Role of extraperitoneal cesarean section.

The matter of attempting to revive extraperitoneal cesarean section as a viable option appears generally to be greeted with considerable emotion. Such emotion usually arises among those unfamiliar with the technique. As shown by the data from the University of Colorado, once one becomes accustomed to the procedure, there appears to be no greater hazard than that of the standard transperitoneal approach. The data cannot be interpreted as showing a distinct advantage to extraperitoneal cesarean section, as there was a substantially higher use of preoperative antibiotics to reduce morbidity. However, the patients who underwent the exttaperitoneal procedure had a greater preoperative morbidity potential, necessitating the use of such antibiotics. Apgar scores remain lower at 1 minute, partly because of the delivery of one stillborn infant and a somewhat higher incidence of premature infants in distress. In addition, the delay in delivery of the fetus frequently encountered when inexperienced surgeons attempt this operation as a new surgical experience is clearly a factor as well. One must accept, however, that the operation has a highly attractive rationale. To place the procedure in proper perspective, a prospective, controlled study based on random selection must be done. One additional control population that would help to sort out some aspects of the benefits of the extraperitoneal approach would be a population of patients in whom routine draining of the retrovesical space is carried out, as is done in the exptraperitoneal operation. With these groups for comparison, the extraperitoneal operation may finally be placed in its true perspective. This can be accomplished only by scientific endeavor, not by speculation. Extraperitoneal cesarean section represents a viable alternative to transperitoneal delivery or cesarean hysterectomy in the presence of uterine infection, presumed or proven. Despite the wealth of information concerning the efficacy of a wide spectrum of antibiotic regimens for the prevention or treatment of postcesarean section morbidity in the modern era, infection remains a problem that has merely been somewhat controlled. It is incumbent upon resident education programs to provide trainees with the broadest spectrum of options and skills. Since the extraperitoneal operation not only has benefits in anatomic training but also possesses a rational basis for the avoidance of serious postoperative pelvic infectious complications, this operation deserves reconsideration in the modern era. The occasional postoperative pelvic abscess that subjects a patient to one or more subsequent operative procedures and to the attendant risks of death or sterility, make any procedure designed to avoid these complications appear more worthwhile. Until the demon of postoperative infection is successfully and permanently caged, we must continue to consider all reasonable options toward this end. Scheider has stated that "a difference to be a difference must make a difference." With this we agraee...