it should become the
standard method for performing CS, especially in low income
countries.
R´esum´e
La c´esarienne (CS) est l’intervention majeure la plus
fr´equemment r´ealis´ee dans beaucoup de pays `a basse ´economie.
Pour ´evaluer une nouvelle technique de c´esarienne, appel´e le
proc´ed´e de “Misgav Ladach”, dans une e´tude randomis´ee `a
l’hoˆpital Nazareth Hospital (Kiambu District, Kenya), 160
patientes ont e´t´e allou´ees soit au proc´ed´e de “Misgav Ladach”
(n ϭ 80) soit `a la c´esarienne traditionnelle CS (n ϭ 80), comme
r´ealis´ee dans la plus grande majorite´ des hoˆpitaux ruraux dans les
pays `a revenu peu ´elev´e. On a analyse´ la dur´ee de l’op´eration, la
pr´esence d’infection et la morbidit´e hyperthermique, le degr´e de
la douleur postop´eratoire, le d´ebut de l’alimentation liquidienne
et solide, le de´veloppement d’une ´eventration, et la survenue
d’une cicatrice hypertrophique. La dur´ee ope´ratoire pour le
proc´ed´e de «Misgav Ladach» a ´et´e significativement plus courte
(20.4 (SD ϭ 6.1) versus 30.4 (SD ϭ 6.1) minutes (p Ͻ 0.001)). On
a not´e cinq cas d’infection pari´etale (6,2%) dans la technique de
Misgav Ladach compar´es `a 16 cas (20.0%) dans le groupe
Acknowledgments
controˆle (p ϭ 0.01). Les patientes dans le groupe Misgav Ladach The authors thank Prof. Maria Rosaria Gatto and Prof. Antonio
ont eu besoin de moins de doses d’analg´esiques dans la p´eriode Gaddi for their assistance with numerical and statistical analyses.
postop´eratoire: 1.3 (SD ϭ 0.6) versus 1.9 (SD ϭ 0.7) ampoules de During the study period Luca Ansaloni and Gianfranco Morino
P´ethidine (p Ͻ 0.001) et 15.1 (SD ϭ 2.0) versus 16.4 (SD ϭ 1.8) were employed in a developing project of a nongovernmental
compresses d’ibuprof`ene (p Ͻ 0.001). La douleur au niveau de la organization, Comitato Collaborazione Medica, supported by the
cicatrice ´etait significativement moindre dans le groupe «Misgav Italian Ministry of Foreign Affairs (project KE/CCM/1819). The
Ladach» avec un score `a l’´echelle visuelle analogue de 3,0 (SD ϭ authors also thank the maternity and theater staff of Nazareth
1.5) versus 4,9 (SD ϭ 2.0), p Ͻ 0.01. De plus, les patients dans le Hospital for their understanding and assistance in the study. Luca
groupe «Misgav Ladach» ont commenc´e `a boire des liquides Ansaloni conceived the study, designed the protocol, and did the
(19.1, SD ϭ 4.5, versus 20.6, SD ϭ 4.0 heures, p ϭ 0.01) et a statistical analysis. Luca Ansaloni and Roberto Brundisini per-
mang´e des aliments solides (41.2, SD ϭ 9.3, versus 46.1, SD ϭ 9.0 formed the cesarean sections, collected data, and carried out the
heures, p Ͻ 0.01) plus toˆt que celles du group de controˆle. A six follow-up of the patients. All investigators contributed to the
semaines, il y avait plus de femmes qui avaient une cicatrice study design and to the writing of the paper.

Ansaloni et al.: Misgav Ladach Cesarean Section
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