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Podcast Family As I've said many times before, I hope that at least one of the main reasons, if not the only reason, that that you listen to the show is because we really try to be at the forefront of the data. We let you know what is hot and fresh in print all the time. But one of the issues with that is sometimes we're so ahead of it that when things officially come out or they repeat, it's like old news to us. But that's actually an advantage because yeah, we've already covered it. So sometimes, you know, look at some of the literature and you know, when we talk with our team about things to cover and a topic comes up and our producer's like, wait a minute, didn't we already do that? Oh no, not again. So while some things may sound a little redundant, it's because they are. But they're good reminders to us in clinical practice that a things have to be retested again to keep proving their validity, b they're tested and disproven, or c they're just good reminders for us of how we should practice. And that's the issue with what we're going to cover today. Now, we've covered hysterotomy closure at C section at least twice before, and I know two times most recently one was in September of 2025 where we covered a then systematic review and meta analysis from the Green Journal dealing with decidual free closure. I'm going to remind ourselves very quickly of what that found from September 2025 when we get out of the intro. But even before that we covered in 2023 again pushing for and advocating for Endometrium free closure at hysterotomy. And in one of those episodes, we said it's kind of a misnomer because there is no endometrium at C section, because the endometrium implies proliferative or secretory, meaning non pregnant. It's actually called a decidua. So while some reports say endometrial free closure, the true anatomical term is decidua free closure is what we're covering now, even though we've covered it twice before. At least twice before. That's what our producer found most recently. There is a new publication. Yeah, brand new, from January 2026, the same month that we're recording this, that once again is under expert review and talks about decidua free closure. Now here's a question. Did they find and verify the same things that we covered twice before or did they come up with something different? Were gonna cover that in this episode. Oh, no, not again. Yep. Even though we've done it, it's a good reminder, guys, here's, here's. If you can't figure out where we're going, Spoiler. Yes, they are advocates of decidua free closure that is linked, at least biologically. And there's some proof to this based on sonographic studies that is linked to weaker hysterotomy closure if you bring the endometrium into the incision. So don't do that. So let me just give you a spoiler right now. Free closure, whether you close the endometrial or decidua by itself and then do the outer layers of the malmitrim or just avoid it all together. That's what I do. That doesn't matter. The point is that you don't include it as a mass closure through and through as a big bite at the hysterotomy, because bringing that endometrial tissue in, that gland and stroma, plus the supravasculature, and sometimes it's, you know, subclinically infected, that weakens the incision. So, yes, we're going to talk about this brand new January 2026 publication. Spoiler. They do make the case for decidua free closure and we're going to cover that. However, here's the issue, guys. So I'm like, great, I'm with you. I'm with this team. It's good. They review good data, but then they say, well, here's what we recommend. Remember, just under expert reviews, not an independent studies, just they looked at the data and this is how they Interpret it. Ah. Because perception is all through the lens that you look through. They do give some recommendations, mainly regarding bladder flap and how to close the hysterotomy that are a little controversial and is not what has been stated in previous expert reviews for evidence based C section or standardization of C section, which we covered. One of the best ones was not long ago out of 2020 and I'll leave that reference by Dalk et al in our reference comments under our narrative description for the podcast. But this was back in 2020, actually November of 2020. It was in the green journal standardized cesarean technique. And this goes kind of against what these experts are saying is the best way to do it. Which proves one thing, guys, sometimes there's more than one way to do it. It's okay, everyone can be right and have a different opinion. Surprise. But the most important part is not to include the decidua into the hysterectomy closure. Oh no, not again. Yep. So even though we have covered this before, we're gonna do it again because it's a good reminder. So our chief paper that we're gonna review, our chief expert review is called Endometrium Free closure technique for Hysterotomy incision at Cesarean Delivery in the American Journal of Obstetricians and gynecology from January 2026. The first solicit author is Antone. All right, I think I've said it up enough. We will be right. This is Dr. Chapa's obgyn no spin podcast. Yep. Back in the day, like the 1880s. Which is where we're going to start a little timeline here with Max Sanger from when we get the Sanger type of C section. That was a classical C section. But Max Sanger, he was a German ob GYN at the University of Leipzig. He was the first one to say, hey, we don't have to do a hysterectomy with these patients. We possibly we could close up the hysterotomy, which again was vertical, but he used wire sutures that were non reactive to close the hysterotomy. Amazing. Now that was back in 1882. Now trust me, this matters what we're talking about here because in that original description, and yes, you can find that original narrative, he actually stated it's important to avoid the decidua, the inner lining of the uterine cavity because it was swollen, bloody and infected. End quote. Yeah, well, because a lot of women had childbirth fever at that time. We're talking about 1880s. But the point Is even back then he said avoid the decidua may have been for different reasons, but now we know that potentially that can bring endometrial glands and stroma into the hysterotomy and definitely, at least ultrasonographically, can lead to the niche defect and potentially, according to some studies, also lead to abnormal placentation. Guys, if we can do something to get ahead of placenta accretis spectrum disorder and maybe ward that off, that would be phenomenal. So very quickly, even though some things are controversial, should we close the uterus in a single layer or two layers? Should it be locking or not locking? That has been a circular argument which we have covered many times before. It's a fascinating discussion, but the most important thing is whether you do locking or not locking, single or double layer, the important thing is that everybody agrees with seems to be avoid the decidua. Now, just to be fair, the title of this expert review that we're covering once again has my pet peeve, but I'll let it go. I'll let it go because these authors, I respect them. One of them is Emmanuel Bujold. Y' all remember that dude Emmanuel Bujold from Canada. I worked with him. My goodness, had to be 15 years ago, we did a conference in Amsterdam presenting on evidence based C section technique back in the day, along with Stephanie Roberti. We've talked about them many times in the past, but these authors, Antone Trich, Emmanuel Bujol, Young Albert Rees, all phenomenal, phenomenal researchers and ob GYN scientists and we've covered them before now. So even though there's some things that are controversial, single versus double locking or not, we've discussed all that. I'll touch on some of the controversial things that these authors do recommend at the end of the episode. But this is going to be very targeted, very quick because it is nothing new. Nothing new. We've already covered this at least twice as far as we can remember. But I love how once again, you know, somebody looks a different direction and discovers the sun in the sky and then says, oh, I've discovered a ball of light in the sky. I am the first. Are you though? Are you though? So let me give you what these authors say. Sorry, not, not, not trying to be sarcastic, but we've already known this. But I love how these authors lay out the purpose, the objective of this expert review as they start their manuscript. So let me read it directly quote. The debate over the best method for uterine closure, as well as the etiology of scar defects remains unresolved End quote. Yes, that's fair. Check. I agree with that. We don't really know what's the best way to close. Although avoiding the endometrium does seem to have a lot of validity. They go on to say, quote, we present the endometrium free closure technique. So let's stop there. We present the endometrium free closure technique as if we had never heard this before. This is eye opening. This is. For the first time I have discovered the endometrium free closure technique. Not being facetious, bro. Bro, this is already a thing. But it's okay. That's okay. Remember, this came out January 2026, even though we covered this September 2025. And then again, we've covered it previously in 2023. I'll leave those references in our show notes as well. Or you can find it in the archive. Whatever. The point is not new. But they go on. Quote, we present the endometrium free closure technique, an approach that requires in depth knowledge of the three layers of the uterine wall. Really, bro? I mean, we learned the three layers in gross anatomy. The three layers are the innermost layer, meaning endometrium. If you're not pregnant or decidu pregnant, then comes the big fat myometrum, then comes the outer serosa. I think that's pretty clear. Nobody should be saying they discovered brand new three layers of the uterine wall. We know this now. They do. Describe that junction, which does actually look a little bit different. Next time you're at a C section, take a look. The myometral decidua or endometrial junction. It has a different color, sometimes a little spongier texture. You can see that. But that's not new. If you pay attention, you know where that's at. The gist of this is, while they are putting this together as a new proposal, A, it's not new at all. B, it's data that we've already said simply just don't include a full thickness bite. Avoid the decidua in your closure. That's the gist of it. We've already said that. And yes, they are shocker advocates for endometrial free closure. Mainly because Antone, the listed author on this, has already provided other publications like a 30 year retrospective review where they looked at subsequent pregnancies in those who had endometrial free closure. And at least according to that review by the same author, there was no issues of abnormal placentation in subsequent pregnancies, however. So that's great news. However, it didn't have a matched control group. It was retrospective. But it does make sense. And that goes with other tissue, Other tissue, other studies that show that bringing endometrial tissue or deciduous tissue into the scar lining could at least produce scar defects like the niche defect. So that brings us briefly to what we covered in September of 2025, which was a systematic review on this topic. You can go back to listen to that episode. But in brief, it was 6 RCTs had a total of 5000 ish patients that compared closure with and without the decidual layer at repair. Okay, very simple. Short of it is, yes, not including the decidua in uterine closure. Had a reduced risk of intermenstrual bleeding. Had a reduced risk of uterine scar defect. But they said, you know, we don't have enough data here to really know about its success on tolac. There's too many confounding factors. The indication for first section was she infected. So there's too many factors there, including use of uterotonic agents and subsequent labor. So they're like, I don't know if it's really any safer for tolac, but at least it reduces some GIN issues like an isthmocele mainly. And reduction of intermenstrual bleeding didn't really change anything in terms of dysmenorrhea or pelvic pain in that review. While others, however, have shown a reduction in dysmenorrhea because blood collects there, it can trigger some cramping. So that's a little controversial. Short of it is there was no harm by avoiding the decidua, but there was potential benefits, at least on the gynecology side. Okay. And again, there is, there is published data that has shown some benefit in reduction in abnormal placentation, although those studies have had its, their limitations. So I want to do this very quickly. This review from January of 2026, which is proposing, like for the first time, it's not the first time, the decidua free closure. We are back at this again. So yes. Oh my goodness, we are doing this again, again, because it's a good reminder to us. So short of it is these authors conclude, quote, while formal changes in surgical guidelines may require further randomized trials, we believe that this technique has the potential to reduce adverse events and provide long term benefits for women's reproductive health. Yes, I agree with that. That's valid. That is both in anatomical and physiological theory. We have seen that plan out, at least on ultrasound. It's fine. What we don't know. And what is still controversial, is it single layer or dual layer? It doesn't matter what kind of suture you use, should it be locking or non locking? Most would agree. Guys, let me just say this right now because it's one of the controversial things that they propose that I'm going to give you very quickly. The three things that they advocate for that is against the typical body of evidence that calls for a standardized C section technique based on clinical evidence. We don't know if it's a double layer closure is any better than a single. Actually the Coronis Collaborative group, we've covered this in the past. The Coronis Collaborative group was a very large study. It was a randomized trial. It did something like 15,000 women. Followed them for like three years. It found no significant difference in outcomes for for various cesarean section techniques including single layer versus double layer hysterectomy closure. So they said, look, you know, if it's thick, close it in two layers. Otherwise you can do a single layer. If it's bleeding, do locking. Otherwise non locking is just fine. Nothing wrong with not locking. Some actually say it heals a little bit better because you don't strangulate the tissue. The short of it is we don't really know if it's single layer or dual layer that is best. You got to do the best that you can to restore anatomy as long as you don't include the endometrium. That's the take home. So have you ever asked is single layer, two layer better? Is it locking or non locking? The answer is which paper do you want me to cite you? Because all of those have data. What is probably best is regardless of what you choose to do, number one, get good hemostasis. Two, don't strangulate tissue. Number three, don't include the decidua as a full thickness bite. That's all. That's a take home message. We're going to wrap that up. But let me give you the three controversial things that I was like. Man, I was with you. Outstanding with you guys. I'm all for deciduous free closure, but then they threw this one in. They recommend the creation of a bladder flap. Now let me stop there for a minute. And they want a sharp dissection of the bladder flap. Most evidence based guidelines, most standardized techniques, most calls for evidence based C section fraction, avoid the bladder flap. You don't have to do that. We already know that. The last review that I really like that showed that was back in 2020, in November of 2020. On standardization of C section, you actually get more bladder injury by making a flap as soon as you cut into the anterior uterine throw so the bladder flap will naturally fall away. So they want a bladder flap even though most evidence based data say that is not necessary. Unless of course a bladder is tacked up and you cannot get to the lower uterine segment. General, just as a routine thing, most do not agree with a bladder flap. That's the first. The second is that they do advocate for a double layer locked suture for each one. So two layers both locked. Again, there's no real data for that. Actually some show that you can strangulate the tissue. Stephanie Roberti showed an inner locking followed by an outer non locking seem to be the best, at least to prevent the niche defect. But they want a double layer locking closure. That is controversial. And then the third thing that is also controversial in this paper is that they recommend suturing back the vesicouterine reflection, also known as the bladder flap. Again, most say don't make it. And if you do make it, definitely don't suture that back up unless there's some weird reason that you have to, because that actually tends the bladder dome upwards. In some reports it's caused urinary hesitancy and frequency and it puts the bladder on an abnormal bladder dome on abnormal tension or has the potential to do that. So they recommend to create a bladder flap and to close it. That is not what most evidence based C section techniques have called for. So those are the three controversial things. One is to make a bladder flap. Next is to close a bladder flap and then the third is to close a hysterotomy in a double layer locking suture. Those are all controversial. So while I was with them that we should focus on an endometrial decidua free closure. And again, nothing new. We've covered that in the past. I am not with them in their recommendation to make a bladder flapper close routinely. Two layers, both locking. So podcast family, relatively quick our commitment. If you're thinking why are we doing this? We've already covered this. True, true, true, absolutely true on all those fronts. We are covering this because our job is to let you know what is hot in press whether we like it or not. Right. And so this is relatively new. This came out January 2026 and because it does have to do with something that we do frequently as obstetricians, which is hysterotomy closure, we elected to cover this. So now that we've done so, I think we are done. We're going to wrap this up. This just came out in the Gray Journal under their section, Expert Review. The title is Endometrium Free Closure Technique for Hysterotomy Incision at Cesarean Delivery. Podcast family, we are thankful for you. We're glad you're part of our podcast community. And now that we've done all that, let's take it home. This has been Dr. Chapa Zobi Gyn, no Spin podcast Podcast family, thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast. Sam.