This chapter should be cited as follows:
Stark M, Glob Libr Women's Med
ISSN: 1756-2228; DOI 10.3843/GLOWM.422183

The Continuous Textbook of Women’s Medicine Series – Obstetrics Module

Volume 20

Surgical Techniques in Obstetrics

Volume Editors: Professor Michael Stark, New European Surgical Academy (NESA) and Charité University Hospital, Berlin, Germany
Professor Sergej Barinov, Omsk State Medical University, Ministry of Health of Russia
Professor Gian Carlo Di Renzo, PREIS International School, Florence, Italy

Chapter

Evidence-Based Cesarean Section for Universal Use

First published: March 2026

AUTHOR(S)

Michael Stark

The New European Surgical Academy (NESA), Berlin, Germany

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INTRODUCTION

Cesarean delivery (CD) is the most frequently performed abdominal operation. However, many operative steps remain variable, which limits meaningful comparison of outcomes across surgeons and institutions. A universal approach should be reproducible, efficient and safe, allowing flexibility when dictated by specific clinical circumstances.

The method described here represents a model of standardization developed and refined over many years. It is based on tissue separation along natural anatomical planes, avoidance of unnecessary dissection and excessive suture material, and elimination of non-essential operative steps. Over three decades of evaluation in different countries, the method has consistently demonstrated advantages in both short- and long-term outcomes when compared with conventional techniques.

Surgical details in CD often reflect local tradition and individual preference rather than evidence. Studies differ regarding key operative steps, including incision type, peritoneal handling, and uterine and abdominal closure. Such variability impairs benchmarking and quality improvement efforts, as it seems that ‘CD’ does not represent a single standardized procedure but rather a spectrum of differing methods.

A universal cesarean method does not imply rigid uniformity. Rather, it denotes an evidence-supported standardized pathway for routine cases, which is simple enough for broad implementation in training, while incorporating clearly defined adaptations for special circumstances, such as repeat CD, an underdeveloped lower uterine segment or obstructed access.

Developed at Misgav Ladach Hospital in Jerusalem, the presented method offers a practical framework for universal application by defining a consistent sequence of steps supported by a logical surgical rationale.¹

The following principles underlie a universal CD method:

Minimize tissue trauma
Separate tissue layers along natural anatomical planes and limit sharp dissection
Preserve vascular integrity
Minimize use of suture material
Standardize incision type, abdominal entry, and uterine opening and closure strategy, unless specific indications require modification.
Ensure surgical steps are reproducible for trainees and transferable across institutions, supporting consistency, safety and global comparability of outcomes

SURGICAL METHOD

Patient preparation and anesthesia

The patient should be positioned supine with a left lateral tilt to reduce aortocaval compression. A mild Trendelenburg position is used to shift the bowel and omentum cephalad, thereby optimizing exposure of the lower abdomen.

Regional anesthesia, when appropriate, is preferred. A Foley catheter should be inserted to decompress the bladder.

A right-handed surgeon should stand on the patient’s right in order to deliver the baby with his/her dominant hand, and supporting safer needle-tip direction away from the bladder during uterine closure. A left-handed surgeon should stand on the left.

Abdominal entry

An adapted Joel-Cohen incision is used with blunt expansion. A straight transverse skin incision is made approximately 2.5 cm below an imaginary line connecting the anterosuperior iliac spines. The incision is initially through the skin only, minimizing unnecessary bleeding and reducing the need for hemostasis. The subcutaneous tissue just in the middle of the skin incision is deepened, and a small (1–2 cm) transverse incision is made in the fascia.

One blade of round-tipped straight scissors is inserted above the fascia and the other below it. The scissors are advanced laterally beneath the blood vessels and the subcutaneous tissue. The fascial incision is extended in the cranial and caudal directions using the surgeon’s index fingers. The rectus muscles are then gently separated laterally using the index and middle fingers.

Peritoneal entry

The peritoneum is opened by gentle repetitive stretching with both index fingers until a small fenestration forms, then widened in the cranial and caudal directions, which creates a transverse opening. Blunt entry minimizes the risk of bowel or bladder injury.

Uterine incision and delivery of the fetus

The vesicouterine peritoneal fold is incised, and the bladder is reflected inferiorly. A transverse incision is then made in the lower uterine segment, using a flat retractor (e.g. a Doyen retractor) to expose the lower segment.

In the case of a very thin lower segment, a cephalad–caudad stretch may be used to open the uterine wall transversely.

The fetus is delivered using the surgeon’s dominant hand, while an assistant applies gentle fundal pressure directed along the fetal axis toward the hysterotomy.

The placenta should be allowed to separate spontaneously when feasible. If separation does not occur, gentle controlled cord traction is performed. Manual removal of the placenta is undertaken only when indicated.

Uterine closure

After uterine exteriorization, the uterine incision is closed with a single-layer, locked continuous suture using size-1 polyglactin on a large (80 mm, semicircle) round-bodied needle. Additional hemostatic sutures are placed as required.

Routine towel packing is not performed. Gauze or a towel may be used selectively to improve visualization or to assist in bladder separation from the uterus. Blood clots are removed manually from the paracolic gutters, and suction is used as needed.

Abdominal closure

Both peritoneal layers are left unclosed. The fascia is closed with a continuous suture. The skin is approximated together with the subcutaneous tissue using a few Donati skin sutures.

Instruments and sutures

A universal CD method should be performed using a minimal instrument set and limited suture material. The following items are recommended:

Surgical instruments

Scalpel, straight round-tipped scissors, Doyen hand retractor (or Kelly retractor), hemostatic forceps (e.g. Rochester-Pean), tissue forceps, needle holder, Foerster sponge forceps.

Sutures (with acceptable equivalents)

Uterus: absorbable braided (e.g. PGA/vicryl/Safil), size 1 on large taper needle

Fascia: absorbable, size 1 on medium taper needle

Skin: non-absorbable (e.g. silk/nylon), size 0 on large cutting needle

Postoperative care principles

A universal surgical technique is incomplete without structured postoperative care aimed at reducing morbidity and promoting early functional recovery.

The core elements are:

Early ambulation – reduces the risk of venous thromboembolism and is generally well tolerated, particularly when limited tissue dissection has been performed.
Early oral hydration (and feeding) – evidence suggests no increased risk compared with delayed intake in uncomplicated cases, with potential benefits for earlier return of bowel function.
Multimodal analgesia, with short-acting opioids administered, as needed.
Chewing gum to stimulate bowel motility.

Wound dressing

Early oozing may be expected due to use of widely spaced sutures. The dressing should be changed after approximately 12 hours, and continued wound protection should be maintained for 2 days.

SURGICAL RATIONALE AND EVIDENCE

Most abdominal operations have transitioned to minimally invasive approaches; however, CD remains one of the few procedures still routinely performed as open surgery. At present, significant variability in technique persists. Differences are observed not only across countries and institutions but often within the same department, reflecting the influence of surgical training, local traditions and individual preference.

Evolution of abdominal and uterine incisions

Until the early twentieth century, the low longitudinal abdominal incision in CD was routine. Introduction of the transverse Pfannenstiel incision at the turn of the century marked an important esthetic and functional shift, improving cosmetic outcomes but requiring extensive tissue dissection.² For decades, surgeons selected longitudinal or transverse approaches based on tradition and institutional culture. The first comparative evaluation of the two incisions was conducted only 71 years after the introduction of the transverse incision, showing how deeply tradition can shape surgical standards before evidence becomes available.³

Today, transverse abdominal (and uterine) incisions predominate, yet longitudinal approaches continue to be used in selected circumstances.⁴ Considerable variation remains regarding abdominal entry, uterine closure and peritoneal handling. Such heterogeneity prevents meaningful comparison of outcomes, and highlights the importance of a standardized technique for evaluating surgical performance.

The Joel-Cohen incision, originally described for abdominal hysterectomy, was incorporated into the Stark (Misgav Ladach) method,⁵ simplifying CD through a tissue-sparing approach. The Joel-Cohen technique emphasizes minimal sharp dissection and greater reliance on blunt separation along anatomical planes. Accumulating evidence has associated this approach with reduced operative time, diminished blood loss, lower febrile morbidity and improved postoperative recovery.⁶^,⁷^,⁸ It is applicable for both primary and repeat operations. In certain situations, such as a poorly developed lower uterine segment, large fibroids, placenta previa or placenta accreta, the abdominal incision may remain transverse, while the uterine incision should be modified as clinically indicated. Women with prior longitudinal or low abdominal scars should be counseled regarding the implications of a different incision site.

Peritoneal entry and tissue handling

Blunt, bi-digital opening of the peritoneum by repeated stretching reduces the likelihood of inadvertent visceral injury, particularly bladder trauma, which has been associated with sharp entry.⁹^,¹⁰

The avoidance of routine abdominal packing is based on the understanding that mechanical abrasion of peritoneal surfaces contributes to postoperative adhesion formation.¹¹

Uterine incision is optimized by placing the incision as low as possible in the lower uterine segment. Histological analysis demonstrates that this region contains mainly fibrous tissue and fewer contractile fibers than in the uterine body.¹² Therefore, repaired lower incision will better withstand the mechanical pressure of subsequent pregnancies. Blunt lateral extension of a small transverse uterine incision, rather than sharp expansion, reduces unintended vascular injury and blood loss.¹³

Delivery of the fetus and placenta

Delivery is achieved by guiding the presenting part upward, assisted by gentle fundal pressure. In selected cases, vacuum extraction may be required.¹⁴

Using the described method enables a skin incision-to-delivery time of less than 2 minutes, which is of utmost importance in cases of fetal distress, as demonstrated in the following video.

Cesarean delivery using the described standardized method in a woman with body mass index of 38. Skin incision-to-delivery time was 88 seconds. Reproduced from Stark M. The Stark (Misgav Ladach) cesarean delivery-a streamlined surgical technique: development, rationale, and clinical outcomes. Am J Obstet Gynecol. 2026 Jan;233(6S):S55–S68.

Evidence consistently supports allowing spontaneous placental separation. Manual removal has been associated with higher blood loss with increased risk of endometritis,¹⁵ reinforcing the principle that physiological processes should be respected unless clinical circumstances dictate intervention.

Exteriorization of the uterus for repair remains debated. Although meta-analyses suggest broadly comparable outcomes between exteriorized and in-situ repair, trials have reported differences in extent of blood loss.¹⁶ Exteriorization offers enhanced visualization, facilitates clot removal and permits adnexal inspection, but must be balanced against patient comfort and intraoperative hemodynamics.¹⁷

Uterine closure and scar integrity

Single-layer closure of a cesarean uterine incision was originally advocated to reduce the amount of foreign material in the uterine wall and minimize tissue reaction. Large, randomized comparisons and systematic reviews have demonstrated no consistent difference between single- and double-layer techniques concerning uterine rupture or scar defect formation in subsequent pregnancies.¹⁸^,¹⁹^,²⁰ Although some observational data suggest variation in rupture risk, methodological limitations and imbalanced study groups complicate interpretation.

The rising global cesarean rate has heightened awareness of cesarean scar niches i.e. indentations at the site of uterine repair, detectable on imaging. Reported prevalence varies widely, while reflecting heterogeneity in definition and study design.²¹ Importantly, current evidence does not clearly implicate closure technique alone as the primary determinant of niche formation.

Peritoneal non-closure and adhesion prevention

One of the more paradigm-shifting departures from historical practice has been the abandonment of routine peritoneal closure. Experimental and clinical observations demonstrate that the peritoneum heals within 1 or 2 days through mesothelial regeneration.²² Suturing peritoneum may promote ischemia, foreign-body reaction and adhesion formation.²³ Comparative studies have reported reduced adhesion rates and shorter operative times when the peritoneum is left open.²⁴^,²⁵ These findings have influenced guideline recommendations and exemplify again the transition from tradition-based to evidence-informed surgery.²⁶

Fascia, subcutaneous tissue and skin closure

In the described CD technique, continuous fascial suturing is followed by selective skin approximation using interrupted Donati sutures that incorporate the subcutaneous layer, thereby obviating the need for routine separate subcutaneous stitches. This approach minimizes foreign body reaction while permitting egress of early postoperative serous and blood discharge, reducing hematoma and seroma formation. Postoperative wound care focuses on ventilation and cleanliness, rather than prolonged occlusive dressing. The larger size of the needle results in less remaining suture material, potentially minimizing foreign-body tissue reaction.²⁷

Concerns regarding the slightly higher placement of transverse incisions have not translated into patient dissatisfaction. Long-term follow-up indicates high levels of maternal acceptance of scar appearance.²⁸

Postoperative recovery and enhanced care

CD extends beyond the operative field into structured postoperative care. Early ambulation is strongly encouraged, as it reduces the risk of thromboembolism and is facilitated by reduced postoperative pain, due to preservation of normal tissue planes during surgery. Early oral intake appears safe and may accelerate bowel function²⁹ particularly when combined with simple adjuncts such as chewing gum.³⁰ Analgesia strategies prioritize oral agents, with short-acting opioids added when necessary.

In uncomplicated cases, discharge from hospital within 2–3 days is feasible and consistent with enhanced recovery principles. Postoperative management integrates thromboprophylaxis, support for breastfeeding and clear patient guidance regarding wound surveillance and mobilization.³¹^,³²

This method reflects a shift from tradition-driven variability toward evidence-guided simplification. Standardization based on these principles not only improves outcomes but also enables meaningful comparison across institutions.

In 1995, the technique was presented at the 14th World Congress of the International Federation of Gynecology and Obstetrics (FIGO) in Montreal, generating international interest.³³ As awareness increased, obstetricians from multiple countries visited Jerusalem to observe the method.

In 1999, a comparative study was conducted at the university hospital in Uppsala, Sweden,³⁴ followed by a comprehensive description of the method which was published and distributed in over 100 countries.³⁵

The reproducibility of these findings across countries and hospitals has strengthened the overall evidence base supporting the method. It has therefore been proposed as a universal strategy for CD, and recommendations have been made for implementation as a standard procedure in different countries.³⁶^,³⁷

CONCLUSION

The CD method described herein represents a shift towards simplification, preservation of tissue integrity and evidence-based surgical practice. Across diverse countries, it has been associated with shorter skin incision-to-delivery times, reduced blood loss, fewer postoperative adhesions, lower analgesic requirements and improved maternal recovery. The reproducibility of these outcomes across different countries underscores its adaptability to varied clinical environments.

As cesarean section rates continue to rise, surgical standardization has become a public health priority. Variability in operative technique contributes to inconsistent outcomes, increased costs and preventable morbidity. This method provides a validated, simplified and teachable approach that can serve as a unifying standard. Obstetric societies, academic institutions and health ministries should move beyond acknowledgment toward formal endorsement. Incorporating the method into clinical guidelines, residency training, certification standards and continuing medical education would further advance standardization and enhance maternal safety.

Adopting a consistent, evidence-based CD technique is a needed step toward reducing morbidity. It is time for professional organizations and policymakers to translate the accumulated evidence into coordinated action, ensuring that CD is performed according to the highest and most consistent standards of care.

PRACTICE RECOMMENDATIONS

Adopt a standardized cesarean delivery technique whenever possible. Standardization reduces surgeon-dependent variability and allows meaningful comparison of outcomes across institutions.
Use a transverse adapted Joel-Cohen skin incision approximately 2.5 cm below the line connecting the anterosuperior iliac spines to facilitate rapid, tissue-sparing abdominal entry.
Favor blunt tissue separation along natural anatomical planes rather than extensive sharp dissection to minimize tissue trauma, bleeding and postoperative pain.
Open the peritoneum bluntly using bi-digital stretching to reduce the risk of inadvertent injury to adjacent organs such as the bladder or bowel.
Place the uterine incision as low as possible in the lower uterine segment, where tissue composition supports stronger healing and better tolerance of future pregnancies.
Allow spontaneous placental separation whenever feasible, using controlled cord traction only when necessary, and avoid routine manual placental removal due to its association with increased blood loss and endometritis.
Close the uterine incision with a single-layer continuous suture, adding hemostatic sutures only when required, to minimize foreign material and tissue reaction.
Leave both visceral and parietal peritoneal layers unclosed, as spontaneous healing occurs rapidly and non-closure may reduce operative time and postoperative adhesion formation.
Use a simplified abdominal closure strategy, including continuous fascial closure and selective skin approximation (with Donati sutures) that incorporates the subcutaneous layer and avoids routine separate subcutaneous suturing.
Promote enhanced postoperative recovery, including early ambulation, early oral intake, multimodal analgesia with limited opioid use, and simple measures such as chewing gum to stimulate bowel motility.

CONFLICTS OF INTEREST

The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.

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REFERENCES

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