الفهرس 
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Abstract
C
esarean section is one of the most common operative procedures performed in modern obstetrics, that become increasingly common in both developed and developing countries for a variety of reasons. Today, thus any useful refinement in the operative technique, however minimal, is likely to yield substantial benefits.
In morbidly obese women with a panniculus the supraumbilical incision is a new technique that showed definite advantages over Pfannenstiel incision that will avoid burying the wound under a large panniculus, and affords excellent abdominal exposure, less blood loss, less post-operative pain, earlier ambulation, and shorter hospital stay. All these advantages were attributed to the minimal tissue manipulation.
Obese fertile women appear to have more adverse pregnancy outcomes compared to women with a BMI inferior to 30: increased risks of gestational hypertension, preeclampsia, gestational diabetes, anemia, induction of labor, instrumental delivery, cesarean section, and severe postpartum hemorrhage. Moreover, their complication rate increases with their BMI.
It is why the gynecological community has been developing alternative surgical technique to try to diminish the complication risks, the current reference being the transverse sub-umbilical incision. These techniques differ from the skin incision for both type and site: transverse or vertical, sub-umbilical or supraumbilical.
In this study, we aimed to evaluate the efficacy and safety of transverse supraumbilical incision compared to Pfannenstiel incision in morbidly obese women undergoing caesarean section.
This randomized controlled trial was conducted at tertiary care hospital at Ain Shams University Maternity hospital from March 2021 till March 2023 and performed on total 50 pregnant women who presented with morbid obesity (BMI > 40).
The current study revealed that the Mean (SD) of age was 31.2(5.1), 30.2(4.7), Mean (SD) of body mass index (BMI) was 47.2(3.3), 45.9(3.1) as regard parity mean (SD) 2(1-3) and 1(1-2) in transverse supra-umbilical and Pfannenstiel group, respectively with no statistically significant difference.
Diabetic patients were found in 24% of patients in supraumbilical group and 20% in Pfannenstiel group with no statistically significant difference and Hypertension was found in 32% of patients in supraumbilical group and 28% in Pfannenstiel group with no statistically significant difference.
As regards the operative time which was chosen as the primary outcome, we found that the mean total operative time (skin-to-skin) was 58.5 ± 5 minutes in TSU incision group and 54.0 ± 4 minutes in Pfannenstiel incision group with no significant difference and the mean operative time skin to uterus incision time was 6.5 ± 0.5 minutes in TSU incision group and 7.0 ± 0.4 minutes in Pfannenstiel incision group with no significant difference.
As regards the blood loss, our study results revealed that there was no statistically significant difference as regards blood loss among the studied groups (p value= 0.647). Consequently, there were no statistically significant differences regarding preoperative and postoperative hemoglobin and hematocrit among the studied groups.
As regards postoperative pain, our study results revealed that there was no statistically significant difference between the two groups as regards postoperative pain perception (VAS score) at hours 2, 4, 6, 12 and 24 hours
Similarly need for additional analgesia and opioid consumption was also statistically non-significant among both studied groups.
Consequently, as to the time to hospital discharge, there was no statistically significant difference among the studied groups discharge.
As regards postoperative complications, our study results revealed there were no statistical significance difference as regards the postoperative complications (delayed intestinal motion, SSI, ICU admission, occurrence of VTE, visceral injuries, vascular injuries and postpartum hemorrhage).
The only encountered surgical site infection (SSI) was in Pfannenstiel incision group in form of seroma, which was managed conservatively and resolved after 5 days.
Post operative ICU admission was only needed for five patients (10%) for post operative care to control the blood pressure due to Pregnancy-Induced Hypertension.
The low incidence of complications and the short operative times reported in our study might be a reflection of the high experience of the surgeons who performed the procedure. Such experience is due to the high number of cases admitted to our hospital, which is a tertiary center for referral of such cases from all over Egypt. However, a higher sample size study may reveal possible significant difference regarding such complications.
We concluded that the transverse supraumbilical incision is a novel promising method for cesarean section in severely and morbidly obese patients (body mass index > 40 kg/m2) with a voluminous abdominal panniculus that offers some practical advantages, such as the easier access to the peritoneal cavity, the surgeon’s comfort and the same postoperative complication rate compared to Pfannenstiel incision.
During our study it became a consistent observation by the performing surgical team that Supraumbilical incision was easily performed by the main surgeon and only one assistant and a scrubbing nurse meanwhile in while performing Pfannenstiel incision at least 2 assistants had to be scrubbed in to elevate the panniculus and facilitate exposure, Hence the supraumbilical incision was associated with a clear benefit in saving valuable man power resources of critical value in especially high-workload setting such as our tertiary center.
The approach to the lower uterine segment in the transverse supraumbilical incision was straight forward for all of the patients and allowed the baby to be extracted in good condition. The intervention was carried out with only one surgical assistant, which is rarely possible with low incisions in such patients.
We strongly recommend applying the transverse supraumbilical incision as an alternative to Pfannenstiel incision for cesarean section in severely and morbidly obese patients (body mass index > 40 kg/m2) with a voluminous abdominal panniculus.