LAUSR

Şahin et al. (2018) performed a ‘double B-Lynch suture’ in 14 patients with postpartum haemorrhage, mainly due to atonic bleeding. If the ‘first B-Lynch suture’ did not achieve haemostasis, ‘a second B-Lynch suture’ was added, which achieved haemostasis in all of the patients. We have some concerns regarding the procedure. They state that ‘after the procedure (the second B-Lynch placement) the uterine incision was closed’. This can be interpreted as (i) the first B-Lynch suture was performed, (ii) its insufficient haemostasis was confirmed, then (iii) the second B-Lynch suture was performed and (iv) finally the incision was closed. This is technically impossible, or at least very difficult. In a B-Lynch suture, the thread should be tightened so that the uterine anterior-posterior wall is tightly compressed, which naturally closes (or at least markedly narrows) the uterine incision (the hysterotomy window). With the window being closed, performing the second B-Lynch suture is impossible, or at least very difficult. For the second suture to be possible: (1) the first B-Lynch suture once tightly tied should be untied so that the window is open or (2) the second suture should be a compression suture that does not require a hysterotomy (such as a Hayman suture (Hayman et al. 2002)) and not a B-Lynch suture. If the first B-Lynch thread remained loosened, whether haemostasis was achieved is indistinguishable and thus, the need for a second suture cannot be judged. One solution may be to make ‘new incision’. Kaya et al. (2015) employed a ‘new incision distal to the original (hysterotomy) incision’ at relaparotomy when B-Lynch suture did not achieve haemostasis. As Kaya et al. (2015) stated, causing more scars in the uterus may lead to a late complication. Whether a ‘new incision’ may solve the problem is yet to be determined. We are also concerned about the intrauterine or extrauterine conditions or the adhesion caused by the ‘double’ B-Lynch suture. Although all of the patients had regular menstrual bleeding, a hysteroscopic and laparoscopic evaluation should have been performed. Haemostatic procedures must be promptly performed ‘just at the time of obstetric haemorrhage’. They should be reproducible for all surgeons. We commend Şahin et al. for devising a new suture, but the technical detail should be described in a more reproducible manner. How the failure of the first B-Lynch suture should be evaluated and how the second B-Lynch suture should be performed should be described in a more reproducible manner.