Journal of Investigative Surgery

ISSN: 0894-1939 (Print) 1521-0553 (Online) Journal homepage: https://www.tandfonline.com/loi/iivs20

An Optimal Uterine Closure Technique for Better

Scar Healing and Avoiding Isthmocele in Cesarean
Section: A Randomized Controlled Study

Ziya Kalem, Aski Ellibes Kaya, Batuhan Bakırarar, Alper Basbug & Müberra
Namlı Kalem

To cite this article: Ziya Kalem, Aski Ellibes Kaya, Batuhan Bakırarar, Alper Basbug & Müberra
Namlı Kalem (2019): An Optimal Uterine Closure Technique for Better Scar Healing and Avoiding
Isthmocele in Cesarean Section: A Randomized Controlled Study, Journal of Investigative Surgery,
DOI: 10.1080/08941939.2019.1610530

To link to this article: https://doi.org/10.1080/08941939.2019.1610530

Published online: 09 May 2019.

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Journal of Investigative Surgery, 0: 1–9, 2019
Copyright # 2019 Taylor & Francis Group, LLC
ISSN: 0894-1939 print / 1521-0553 online
DOI: 10.1080/08941939.2019.1610530

ORIGINAL RESEARCH

An Optimal Uterine Closure Technique for Better Scar

Healing and Avoiding Isthmocele in Cesarean Section:
A Randomized Controlled Study
Ziya Kalem1, Aski Ellibes Kaya2, Batuhan Bakırarar3, Alper Basbug2 and
M€uberra Namlı Kalem4

1
Department of Obstetrics and Gynecology, Gurgan Clinic IVF and Women Health Center, Ankara, Turkey;
2
Department of Obstetrics and Gynecology, Duzce University, Duzce, Turkey; 3Department of Biostatistics, Ankara
University, Ankara, Turkey; 4Department of Obstetrics and Gynecology, Liv Hospital Ankara, Ankara, Turkey

ABSTRACT
Objective: The aim of this study is to compare the effects of two different uterine closure techniques, used
during cesarean section (CS) operations on isthmocele formation. Material and Methods: This prospective,
randomized, controlled study was performed on 138 patients in a university hospital between the dates
December 2016 and August 2017. Uterine closures were performed using the double-layer, far-far-near-near
(FFNN) unlocked technique, in the study group (n ¼ 70) and using a single-layer continuous locked (SLL)
technique in the control group (n ¼ 68). The presence of isthmocele, residual myometrial thickness (RMT),
postmenstrual spotting, dysmenorrhea, chronic pelvic pain and uterus position were evaluated in postopera-
tive sixth month. Results: Isthmocele formation was less frequent and RMT was greater in the study group
when compared to the control group (p < 0.001 and p < 0.001, respectively). Duration of operation, amount
of blood loss and additional hemostatic suture requirement were not significantly different between the two
groups (p ¼ 0.221, p ¼ 0.520 and p ¼ 0.930, respectively). Postmenstrual spotting was less common in FFNN
group, while the rates of chronic pelvic pain and dysmenorrhea were not significantly different between the
groups (p ¼ 0.002, p ¼ 0.205 and p ¼ 0.490, respectively). Conclusion: The findings of the present study demon-
strate that uterine closure using the FFNN technique is beneficial in terms of providing protection from isth-
mocele formation and ensuring sufficient RMT. This method has the potential to become the optimal
uterine closure technique, but the findings of the present study should be supported by large-scale studies
in the future.
Keywords: cesarean; isthmocele; suturing technique; residual myometrial thickness; scar healing; double-
layer suturing

INTRODUCTION contrast-enhanced sonohysterography in a random

Isthmocele, which was first defined in 1995 by
Morris, is a uterine scar defect resulting from the
poor healing of an incision in the uterus [1]. In fact,
the frequency of niche occurrence varies in patients
who have had a cesarean section (CS). While the rate
of isthmocele detection in pelvic ultrasonographies
varies between 6 and 36 percent, the range
is between 56 and 84 percent when using a
population of women with a history of CS [2]. The
most common gynecologic problems associated with
isthmocele include menstrual spotting, dysmenor-
rhea, dyspareunia, chronic pelvic pain and infertility
[3, 4], and there is also an increased risk of scar preg-
nancy, placentation abnormalities and the develop-
ment of uterine ruptures in future pregnancies [5, 6].
Considering the worldwide increase in rates of
CS operations, the current rate of isthmocele and

Address correspondence to M€ uberra Namlı Kalem, MD, Department of Obstetrics and Gynecology, Liv Hospital Ankara, Ankara,
Turkey. E-mail: muberranamli@hotmail.com

Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iivs.
Supplemental data for this article is available online at https://doi.org/10.1080/08941939.2019.1610530.

1
2 Z. Kalem et al.
associated complications should not be overlooked.
Although hysteroscopic and laparoscopic isthmocele
repair procedures have demonstrated high success
rates [7, 8], measures to prevent the formation of
isthmocele during CS operations should be the pri-
mary goal. The selected uterine closure technique is
considered to be the most important factor affecting
isthmocele formation [9, 10], although other factors
include close proximity of the uterine incision to the
cervix, the formation of adhesions, myometrial
ischemia and impaired wound healing [11, 12].
An optimal uterine closure technique should
ensure better scar healing, reduce the risk of isthmo-
cele formation and also decrease risks related to the
most important long-term complications, including
placentation abnormalities and uterine rupture. We
believe that the endometrial sparing double-layer
unlocked suture technique – defined in 2012 by Babu
and Magon as a continuous modified mattress suture
– is the optimal technique for uterine closures. This
technique ensures full-thickness decidua-to-decidua,
myometrium-to-myometrium and serosa-to serosal
approximation of the uterine cut margins and good
homeostasis. The method also eliminates the eversion
problems associated with single-layer sutures, vascu-
larization problems resulting from locking, and endo-
metrial inversion problems seen in sutures including
the endometrium [13].
The present study was carried out to compare
the modified mattress suture technique, which was
described by Babu and Magon as a uterine closure
technique for CS operations, with the conventional
single-layer locked technique, in terms of their
effects on isthmocele formation.
MATERIALS AND METHODS
This prospective, randomized and controlled trial
was carried out to compare two different uterine
closure techniques used for CS operations, and
included 138 patients between December 2016 and
August 2017. The study was granted ethics commit-
tee approval by the Duzce University Medical
Faculty Ethics Committee, and all participants pro-
vided written informed consent.
The study inclusion criteria were as follows:
women aged between 18 and 40 years with a BMI of
15.5–34.9, had a single pregnancy, were at more
than the 38th week of pregnancy and underwent CS
operation. The exclusion criteria were as follows:
presence of diabetes or hypertension, thrombophilia,
a previous history of CS or other uterine surgeries,
has lower segment myoma (a congenital uterine
abnormality), placental decollement or placenta pre-
via. Additionally, patients who were found to have
very thin low segments (less than 0.5 cm) during the
FIGURE 1. Schematic representation of far-far, near-near
suture technique.
CS operation were also excluded from the study, as
this is not appropriate for the investigated uterine
closure technique.
In total, 138 patients included to the study were
randomized at a ratio of 1:1 and divided into two
groups using a computer system. A Pfannenstiel
incision was made and a Kerr incision was made on
the lower uterine segment of all patients. Following
a 2 cm transverse incision, the lower uterine segment
was opened by cutting myometrium with scissors.
In the control group, the uterine closure was carried
out using a continuous single-layer locked closure
technique. The suture passed from the junction of
the endometrium and myometrium, and was locked
to enclose the complete myometrium and perime-
trium, while the suture did not enclose the decidua
and the visceral peritoneum was not closed. The
suturing technique used in the study group, as
shown in Figures 1 and 2, was the far-far-near-near
(FFNN) continuous unlocked double-layer method,
carried out in a single step. The steps followed dur-
ing this suturing technique, which will be referred
to hereafter as FFNN, were as follows. First, a sin-
gle-suture was made to both ends of the incision
line; then, the needle was inserted starting 1 cm
away from the lower margin of the incision(x0) and
coming out at the junction of the myometrium and
decidua of the lower edge of the incision (z0) and
the myometrium was covered in a single-layer.
Afterwards, the needle was inserted at the junction
of the decidua and myometrium of the upper edge
of the incision (z1), and came out 1 cm away from
the margin of the upper edge (x1) and the first loop
formed was kept at traction. In the next step, a
superficial bite was taken from the outer border of
the subperitoneal fascia and the outer myometrium
from the lower edge (y0), while the needle was fac-
ing the same direction the same transition was
repeated on the cranial side (y1). While the assistant
was holding two loops, the first and the larger loop
was pulled first and then the superficial loop was
pulled, thus the tissues were brought opposite to
each other and while the assistant was maintaining
Journal of Investigative Surgery

FIGURE 2. Top view of tissue sutured by far-far, near-near
suture technique.
the traction of the thread the surgeon continued the
same process for the next bite. The next suture was
made leaving a 1–1.5 cm gap without locking. This
method (as required in any ideal surgical method)
allows the accurate opposite approximation of the
serosa, myometrium and decidual tissues. A full-
thickness approximation prevents the inversion or
eversion of the tissue layers, while also preventing
the problem of insufficient vascularization due to
locking. Decidual tissues were not included in the
suture in this patient group. Additionally, as the
serosal layers were approximated completely oppos-
ite to each other, the visceral peritoneum was not
closed either in the study or in the control group.
The parietal peritoneum was also not sutured in
either of the groups.
During all of the CS procedures performed in
this study, uterine closure was carried out using
synthetic absorbable No:1 Polyglactin (Coated
VICRYLV R [polyglactin 910] Sutures, Ethicon, NJ,
USA). All patients were given an intraoperative sin-
gle dose of intravenous antibiotics (1 gram cefazolin)
_
(Bilim Ilaç, Istanbul, Turkey).
During the follow-up of the patients, demo-
graphical data were recorded and data on the
# 2019 Taylor & Francis Group, LLC
3
FIGURE 3. Ultrasonographic appearance of isthmocele,
residual myometrial thickness and uterus position.
patients’ age, BMI, previous pregnancies, number of
births and dilation and curettage (D&C) was col-
lected, and the cervical dilatation at the operation
was also recorded for patients in labor. CS indica-
tions, the duration of operation and any additional
suture requirements were noted. In order to calcu-
late the amount of blood loss, the difference
between the preoperative hemoglobin levels and the
levels measured at the postoperative 36th hour was
calculated. All patients included to the study were
asked to return for a control visit six months after
CS. During this visit, a clinical examination was
made using a vaginal B-ultrasound (Voluson 730
Expert; General Electric Healthcare, Solingen,
Germany) was obtained to determine the presence
of isthmocele, residual myometrial thickness (RMT)
and uterus position (Figure 3). One year after CS all
4 Z. Kalem et al.

patient were asked about the presence of dysmenor- Power analysis

rhea, postmenstrual spotting and chronic pelvic pain
by phone call.
Statistical analysis
All statistical analyses were performed using the
SPSS for Windows 11.5 software program (SPSS
Inc., Chicago, IL). Descriptive statistics were pre-
sented as mean ± SD and median (min-max) for
quantitative variables, and numerically (percentage)
for qualitative parameters. For the quantitative vari-
ables, the potential significant differences between
the categories of the binary qualitative variables
were tested by a Mann-Whitney U-Test, as these
parameters did not meet the assumptions of normal
distribution. A chi-square test and a Fisher Exact
Test were used to test the relations between two cat-
egorical variables. A linear regression analysis was
carried out to investigate how a measured depend-
ent variable was affected by one or more independ-
ent variables, and to what extent the change in the
dependent variable could be attributed to the inde-
pendent variable(s). A multiple logistic regression
was performed to ascertain the effects of one vari-
able or more than one variable together on the likeli-
hood that participants will develop isthmocele. A p
value of 0.05 was considered statistically significant.
The power of the study was estimated to be 0.99 in
a power analysis performed using a Student T-Test
on a sample of 138 people at a significance level of
0.05, assuming the mean ± SD values of the Group
categories (Control-Case) for the RMT quantitative
variable were 5.09 ± 1.79 and 8.52 ± 2.82, respectively.
RESULTS
The study included 138 patients, including 70
patients in the study group and 68 patients in the
control group. A flow diagram of the participants is
given in Supplemental File 1. Demographical charac-
teristics, operational data and postoperative findings
were evaluated and compared between the two
groups, and the numerical data collected in this
study are presented in Table 1, while categorical
data are shown in Table 2, along with the compari-
sons of the two groups. The results revealed no stat-
istically significant differences between the study
groups in terms of demographical data, indications
for operation or operation-specific parameters. The
results of the postoperative evaluations showed that
RMT was found to be significantly statistically lower
and the rates of isthmocele development, and

TABLE 1. Demographical characteristics, operational data and postoperative findings (numeric data)

Groups
SLL suture (n ¼ 68) (Control) FFNN suture (n ¼ 70)
Median Median
Variables Mean ± SD (Min-Max) Mean ± SD (Min-Max) p Value

Age (year) 29.25 ± 6.27 29.00 28.94 ± 5.17 29.00 0.773

(19.00–40.00) (19.00–40.00)
BMI 26.04 ± 2.37 25.82 25.90 ± 2.28 25.87 0.735
(21.00–31.00) (21.32–30.59)
Gravida (n) 1.97 ± 1.55 1.00 1.36 ± 0.85 1.00 0.052
(1.00–6.00) (1.00–5.00)
Parity (n) 0.85 ± 1.20 0.00 0.30 ± 0.73 0.00 0.071
(0.00–4.00) (0.00–3.00)
D&C (n) 0.35 ± 0.79 0.00 0.19 ± 0.52 0.00 0.092
(0.00–5.00) (0.00–3.00)
Gestational weeks at delivery 38.50 ± 2.7 38.60 39.40 ± 3.6 39.10 0.646
(38.00–41.00) (38.00–41.00)
Birthweight (g) 3230.76 ± 506.24 3225.00 3260.26 ± 485.74 3276.50 0.785
(1525.00–4850.00) (1950.00–4920.00)
Cervical dilatation at operation (cm) 1.34 ± 1.79 0.00 0.84 ± 1.71 0.00 0.067
(0.00–7.00) (0.00–9.00)
Operative time (minute) 36.91 ± 6.23 35.00 35.71 ± 7.68 35.00 0.221
25.00–50.00) (25.00–55.00)
Blood loss (g/dL) 1.08 ± 0.63 1.00 1.01 ± 0.64 0.95 0.529
(Preoperative Hb-Postoperative Hb) (1.00–2.60) (0.00–2.70)
RMT (mm) 5.09 ± 1.79 5.05 8.52 ± 2.82 8.65 <0.001
(1.96–11.00) (2.30–13.10)

BMI, body mass index; RMT, residual myometrial thickness, D&C: dilatation-curettage.

Journal of Investigative Surgery

 TABLE 2. Demographical characteristics, operational data and postoperative findings (categorical data)

Group
FFNN

# 2019 Taylor & Francis Group, LLC

SLL (n ¼ 68) (Control) (n ¼ 70)
Variables n % n % p Value

CS indications Prolonged labor 11 14.3 7 9.7 0.123a

CPD 6 7.8 8 11.1
Pathological cardiotocography 12 15.6 7 9.7
Macrosomy 7 9.0 5 6.9
Breech presentation 9 11.7 2 2.8
Other malpresentations (transverse, oblique) 4 5.2 6 8.3
Maternal pelvic deformity 3 3.9 5 6.9
Primary genital herpes 2 2.6 4 5.6
Active vulvovaginal HPV lesions 2 2.6 7 9.7
Abnormal fetal Doppler 3 3.9 4 5.6
Others (maternal anxiety, acute appendicitis, maternal trauma, maternal cardiomyopathy) 9 11.7 15 20.8
Additional hemo- No 54 79.4 59 84.2 0.930a
static suture Yes 13 19.1 11 15.7
requirement
Isthmocele No 40 58.8 63 90.0 <0.001b
Yes 28 41.2 7 10.0
Postmenstrual No 53 77.9 67 95.7 0.002b
spotting Yes 15 22.1 3 4.3
Dysmenorrhea No 63 92.6 67 95.7 0.490a
Yes 5 7.4 3 4.3
Chronic pel- No 64 94.1 69 98.6 0.205a
vic pain Yes 4 5.9 1 1.4
Uterus position Anteverted 55 80.9 58 82.9 0.827b
Retroverted 13 19.1 12 17.1

CPD, cephalopelvic disproportion; HPV, human pappilloma virus.

a
Fisher exact test.
b
Chi-square test.
5
6 Z. Kalem et al.

TABLE 3. RMT (linear regression) when variables were introduced to the model one by one

95% Confidence Interval

Independent variables b S.E R 2
p Value Lower limit Upper limit

Group (FFNN) 3.043 0.404 0.347 <0.001 2.634 4.232

Parity 0.643 0.238 0.051 0.008 1.115 0.172
D&C 0.857 0.370 0.038 0.022 1.588 0.126
Cervical dilatation at operation 0.342 0.139 0.042 0.015 0.617 0.066
Uterine position (Anteversion) 0.124 0.649 0.001 0.848 1.407 1.158

RMT, residual myometrial thickness; FFNN, far-far, near-near technique.

TABLE 4. Isthmocele (logistic regression) – when all variables were introduced to the model one
by one

95% Confidence Interval

Independent variables (reference category) b S.E. OR p Value Lower limit Upper limit

Group (FFNN) 1.841 0.468 6.300 <0.001 2.515 15.779

Parity 0.203 0.179 1.225 0.258 0.862 1.740
D&C 0.496 0.284 1.641 0.081 0.941 2.863
Cervical dilatation at operation 0.201 0.104 1.222 0.054 0.997 1.498
Uterine position (retroversion) 1.500 0.466 4.481 <0.001 1.799 11.159

FFNN, far-far, near-near technique.

postmenstrual spotting were significantly higher in DISCUSSION

the controls than in the study group (Tables 1
and 2).
None of the patients included in the study
developed uterine atony or endometritis.
A linear regression analysis was carried out to
evaluate the factors potentially affecting the RMT of
the patients (Table 3). RMT was seen to decrease as
the number of parities and previous dilatation-curet-
tage (D&C) procedures increased, RMT also
decreased when cervical dilatation was high during
CS. A multiple linear regression model was found
to be RMT 5 5.533 1 3.264 * Group (FFNN) 1
(20.523) * D&C 1 (20.196) * Cervical Dilatation
and the p values of the relevant variables were
<0.001, 0.086 and 0.091, respectively. When these
variables were incorporated into the model together,
they accounted for 37.7 percent of the change in the
RMT variable.
A multiple logistic regression analysis was car-
ried out to ascertain the effects of group (FFNN),
D&C and retroversion together on the likelihood of
isthmocele formation (Table 4). The logistic regres-
sion model was found to be statistically significant
(p < 0.001), explaining 31.3 percent (Nagelkerke R2)
of the variance in isthmocele, and correctly classify-
ing 74.5 percent of cases. The control group (SLL)
was 6.89 times more likely to develop isthmocele
than the FFNN group, and the retroverted uterine
position was 6.57 times more likely to be associated
with isthmocele than uterine anteversion. The
increasing number of D&C was associated with an
increased likelihood of developing isthmocele.
In the present study, the rate of isthmocele develop-
ment was found to be lower, and RMT was
increased in the group in which the endometrial
sparing, unlocked double-layer FFNN suture tech-
nique was used as the method of uterine closure
during a CS operation, when compared to the group
that underwent a single-layer locked closure tech-
nique. The duration of operation, amount of blood
loss and additional hemostatic suture requirements
did not differ significantly between the groups.
While the rate of postmenstrual spotting was lower
in the FFNN group, the rates of chronic pelvic pain
and dysmenorrhea were not significantly different
between the groups.
In a search of literature related to the potential
etiologic factors associated with the development of
isthmocele, incomplete closure of the uterine wall
comes to the fore as the most powerful hypothesis
[12]. The most important feature of the uterine clos-
ure technique used in this study is that it allows a
complete opposite approximation of the tissue
layers, which is a primary surgical principle [14].
The endometrium–myometrium junction is passed
and a superficial bite is taken from the serosal sur-
face in this method, after which, a complete layer is
passed in the myometrium and the layers are
approximated opposite to each other. In this way,
the endometrium and perimetrium are also located
completely opposite to each other.
The benefits of single- or double-layer closures
of the uterus are also a matter of debate in literature

Journal of Investigative Surgery


[2]. In a recently published meta-analysis [15] and a
prospective cohort study reported by Vikhareva
Osser and Valentin [16], no difference was found in
terms of the formation of cesarean scar defects
between single- or double-layer closures of the ute-
rus. However, the double-layer closure method is
currently recommended by certain teams for the
prevention of the formation of isthmocele [17–19]. In
the present study, a double-layer technique was
used in the group with a lower rate of isthmocele
development, leading us to believe that the double-
layer technique is more effective in ensuring the sta-
bilization of the myometrium, which is both thick
and dynamic due to its contractility.
There have been reports in literature suggesting
that the endometrium should be incorporated into
the suture to prevent uterine scar defects, and the
full-thickness suture method ensures better wound
healing [17, 20]. We, on the other hand, believe that
full-layer suturing of the uterus including the endo-
metrium may lead to a weaker scar healing, since it
will cause a decidual inclusion in the scar tissue and
facilitate the formation of a niche. For this reason,
we did not include the deciduas in the suture in
either the study or control groups, and there are a
number of reports in the literature to support this
[21–23]. In several animal experiments, Poidevin
demonstrated that suturing the complete thickness
of the uterus, including the endometrium, led to
inclusions of endometrial tissue in the scar, resulting
in scar defects several weeks or months later [24].
Among the previous studies in the literature
comparing locked and unlocked suture techniques
for uterine closure, Ceci et al. [25] identified no sig-
nificant difference between the two techniques in
terms of scar defects, whereas Yasmin et al. [26]
reported higher RMT in the unlocked group.
Roberge et al. [18] also found that the closure of ute-
rus by the locked suture technique reduced RMT,
and concluded:
It is possible that the locked suture, by being
more hemostatic, can cause a strangulation of the
scar tissue and leads to weaker healing. It is also
possible that the weakness of the scar in the
locked suture is secondary to the fact that this
technique is usually performed with inclusion of
the inner part of the uterine wall (decidua/
endometrium) in the scar tissue.
According to a recent systematic review, only
the “locked” single-layer closure was associated
with uterine rupture [23]. Similarly, we also believe
that the locked suture technique should not be used
for uterine closure in CS.
One of the factors impairing scar healing after a
CS operation is tissue inversion and eversion during
# 2019 Taylor & Francis Group, LLC
7
uterus closure [12, 27]. The eversion of myometrium
to serosa increases the possibility of adhesions, and
its inversion into the cavity results in postoperative
endometrial defects [28]. The invasion of endomet-
rium into the myometrium also facilitates the devel-
opment of adenomyosis [29], and all such events
contribute to niche formation. With this in mind,
particular attention was paid to this issue in both
suturing groups in the present study, and the sur-
geon was particularly careful to ensure the opposite
approximation of the tissues in the control group,
whereas the FFNN method already eliminates the
possibility of inversion and eversion.
In the present study, a multiple regression ana-
lysis was carried out to evaluate the factors affecting
isthmocele development other than the uterine clos-
ure technique. A previous history of D&C was
found to increase the risk of isthmocele, while ute-
rus retroversion was also accompanied by an
increased rate of isthmocele formation. A further
regression analysis carried out to investigate the fac-
tors affecting RMT indicated that increased cervical
dilatation during CS, having a previous history of
childbirth and D&C were found to be associated
with a lower RMT. There are also studies in litera-
ture that report that the number of previous births
and history of D&C reduces RMT and increases the
possibility of cesarean scar defects [2, 12]. Similarly,
increased cervical dilatation at the time of the CS
operation was listed among the risk factors for
incomplete healing of uterine incisions in literature
[16, 30].
This is the first prospective randomized con-
trolled study in literature to compare the rate of
isthmocele formation and RMT between the single-
layer locked closure technique and the FFNN tech-
nique, which we believe is the optimal uterine clos-
ure technique in CS operations. In the present
study, all operations were performed by the same
surgeon, in both study and control group, to avoid
any potential differences that may occur due to the
surgical techniques of different surgeons, which is a
factor that enriches the power of this study. The crit-
ical limitation of this study is the single-layer suture
technique of the control group. It would be more
appropriate study design to compare patients with
continuous unlocked double-layer suture as the con-
trol group and patients with FFNN suture as the
study group. The other limitations of this study is
the absence of subgroups, and a comparison of both
suture techniques between subgroups such as endo-
metrium included-excluded, and peritoneum
sutured-non-sutured would increase the value of
this study.
FFNN technique prevents istmocele develop-
ment and contributes more RMT because this tech-
nique provides complete approximation of the tissue
8 Z. Kalem et al.
layers, eliminates the possibility of inversion/ever-
sion and does not have detrimental effect on tissue
vascularization and scar healing because of the
unlocked nature of suture.
In conclusion, the findings of the present study
demonstrate that the use of the FFNN technique for
uterus closure can prevent the formation of isthmo-
cele, and can preserve sufficient RMT after CS oper-
ations. This method has the potential to become the
optimal uterine closure technique, and so our find-
ings should be supported by larger scale studies in
the future.
COMPLIANCE WITH
ETHICAL STANDARDS
Ethical approval: All procedures performed in
studies involving human participants were in
accordance with the ethical standards of the
institutional and/or national research committee
and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.
Informed consent: Informed consent was obtained
from all individual participants included in
the study.
DECLARATION OF INTEREST
The authors declare that there is no conflict
of interest.
FUNDING
The authors declared that this study has received no
financial support.
ORCID
Alper Basbug http://orcid.org/0000-0003-
1825-9849
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