A new era in teaching: how advanced optical recording technology could change the postcesarean delivery complication conundrum

Published:September 13, 2022DOI:


      The last 4 decades have seen increased complications after cesarean deliveries. Despite an incomplete understanding of their etiology, surgical practices have been adopted, creating disproportionate morbidity and the absence of preventive strategies. Additional research tools are needed for further investigation.


      This study aimed to evaluate the VITOM high-definition optical recording system as a tool to highlight cesarean operative steps and surgical techniques and assess the use of its video recordings for operating room team teaching and research potential.


      Contemporaneous cesarean delivery techniques offer no resolution to long-term postcesarean sequelae. From March 2015 to February 2022, a novel tool, VITOM exoscope, was evaluated and used to photograph and video record 104 elective cesarean deliveries. The images were projected on a large screen to be viewed by scrubbed-in and unscrubbed personnel and recorded for future use. During this period, staff participants in 3 designated operating rooms reached 514, including 168 trainee residents, 5 nurse practitioners, 6 physician assistants, 21 medical students, 70 surgical technicians, and 110 circulating nurses. The maternal ages of patients varied from 21 to 49 years. Gestational ages ranged from 28 0/7 to 41 6/7 weeks of gestation. Selected photographs of crucial cesarean surgical steps were taken and printed. Video recordings were stored in designated institutional data storage and uploaded onto a secure drive for further use. After every case, debriefing was held, and subjective opinions were obtained from the various participants.


      The VITOM was used for 104 cesarean deliveries. Setup time was reduced from 7 minutes initially to 3 minutes with more experience. All staff participants had only positive evaluations and remarks about the image quality and the clear delineation of specific anatomic landmarks. By polling medical students and residents in training, the VITOM experience was described as very useful and, in a few cases, only somewhat useful. The scrubbed surgical technicians and circulating nurses gained a better understanding of surgical layers, improving their ability to anticipate subsequent surgical steps, thereby streamlining operating flow and efficiency. Unscrubbed personnel could also follow the operation's progression despite being remote from the sterile field. Anesthesiologists could follow the operative field and eventual blood loss in plain view. Recorded videos and still photographs were used at clinical teaching conferences and in peer-reviewed publications, enhancing understanding of cesarean delivery techniques.


      The VITOM exoscope provided superb image quality, enabling a clear vision of the anatomic structures of the cesarean operation. It is a promising additional research tool to capture important details of the employed surgical techniques and provides a possible insight into long-term postcesarean sequelae.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology MFM
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Antoine C
        • Young BK.
        Cesarean section one hundred years 1920-2020: the good, the bad and the ugly.
        J Perinat Med. 2020; 49: 5-16
        • Dodd JM
        • Anderson ER
        • Gates S
        • Grivell RM.
        Surgical techniques for uterine incision and uterine closure at the time of caesarean section.
        Cochrane Database Syst Rev. 2014; CD004732
        • Gedikbasi A
        • Akyol A
        • Ulker V
        • et al.
        Cesarean techniques in cases with one previous cesarean delivery: comparison of modified Misgav-Ladach and Pfannenstiel-Kerr.
        Arch Gynecol Obstet. 2011; 283: 711-716
        • Berghella V
        • Baxter JK
        • Chauhan SP.
        Evidence-based surgery for cesarean delivery.
        Am J Obstet Gynecol. 2005; 193: 1607-1617
        • Dahlke JD
        • Mendez-Figueroa H
        • Rouse DJ
        • Berghella V
        • Baxter JK
        • Chauhan SP.
        Evidence-based surgery for cesarean delivery: an updated systematic review.
        Am J Obstet Gynecol. 2013; 209: 294-306
        • Dahlke JD
        • Mendez-Figueroa H
        • Maggio L
        • Sperling JD
        • Chauhan SP
        • Rouse DJ.
        The case for standardizing cesarean delivery technique: seeing the forest for the trees.
        Obstet Gynecol. 2020; 136: 972-980
      1. Hamilton, B. E., Martin, J. A., & Osterman, M. J. (2021). Births: provisional data for 2020. National Center for Health Statistics (U.S.). Division of Vital Statistics. NVSS vital statistics rapid release; report no.12.

        • Timor-Tritsch IE
        • Monteagudo A
        • Cali G
        • et al.
        Cesarean scar pregnancy and early placenta accreta share common histology.
        Ultrasound Obstet Gynecol. 2014; 43: 383-395
        • Mogos MF
        • Salemi JL
        • Ashley M
        • Whiteman VE
        • Salihu HM.
        Recent trends in placenta accreta in the United States and its impact on maternal-fetal morbidity and healthcare-associated costs, 1998-2011.
        J Matern Fetal Neonatal Med. 2016; 29: 1077-1082
        • Chen YY
        • Tsai CC
        • Kung FT
        • Lan KC
        • Ou YC.
        Association between hysteroscopic findings of previous cesarean delivery scar defects and abnormal uterine bleeding.
        Taiwan J Obstet Gynecol. 2019; 58: 541-544
        • Stegwee SI
        • Beij A
        • de Leeuw RA
        • Mokkink LB
        • van der Voet LF
        • Huirne JAF.
        Niche-related outcomes after caesarean section and quality of life: a focus group study and review of literature.
        Qual Life Res. 2020; 29: 1013-1025
        • Vissers J
        • Hehenkamp W
        • Lambalk CB
        • Huirne JA.
        Post-caesarean section niche-related impaired fertility: hypothetical mechanisms.
        Hum Reprod. 2020; 35: 1484-1494
        • Abalos E
        • Addo V
        • CORONIS Collaborative Group
        Caesarean section surgical techniques: 3 year follow-up of the CORONIS fractional, factorial, unmasked, randomised controlled trial.
        Lancet. 2016; 388: 62-72
        • Antoine C
        • Alexander JS
        • Yaghoubian YC
        • Harary JM.
        Variations in uterine closure technique: an institutional survey of obstetricians and implications for patient counseling and prevention of adverse sequelae.
        J Perinat Med. 2022; ([Epub ahead of print])
        • Sholapurkar SL.
        Etiology of cesarean uterine scar defect (niche): detailed critical analysis of hypotheses and prevention strategies and peritoneal closure debate.
        J Clin Med Res. 2018; 10: 166-173
        • Antoine C
        • Pimentel RN
        • Reece EA
        • Oh C.
        Endometrium-free uterine closure technique and abnormal placental implantation in subsequent pregnancies.
        J Matern Fetal Neonatal Med. 2021; 34: 2513-2521
        • Antoine C
        • Pimentel RN
        • Timor-Tritsch IE
        • Mittal K
        • Bennett TA
        • Bourroul FM.
        Origin of a post-cesarean delivery niche: diagnosis, pathophysiologic characteristics, and video documentation.
        J Ultrasound Med. 2021; 40: 205-208
        • Kadaba V
        • Shafi F
        • Ahluwalia HS.
        The VITOM® exoscope in oculoplastic surgery: the 5 year Coventry experience.
        Eye (Lond). 2021; 35: 3137-3140
        • De Divitiis O
        • D'Avella E
        • Denaro L
        • Somma T
        • Sacco M
        • D'Avella D
        Vitom 3D: preliminary experience with intradural extramedullary spinal tumors.
        J Neurosurg Sci. 2019; ([Epub ahead of print])
        • Crosetti E
        • Arrigoni G
        • Manca A
        • Caracciolo A
        • Bertotto I
        • Succo G.
        3D exoscopic surgery (3Des) for transoral oropharyngectomy.
        Front Oncol. 2020; 10: 16
        • Taylor B
        • Myers EM.
        Initial gynecologic experience using the VITOM® HD exoscope for vaginal surgery.
        J Minim Invasive Gynecol. 2015; 22: S103
        • Antoine C
        • Meyer JA
        • Silverstein JS
        • Alexander J
        • Oh C
        • Timor-Tritsch IE.
        The impact of uterine incision closure techniques on post-cesarean delivery niche formation and size: sonohysterographic examination of nonpregnant women.
        J Ultrasound Med. 2022; 41: 1763-1771
        • Abalos E
        • Addo V
        • CORONIS Collaborative Group
        Caesarean section surgical techniques (CORONIS): a fractional, factorial, unmasked, randomised controlled trial.
        Lancet. 2013; 382: 234-248
        • Abalos E
        • Oyarzun E
        • CORONIS Collaborative Group
        CORONIS - international study of caesarean section surgical techniques: the follow-up study.
        BMC Pregnancy Childbirth. 2013; 13: 215
        • CAESAR Study Collaborative Group
        Caesarean section surgical techniques: a randomised factorial trial (CAESAR).
        BJOG. 2010; 117: 1366-1376
        • González-Quintero VH
        • Cruz-Pachano FE
        Preventing adhesions in obstetric and gynecologic surgical procedures.
        Rev Obstet Gynecol. 2009; 2: 38-45
        • Nabhan AF.
        Long-term outcomes of two different surgical techniques for cesarean.
        Int J Gynaecol Obstet. 2008; 100: 69-75
        • Lyell DJ
        • Caughey AB
        • Hu E
        • Daniels K.
        Peritoneal closure at primary cesarean delivery and adhesions.
        Obstet Gynecol. 2005; 106: 275-280
        • Turrentine MA
        • Andres RL.
        Recurrent Bandl's ring as an etiology for failed vaginal birth after cesarean section.
        Am J Perinatol. 1994; 11: 65-66
        • Malvasi A
        • Tinelli A
        • Pacella E.
        Mass closure of visceral peritoneum at cesarean section. A proposal method.
        J Matern Fetal Neonatal Med. 2010; 23: 345-346
        • Malvasi A
        • Tinelli A
        • Gustapane S
        • et al.
        Surgical technique to avoid bladder flap formation during cesarean section.
        G Chir. 2011; 32: 498-503