Acta Obstet Gynecol Scand 1999; 78: 615–621 Copyright C Acta Obstet Gynecol Scand 1999

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Acta Obstetricia et
Gynecologica Scandinavica
ISSN 0001-6349

ORIGINAL ARTICLE

The Misgav Ladach method for cesarean

section: method description
GUNNAR HOLMGREN1, LENNART SJÖHOLM2 AND MICHAEL STARK3
From the 1Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden, the 2Ryhov County Hospital,
Jönköping, Sweden, and the 3Department of Obstetrics and Gynecology, Misgav Ladach Hospital, Jerusalem, Israel

Acta Obstet Gynecol Scand 1999; 78: 615–621. C Acta Obstet Gynecol Scand 1999

Subject. A method description is given for the Misgav Ladach method for cesarean section.
This is based on the Joel-Cohen incision originally introduced for hysterectomy.
Method. The incision is a straight transverse incision somewhat higher than the Pfannenstiel
incision. The subcutaneous tissue is left undisturbed apart from the midline. The rectus sheath
is separated along its fibres. The rectus muscles are separated by pulling. The peritoneum is
opened by stretching with index fingers. The uterus is opened with an index finger and the
hole enlarged between the index finger of one hand and the thumb on the other. The uterus
is closed with a one-layer continuous locking stitch. The visceral and parietal peritoneal layers
are left open. The rectus muscle is not stitched. The rectus sheath is stitched with a continuous
non-locking stitch. The skin is closed with two or three mattress sutures. The space in between
is apposed with non-traumatic forceps for 5 minutes.
Results. The basic philosophy is to work in harmony with the body’s anatomy and physiology
and not against them. The method is restrictive in the use of sharp instruments, preferring
manual manipulation.
Conclusion. The method gives quicker recovery, less use of post-operative antibiotics, anti-
febrile medicines and analgesics. There is a shorter anesthetic and shorter working time for
the operative team. It is suitable for both emergency and planned operations.

Key words: cesarean section; Joel-Cohen incision; Misgav Ladach

Submitted 18 September, 1998

Accepted 16 February, 1999

‘Embedded in the name Cesarean section lies an
aura of greatness, something elevated above the
mundane. This is a name worthy of the operation
by which it is possible, under certain circum-
stances, to save two lives otherwise destined indis-
putably for a certain death’. These words by the
future Professor of Obstetrics and Surgery at
Uppsala University, Karl Gustaf Lennander in
1889 show the standing of this operation even at
that early stage. Two decades prior to this, the mat-
ernal death rate following Cesarean section was es-
timated at 75%.
Abbreviations:
IMCH: Section for International Maternal and Child Health;
RCT: randomized controlled trial; FIGO: The International
Federation of Gynecology and Obstetrics.
When Murdoch Cameron (Glasgow) in 1878
managed to carry out eight consecutive sections
without a single maternal death by suturing the
uterus (refining the classical uterine incision of
Sänger) this was seen as a major breakthrough.
Prior to this Porro in Milan (1876) had already
introduced the operation of Cesarean section with
sub-total amputation of the uterus. This saved the
life of the mother but precluded any further preg-
nancies.
Munro Kerr in Glasgow had modified an oper-
ation developed by Krönig (transperitoneal lower
segment section with extraperitoneal closure) and
in 1911 introduced his method of transverse in-
cision in the lower uterus. He further refined the
method and slowly it won international acceptance
but it was not until 1949 that the overwhelming
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616 G. Holmgren et al.
majority accepted it as the standard procedure. now been tested in a randomized controlled trial
This occurred at the 12th British Congress of Ob- (RCT) carried out in this Department in Uppsala
stetrics and Gynecology and, when there was gen- and reported by Elisabeth Darj and Marie-Louise
eral assent to his method, Munro Kerr leaped to Nordström (7). The method is found to be signifi-
his feet proclaiming: ‘Allelujah! The strife is o’er cantly quicker to perform than the Pfannenstiel
the battle done’. method with a reduced amount of bleeding and
One variation in his method was the use of the diminished postoperative pain. As far as we are
lower transverse abdominal incision introduced by aware this is the first RCT of the method. Further
Pfannenstiel in 1896 and published in 1900. Be- RCTs of the method in a number of centers in
cause of cosmetic considerations and a decrease in Africa and Asia are in the pipeline.
wound hernias, this method has gradually become Knowledge of the method spread after the
standard in many developed countries. However, it FIGO World Congress of Gynecology and Obstet-
has some disadvantages. It may be too slow for rics in Montreal in September 1994. At the follow-
emergency sections. The subaponeurotic dissection up FIGO Congress in August 1997, in Copen-
of the rectus sheath takes time. It is sometimes ac- hagen, four presentations showed the advantages
companied by troublesome bleeding from perfor- of the method.
ating vessels. Postoperative hematomata and ab-
scess formation are not uncommon such that some
Here follows the method description
surgeons routinely drain this space. Since it does
not strictly follow Langer’s lines it may be ac- The surgeon stands on the right side of the patient
companied by unsightly guttering when the patient if he is right-handed or the left side if left-handed.
stands erect, if the repair at the end of the oper- The abdominal incision is a straight transverse
ation is not meticulous. superficial incision in the skin about 3 cm below
Recently some new thinking has led to the the line joining the anterior superior iliac spines
launching of a package of refinements put together (Fig. 1). It can be higher if necessary in the few
by Dr. Michael Stark and given the name: the Mis- cases where necessary:
gav Ladach method. This is the name of the hospi-
1. Identify the midline and pinch three marks
tal in Jerusalem where the method has evolved, be-
in the skin crease, one in the midline and
ginning in 1983.
one at either end of your planned incision.
The new method grew out of an approach to
Stretch the skin slightly sideways in the di-
opening the abdomen developed by Professor Joel
rection of the skin crease.
Cohen for abdominal hysterectomy in 1954 and
Stretching the skin in this way gives less
popularized in his monograph ‘Abdominal and
distortion and a straighter incision which fol-
Vaginal Hysterectomy’ in 1972 (1).This method of
lows Langer’s lines.
opening the abdomen has been practised by a
2. Cut through the skin only with an incision
number of obstetricians for Cesarean sections fol-
around 17 cms long. This should not go into
lowing Stark’s lead but to this he has added a num-
the subcutaneous tissue.
ber of new features which combine to make a
This shallow incision is virtually bloodless.
package of refinements which have not been pre-
3. Deepen the incision in the midline with the
viously used. In the Pfannenstiel method the body
knife in a short transverse cut of about 2-3
is perceived as static and the incision cuts its way
cms through the fat, down to the rectus
through with disregard to structural anatomy
whereas in the Joel-Cohen incision the anatomical
structures are respected and the opening follows
the principles of surgical minimalism.
The claimed advantages of the Misgav Ladach
method as shown in non-randomized trials are im-
pressive: it is said to be less traumatic for the
mother with quicker post-operative recovery (2),
less febrile reactions (2,3), less need for antibiotics
(4), a shorter period before normal bowel function
returns (5), less peritoneal adhesions and less scar-
ring in the abdominal layers (2,4). It is said to
cause less bleeding in the abdominal wall (6), and
is said to be so quick that it can be used for both
planned and emergency sections (2). It is also a
method that is easy to learn. These claims have Fig. 1. Level of incision.

C Acta Obstet Gynecol Scand 78 (1999)

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Misgav Ladach method for cesareans 617
sheath. Do not attempt any freeing of the 7. Pull the rectus muscles apart. Both surgeon
subcutaneous tissue. and assistant push their index and middle
The blood vessels and nerves in the subcu- fingers in the midline between the rectus
taneous tissue and fat remain intact and in muscles, encircling the whole muscle bellies
the midline there is virtually a bloodless field. and then pull with smooth, balanced and in-
4. Make a small transverse incision in the creasing force (Fig. 5). The movement is
sheath with the knife (Fig. 2). with slight outward rotation causing the
5. Enlarge the transverse incision bilaterally upper section to open more on a curve than
underneath the fat and subcutaneous tissue the lower section. It is often necessary for
without disturbing them: place the tip of a both to place their other index and middle
partly open pair of scissors (supported fingers over the two that are in the gap in
underneath by your left index finger) with order to get the force needed to make a big
one blade under the cut sheath and one bla- enough opening.
de above. Push the scissors along the direc- This step displaces all the vessels and
tion of the fibers in a transverse direction
following the curvature of the body as you
go further out (Fig. 3). Do this away from
you and then towards you.
At this level the rectus muscle does not
need separation from the sheath because it is
above the level of the pyramidalis muscle and
moves freely over the fascia. The scissors
should only be opened slightly and thus on
pushing will be guided by the fascia.
6. Gently separate the fascial borders (rectus
sheath) and the rectus muscles by pulling
caudally and cranially using the two index
fingers to make room for the next step (Fig.
4).

Fig. 4. Open up the rectus sheath.

Fig. 2. Incise the rectus sheath.

Fig. 3. Split the rectus sheath. Fig. 5. Separate the rectus muscles.

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618 G. Holmgren et al.
nerves under the protective layer of subcuta-
neous tissue. If done correctly this step is vir-
tually bloodless. The peritoneum is now
brought into view.
8. Stretch the parietal peritoneum open in a
transverse way, using your index fingers to
stretch the tissues repeatedly until a small
hole is made. Go as high up as is easily ac-
cessible (Fig. 6). Enlarge this hole by
stretching it with your two index fingers in a
caudal and cranial direction simultaneously.
If this enlargement is done in a caudal and
cranial direction, the opening of the perito-
neum will be transverse and thus save the
bladder from injury. Using the fingers to open
and enlarge saves the underlying bowel from
injury.
9. Identify the lower segment of the uterus and
the upper limit of the bladder.
10. Make a transverse superficial incision
through the visceral peritoneum 1 cm. above
the bladder limit with the scalpel. Avoid
blood vessels and go out far enough on
either side (about 10–12 cms in total) so that
the head and baby can be delivered through
the opening. Use a mobile retractor (such as
Fritsch or Doyen’s) to give good visibility
with the assistant following your movement
as you cut with the scalpel.
11. Push the cut visceral peritoneum and blad-
der down using two fingers or a swab.
12. Make a small transverse incision in the
lower uterine segment with a scalpel or your
right index finger.
13. Stretch the hole transversely to either side
using your right thumb mainly to steady
Fig. 6. Open the parietal peritoneum.
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and your left index finger to separate the
uterine muscle fibers towards the patient’s
right side. Open more to the right than the
left since the uterus in late pregnancy is
usually rotated towards the right.
The thumb is broader than the index finger
thus favoring more opening towards the right
and minimizing risk of damage to the more
vulnerable vessels on the left side.
14. Place two fingers below the head and release
the head. The assistant now pushes on the
fundus of the uterus in order to bring the
baby down and your fingers guide the head
out of the uterine opening.
15. Manually remove the placenta after deliver-
ing the baby, by placing your whole hand
inside the uterine cavity and gently freeing
the placenta from its bed. At this point the
anesthetist may give 10 units oxytocin or 0.5
mg. ergometrine i.v. (this is commonly not
necessary).
The manual removal makes the third stage
of the delivery quicker and avoids unnecess-
ary bleeding.
16. Bring the upper uterus out of the abdominal
wound by placing your whole hand behind
the uterus. Massage the uterus to stimulate
contraction, and if there is vigorous
bleeding from the placental bed, squeeze the
uterus between your palms.
The hemostasis brought about by these
measures is so adequate that it often replaces
the need of oxytocin or ergometrine. Not all
gynecologists bring out the uterus. Massage
can even be done inside the abdomen.
17. While persisting with massage, clean out the
inside of the uterus with a towel to remove
any remnants of membranes and further
stimulate contraction and retraction of the
uterus.
18. Grasp the center of the caudal part of the
cut uterine edge with a non-traumatic clamp
such as Green-Armytage forceps.
(Dilate the cervix, if she is not in labor,
with a thick cervical dilator using a single
downward movement that deposits the di-
lator in the vagina for removal after the op-
eration).
Some gynecologists question this step in a
community with a high incidence of genital
infections since in theory it could spread bac-
teria from the vagina to the uterus. This risk
is reduced if the vagina is washed out with an
antiseptic prior to the operation.
19. Repair the cut uterine wall with a one-layer
repair using a continuous locked stitch (Fig.
7). Start at the lower edge of the cut nearest

Fig. 8. Suture the rectus sheath.
Fig. 7. Suture the uterus.
yourself and use a long length of chromic cat-
gut (or an equivalent absorbable material)
No.1 on a large round-bodied needle (80 mm
diameter). Take big enough bites from the
lower to the upper edge to get secure hemo-
stasis but being careful on the lower edge to
keep well away from the bladder.
In special circumstances there may be a
need for a second layer or for single cross-
stitches to bring hemostasis to one bleeder.
Closure in a single layer not only saves
time but also gives less ischemia and gives
better healing with less sacculation. It may
also reduce the incidence of febrile morbidity.
Using a locked stitch is surprisingly not as-
sociated with local ischemia since retraction
of the uterus reduces tissue volume and thus
releases any tension around the stitch. Stitch-
ing of the uterus is only for hemostasis and
not to provide mechanical strength since re-
traction so quickly loosens all stitching within
hours of the operation. Within 8 months ul-
trasound shows that the scar has shrunk to 8
mm. in length.
20. Check that all bleeding has stopped and
that the blood pressure is normal so that
hemostasis is not threatened after the oper-
ation. If necessary add single cross stitches
to stop any small bleeding points.
21. Remove blood clots but do not put packs or
towels into the peritoneal cavity to try to
mop up all the liquid blood.
Liquid blood is absorbed by the perito-
neum. The amniotic fluid that is spilled into
the peritoneal cavity has a bacteriostatic ef-
fect. The minimal interference with the bowel
is important to allow early alimentation.
22. Leave visceral and parietal peritoneum un-
stitched. Bring down the omentum to cover
the repaired uterine wall.
Leaving the peritoneum open is most im-
portant to prevent adhesions developing.
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Misgav Ladach method for cesareans 619
Within a short time a new peritoneum will
form.
It is probable that the stitching of the per-
itoneum leads to local ischemia which stimu-
lates a repair response by the body causing
adhesions.
23. Identify the two layers of the fascia at either
corner and grasp them with artery forceps.
Use two more forceps on the upper and
lower cut edges two-thirds of the way along
the fascial cut.
24. Start stitching the fascia at the end of the
cut nearest you. Start the stitch from the in-
side out on the upper border and then from
the outside in on the lower border so that
the knot is buried inside the fascia (Fig. 8).
Use Vicryl No.1 or an equivalent absorbable
material that is strong enough to withstand
the tension of early ambulation. Each bite
goes slightly diagonally across the cut.
Use a continuous running suture which
need not be a locked suture unless there are
special reasons. Do not interfere with the
blood supply at either end by going beyond
the end of the cut.
25. Close the skin using two or maximum three
mattress sutures. Pinch the skin together
with Allis or Babcock forceps in the interval
between the sutures so that each edge is in
exact apposition to the other.
Leave the Allis forceps on for 5–10 min-
utes and then remove them. The edges will
now stick to each other.
This type of very simple repair saves time,
reduces the incidence of keloids and gives the
best scar.
26. Start oral fluids immediately and get the pa-
tient out of bed as soon as the anesthetic
has worn off.
There is no need for post-operative star-
vation, and ileus after this method is rare.
Early mobilization reduces the risk of throm-
C Acta Obstet Gynecol Scand 78 (1999)

620 G. Holmgren et al.
bosis and shortens post-operative pain. Less
pain makes early commencement of breast-
feeding easier within the first hours after the
operation. This will also help contraction and
involution of the uterus.
27. Remove the stitches on the 5th post-operat-
ive day.
This early removal of stitches reduces the
risk of infection and keloids.
Discussion
Many of these features are already in use by ex-
perienced gynecologists but the method of opening
and the level of the skin incision were new when
introduced for Cesarean sections at the Misgav La-
dach Hospital. Likewise leaving the peritoneal
layers unsutured was novel in obstetrical oper-
ations when first introduced by Dr. Stark in 1984
(4) (leaving the parietal peritoneum open was in-
troduced by him in 1983 and leaving both perito-
neal layers open in 1984) although well known
among general surgeons. At this time Harold Ellis,
the initiator of non-suturing of peritoneum in
General Surgery, was unable to advise Dr. Stark
on whether non-suturing is feasible also in obstet-
rical operations. Many obstetricians have followed
in his footsteps (8–10).
The Joel-Cohen skin incision is distinctive (1).
Being transverse it heals better than a midline ver-
tical incision with less risk of herniation (11,12).
Being higher than the Pfannenstiel it is easier to
perform with no subaponeurotic dissection necess-
ary and thus less bleeding (3). It can be used in all
emergency sections unlike the Pfannenstiel which,
in ‘crash’ sections, may be too slow. There is less
risk of keloid formation of the resultant scar, a
particular risk in Africa (13).
The subcutaneous tissue is not disrupted except
in the midline. Hemostasis is not necessary, saving
time as well as reducing local tissue damage by
electro-coagulation or ischemia after tying off
blood-vessels. Such areas may be the site of sub-
sequent infection.
The placenta is removed manually (6) quicken-
ing the third stage of labor and possibly reducing
bleeding. This latter claim runs counter to a num-
ber of studies collated in the Cochrane review of
the subject which suggest more total blood loss
and more transplacental bleeding.
The upper uterus is brought out of the abdomen
and massaged. This massage reduces bleeding and
the risk for a post-partum hemorrhage (6). Ex-
teriorization of the uterus makes stitching easier
and does not increase the risk of infection, of
nausea or vomiting or of venous air embolism (2).
Suturing the uterus with a single continuous
C Acta Obstet Gynecol Scand 78 (1999)
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locked stitch is quicker and causes less local is-
chemia with less sacculation afterwards (6, 14–16)
and was shown to be associated with less deform-
ity of the scar on radiography in the Cochrane re-
view and with no added risk of bleeding or infec-
tion.
Leaving the visceral and parietal peritoneum un-
sutured saves time, suture material (2, 4, 8–10, 17,
18) and reduces the risk of adhesions (18, 19), thus
making a repeat Cesarean section easier. Suturing
the peritoneal layers is a completely unnecessary
step, since the peritoneum heals by soon forming
a new peritoneal layer (4, 17).
The peritoneal cavity is left undisturbed as much
as possible and spilled liquour and liquid blood is
not mopped up (6, 20–22). Only easily accessible
blood clots are removed. This rule must be modi-
fied when infection is already present. Avoiding the
use of packs or towels in the peritoneal cavity is
better for recovery of bowel function (20). For low-
income-countries working under less than ideal
conditions it is also cheaper and removes the risk
of leaving a pack or towel inside the cavity. Any
spillage of amniotic fluid is bacteriostatic in effect
(21, 22).
The skin is closed with a few large stitches (6).
This very simple closure is quick, cheap, and gives
a better scar with less risk of keloids.
The patient is rapidly mobilized and is allowed
to drink straight away after the operation (5). This
allows quick recovery with a shorter hospitaliza-
tion for the patient (2) and less risk of thrombosis,
infection and ileus.
Summary
The method is based on the principles of surgical
minimalism and working in harmony with the
body’s anatomy and physiology and not against
them. Manual manipulation is used as far as poss-
ible instead of surgical instruments as this is kind-
est to the tissues.
The eight layers of suturing advocated by Mun-
ro Kerr have been reduced to three with seemingly
no loss of strength of the resulting scar, and less
scar tissue and adhesion formation.
The benefits of the method, with less pain post-
operatively and quicker recovery, are all a by-prod-
uct of doing the least harm during surgery and
removing every unnecessary step.
This method is appealing for its simplicity, ease
of execution and its time-saving advantage. This
is undoubtedly why the method has already been
adopted in many developed and developing coun-
tries. It is rare for a new method to have such wide
application in settings with both high and low
levels of resources.

Acknowledgments
Funding for the method study and making of teaching videos
about the method came from Sida and SMR (both Stockholm,
Sweden).
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Address for correspondence:
Gunnar Holmgren, M.B., Ch.B.
IMCH
Department of Women’s and Children’s Health
University Hospital
Entrance 11
S-751 85 Uppsala
Sweden
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