Podcast Summary: Dr. Chapa’s OBGYN Clinical Pearls

Episode: Another Pub on Hysterotomy Closure
Date: January 29, 2026
Host: Dr. Chapa
Main Topic: Discussion of a new expert review (January 2026) on “endometrium (decidua) free closure” for hysterotomy incisions at cesarean delivery, with practical insights on current best practices, ongoing controversies, and review of evidence base.

Episode Overview

Dr. Chapa revisits the topic of how best to close the uterine incision (hysterotomy) at cesarean section—specifically focusing on whether the endometrium (more accurately, the decidua in pregnancy) should be included or excluded from the closure. A new expert review from January 2026 makes familiar recommendations, supporting “decidua-free” closure techniques, but also advocates some controversial surgical steps that go against established evidence-based practices. Dr. Chapa critiques the new paper, contextualizes it with past literature, and delivers clear take-home points for clinical practice.

Key Discussion Points and Insights

1. Why This Topic Again?

• Repetition is a Reminder:
  • Dr. Chapa emphasizes the importance of revisiting certain topics as new publications arise—even if the evidence is not fundamentally new.
  • “While some things may sound a little redundant, it’s because they are. But they’re good reminders to us in clinical practice…” (04:11)

2. Historical Background

• Max Sanger (1882):
  • The concept of carefully closing the uterine incision dates back to the 1880s. Early advice was to avoid bringing “the inner lining of the uterine cavity” (decidua) into the closure due to infection risks.
  • “He actually stated: it’s important to avoid the decidua, the inner lining of the uterine cavity because it was swollen, bloody, and infected.” (09:47)

3. Why Avoid Including the Decidua?

• Biological Rationale and Evidence:
  • Including decidua in the hysterotomy increases risk of weaker uterine closure, “niche” defects (small pouch at scar site), and possibly abnormal placentation later.
  • “Bringing that endometrial tissue in, that gland and stroma...that weakens the incision.” (06:23)
  • Evidence from multiple studies now supports these concerns; sonography shows weaker or defective healing if decidua is included.

4. Recent and Key Studies Reviewed

• September 2025 Systematic Review (Green Journal):

  • 6 RCTs, ~5,000 patients; compared closure with and without decidua.
  • Findings: Decidua-excluding closure showed:
    • Lower risk of intermenstrual bleeding.
    • Lower risk of uterine scar (niche/isthmocele) defects.
    • No significant impact on dysmenorrhea or pelvic pain (controversial).
    • Impact on abnormal placentation risk is supported, but evidence is not definitive.
  • “There was no harm by avoiding the decidua, but there was potential benefits, at least on the gynecology side.” (24:48)

• January 2026 Expert Review (Chief Paper for the Episode):

  • Title: "Endometrium Free Closure Technique for Hysterotomy Incision at Cesarean Delivery" (First author: Antone).
  • Presents this closure as a “new” method, but Dr. Chapa critiques this as well-trodden ground.
  • “We present the endometrium free closure technique, an approach that requires in depth knowledge of the three layers of the uterine wall. Really, bro? ...We know this.” (16:53)

5. The Remaining Controversies

• Single vs. Double Layer Closure:
  • No clear evidence favoring one; large studies (Coronis Collaborative) found no outcome differences.
  • “What is probably best is regardless of what you choose to do… don’t include the decidua as a full thickness bite. That’s all. That’s the take home message.” (29:52)
• Locking vs. Non-Locking Sutures:
  • No definitive data. Key priorities are good hemostasis, avoiding tissue strangulation, and not including decidua.

6. Controversial Points From the 2026 Review

• Dr. Chapa identifies three recommendations that go against most evidence-based guidance:

  1. Routine Bladder Flap Creation with Sharp Dissection:
     • Most current guidelines call for avoiding the bladder flap unless required, as it may actually increase bladder injury risk.
     • “Most evidence based guidelines, most standardized techniques ... avoid the bladder flap. You don’t have to do that.” (33:17)
  2. Double Layer Locked Closure for Each Layer:
     • Efficacy versus single-layer and/or non-locking is not clearly supported.
  3. Routine Closure (Suturing) of the Bladder Flap (Vesicouterine Reflection):
     • Most recommendations argue against routine closure.
     • Can cause bladder displacement, tension, and may lead to urinary symptoms.

• Memorable critique:

  • “I was with them that we should focus on an endometrial decidua free closure... I am not with them in their recommendation to make a bladder flap or close routinely two layers, both locking.” (39:30)

7. Take-Home Messages

• Universal Recommendations:
  • Avoid including decidua (endometrial lining) in hysterotomy closure.
  • Closure technique (single vs. double layer, locking vs. non-locking) less important than avoiding decidua and ensuring good surgical technique.
  • Be skeptical of recommendations to routinely create/close bladder flaps or to always use double layer locked closure—these are not universally evidence-based.

Memorable Quotes & Moments

• On the Recurrence of Topics:

  • “Oh no, not again… Even though we’ve done it, it’s a good reminder…” (05:41)

• On Evidence and Subjectivity:

  • “Perception is all through the lens that you look through. They do give some recommendations... that are a little controversial.” (07:40)

• On Medical Literature Hype:

  • “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?” (15:13)

Timestamps for Important Segments

• Historical context and Sanger’s technique: 09:20–12:10
• Rationale for decidua-free closure: 05:40–07:15, 12:10–14:20
• Critique of the “new” January 2026 paper: 15:13–19:40
• Key 2025 systematic review findings: 24:00–26:50
• Big controversies (bladder flap, suture method, flap closure): 33:00–39:30
• Practical summary and closing advice: 39:00–42:00

Summary Table: Practice Pearls

| Issue/Technique | Evidence-based Recommendation | Controversy Supported by 2026 Review | |------------------------------------------|------------------------------------------------------|---------------------------------------------| | Include decidua in closure? | Avoid inclusion (decidua-free closure) | No—reinforces current evidence | | Single vs. double layer closure | Either is reasonable; no proven difference | Double layer locked, per controversial review| | Locking vs. non-locking | Either; avoid tissue strangulation | Both layers locked, per controversial review | | Bladder flap creation? | Not routinely; avoid unless needed | Recommend routine creation (controversial) | | Bladder flap closure? | Not routinely; avoid | Recommend routine closure (controversial) |

Clinical Take-Home Message

“Regardless of how you choose to close, get good hemostasis, don’t strangulate tissue, and don’t include the decidua as a full thickness bite.” (29:55)

For more context, see the January 2026 expert review (“Endometrium Free Closure Technique for Hysterotomy Incision at Cesarean Delivery”), the September 2025 meta-analysis, and the 2020 Green Journal guidelines (Dalk et al).

Dr. Chapa and his team aim to keep their listeners up-to-date but challenge them to think critically about new publications and recognize both the evolution and redundancy within OBGYN evidence.

Written for clinicians, residents, and students who want up-to-date and practical advice, this episode clarifies what’s new, what’s not, and what really matters for optimal cesarean closure technique.