The rate of caesarian deliveries is constantly rising throughout the western world, and in some cases accounts for 40% or even more births. In Israel, the rate of caesarian deliveries is about 25-28% of births, and this rate is expected to rise in the coming years.
Caesarean procedures have been performed for hundreds of years and over time have developed from an intervention used for women who were on the verge of death, in which the fetus was removed from the abdomen but nobody knew how to close the abdomen, and they all died; through the classic caesarean in which the abdominal and uterine incision is longitudinal and requires lengthy recovery and means the women is then unable to ever give birth naturally, down to the caesarean procedure that has been accepted for about 30 years and was developed in Misgav Ladach Hospital in Jerusalem, and involves a lateral incision in the skin and the uterus without cutting the muscles of the abdominal wall but rather separating them along a central line. Since many women rightly demand immediate contact with the newborn infant following the delivery, a more friendly procedure has been recently developed whereby the infant is placed next to the mother in the operating theater and in the recovery room, although this is not straightforward since it restricts the mother’s movements and she may have considerable pain in the first few days. It seems that the time has come to move to the next stage in the evolution of caesarean procedures.
Over 20 years ago, Dr. Dennis Fauck, a surgeon by training who then specialized in gynecology, started performing the extraperitoneal caesarian section called after him. Recovery time is very fast, similar to that following a normal birth!!! The incision in the skin is lateral, as is currently accepted, but the surgery is done in a completely different body space. This surgery has a number of advantages:
The combination of all these elements significantly reduces the pain following the procedure and the mother quickly regains more movement, resumes eating and drinking, and is quickly discharged.
Use of this technique requires special training which I received in France. Today only 10 physicians are approved to perform this procedure, and their names are given on the French internet site dealing with this subject.
I perform these procedures at the Nazareth EMMS Hospital (Israel).
Is it possible to perform this surgery in cases of Placenta Accreta?
The recommendation is to perform this surgery on Placenta Accreta in a tertiary hospital, due to the risk of requiring a large blood transfusion. This surgery is not yet performed in tertiary hospitals in Israel.
Is there an advantage for this method if it is my fourth caesarean procedure?
Certainly, the surgeon enters the abdominal space at a different level from the previous surgeries and therefore he will encounter less adhesions, and in any case recovery is far easier.
Are the procedures done in Jerusalem?
At this stage this procedure is done in only three places – Bnei Zion Hospital and Carmel Hospital are in the stages of training, and I myself perform this procedure only in the English Hospital in Nazareth. At this stage I am the only physician using this technique in Israel, but I hope there will soon be more trained physicians.
The price for the surgery includes the hospital fee, the stitches and special glue that I bring, review and advice beforehand, monitoring afterwards, with instruction by Sivan Navot on exercises and the use of breathing device. The cost of the procedure including VAT is NIS 15,000 as a private patient. In public hospitals the surgery is done without cost.
Reverse T incision
There is nothing to prevent performing the surgery after a reverse T incision in the uterus.
This procedure is currently starting to take place as part of training in the public hospitals Bney Zion and Carmel. I hope that other hospitals will take up the challenge and join us. I would be delighted to teach any interested physician how to use this method in any hospital in Israel, in my own time and with no charge.
Of course, extra-uterine fibroids can sometimes complicate any type of caesarean procedure, depending on their location and size. Contact me for more information.
At this stage, this surgery is not done at Sheba, and the caesareans I perform at Sheba are of the type developed at Misgav Ladach and not the Fauck type.
Complications – as with every caesarean procedure, there may be complications such as hemorrhage, infection and damage to adjacent organs. According to the data provided by the French for 3,441 operations, the rate of complications was very low, similar to the rate experienced in regular caesarean procedures. The use of special subcutaneous stitches reduces the rate of infections of the surgical wound. So far there has been no study comparing the French technique and the usual Misgav Ladach technique. The first comparative study will take place in the coming months in the Carmel and Bnei Zion hospitals. In the first stage we will demonstrate the benefits of this surgery in terms of recovery and also compare the rate of complications.
This procedure can also be performed in urgent cases, except for situations where the fetus must be quickly rescued, when the faster Misgav Ladach technique should be used.
This surgery is very friendly since apart from the absence of separation, the mother is an active participant in the abdominal delivery, using the breathing device and seeing the birth.
This procedure is excellent for repeated surgeries, because the entry to the abdominal space after the skin is opened is from a slightly different location and there are fewer adhesions to pass through on the way to the uterus, and on the other hand, the mother has a basis for comparison – and very many women have already told me that the recovery process is like night and day compared to the recovery they experienced after previous caesarean section/s.
The skin incision is in the same place as the incision in regular caesarean procedures, about 10 cm along the bikini line. If there was a previous operation, the opening is done through the scar, so that afterwards there is only one scar left.
The operation can even be done after previous caesarean sections where there were adhesions or a uterine tear.
After one Fauck procedure, there can be additional Fauck or regular caesarean sections, and vice versa.
The surgery can also be done after contractions develop if the mother and the surgeon are near a suitable hospital. However, since at present this only applies to hospitals in the north, there is a preference for elective procedures.
The procedure can be booked directly with Bnei Zion and Carmel hospitals, and they arrange a suitable date with me, when I take leave from Sheba and come to assist in the operation.
At this stage we have not defined the date for completing the training and starting the study, and therefore I am present at all procedures using this technique at Bnei Zion and Carmel.
The English Hospital in Nazareth is managed by a Scottish association and run by Christian Arabs and nuns. It was the first maternity hospital in Israel and has been active for over 150 years. The head of the Department is Dr. Jimmy Jadhoun who specialized at Hadassah Hospital, Jerusalem. There are about 3,000 births each year, with an emphasis on births in motion and natural births. The hospital has a section for premature infants and intensive care for premature infants, and premature infants are often sent there from other hospitals. They hospital has been awarded the Ministry of Health quality prize several times. The Hospital’s A&E Department was awarded national second prize for quality control in 2017. It also has an intensive care unit for adults.