Dr. Olivier Ami, Groupe Ramsay Générale de Santé, Maternité de La Muette, Paris
Dr. Bénédicte Simon, Groupe Ramsay Générale de Santé, Les franciscaines, Versailles
Dr. Richard Benhamou, Groupe Ramsay Générale de Santé, Maternité de La Muette, Paris
Dr. Mathieu Fauck, Centre Hospitalier Robert Bisson, Lisieux
Dr. Luka Velemir, Polyclinique Santa Maria, Nice
Dr. Denis Fauck, Groupe Ramsay Générale de Santé, Lambert, La Garenne Colombes
Disclaimer : Extra-peritoneal cesarean using the "French AmbUlatory Cesarean Section" technique (FAUCS) requires proper training with senior obstetricians who routinely perform this procedure. Fellowship is more relevant than ever. We advise against attempting to do this technique without proper training and/or mentoring. Any colleague who so requests will be welcome to learn and train free of charge from one of the operators listed at the end of this page.
Cesarean's etymology (cesaere: "to cut") and the first testimonies of such operations date from Antiquity. Extra-peritoneal cesarean began in the 19th century.
As early as 1823, Louis-Auguste Baudelocque described it in his thesis as a "new procedure for cesareans" with an extra-peritoneal approach. This concept was dictated by the observation of an extremely high maternal mortality rate related to cesareans at that time. Unfortunately, his thesis was rejected by his masters at the time, because two fields started to clash: "Cesareans" (those who practiced cesareans) and "symphisians" (those who cut the pubic symphysis); and at that time the symphisians prevailed.
Subsequently, different techniques for extra-peritonization of the uterine scar were described, with the same concern of avoiding contamination of the peritoneal cavity with infected amniotic fluid [Mokgokong, et al., 1974].
Two techniques were commonly used: the detachment of the bladder dome, with the risk of bladder wounds that this involved due to the intimate bladder closure there, or the intra-peritoneal opening to suture, over the hysterotomy, the parietal leaf with the visceral leaf of the peritoneum, thus extra-peritonizing the scar.
The advent of antibiotics and the relative technical complexity of the extra-peritoneal approach have had a negative impact on this type of cesarean section, which has retained very few indications. Short articles have been regularly published on the subject, and several authors have stressed the potential benefits of an extra-peritoneal cesarean in terms of post-operative comfort of the patients.
The technique described in 1996 by Denis Fauck and Jacques Henri Ravina is very different from all these other techniques, because it combines a large number of innovations in the approach and realization, does not require any new prostheses or drugs, and the latest scientific developments to allow for earlier autonomy.
In addition to the extra-peritoneal approach, the use of a vertical paramedic fascial incision, routinely used in vascular surgery for large pelvic bones and abdominal surgery, permits a quicker rehabilitation in the immediate postoperative period.
The absence of a urinary catheter and the respect of the main functions (immediate mobility, first normal meal, possibility of carrying the child immediately) allow patients to leave on the same day and make this ambulatory technique an interesting alternative to the classic technique. The average stay can thus be as short as that of a normal delivery, whereas for the intra-peritoneal cesarean, the average stay is 6 days. This explains the name chosen for this international technique: the "French AmbUlatory Cesarean Section" (FAUCS).
See the detailed article in English describing the FAUCS technique and its results: Article in English describing the complete technique and its results
On the website of the journal "International Journal of Gynecology & Clinical Practices": The open online journal IJGCP
The FAUCS technique has been successfully implemented in Tunisia where it is being developed, and a prospective cohort study has been carried out in a university environment : Article in English describing the safety of the technique and the feasibility of its implementation in another team
The FAUCS technique has also been validated by a randomized prospective study which has been published in PlosOne in 2021 : Prospective randomized study
If you are an ObGyn professional, you can contact us if you wish to participate in our future multicenter prospective randomized study (dr.olivierami@gmail.com).
See the film on the surgical steps of the FAUCS technique : film explaining the FAUCS technique
See also the film about the FAUCS technique published in the "International journal of gynecology and obstetrics" showing glue skin : film showing FAUCS with glue skin
To satisfactorily respond to the steady increase in the rate of cesareans which now affect about one in four to five women in France, our practice tends to obtain better postoperative comfort with immediate mobilization and less morbidity (measured over a scaled down average stay length).
The technique involves a low horizontal cutaneous incision (at the level of the elastic of the underpants), followed by a vertical paramedic aponeurotic incision and a para-vesical extra-peritoneal approach. There is no urine catheter required. The suture of the uterine section is made, and the cutaneous suture is closed using surgical cutaneous glue.
Obtaining early maternal autonomy is paramount, and this is different than early rehabilitation: here, it is not due to the powerful analgesics that a mother can get up and take care of her child, but thanks to a real reduction of pain and impact of the surgery on the major functions (no urinary catheter, no peristaltic stimulation due to the non-opening of the peritoneum, mobility preserved by the opening of the aponeurosis in the sense of respecting muscle function, reduction of pain by minimal invasiveness and separation reduction).
The FAUCS technique can be performed in emergency or scheduled conditions. Placenta praevia or prematurity are not contraindications. However, we do not practice this technique when the condition of the child is uncertain at the time of cesarean, so as not to discredit the method. A good mastering of obstetrical mechanics during cesarean section by the obstetrics surgeon is necessary.
Link to the video showing the results of a FAUCS : Extra-peritoneal cesarean with Paloma Chaumette
The FAUCS extra-peritoneal cesarean technique offers many advantages in terms of patient comfort and post-operative autonomy. Nevertheless, it is intended for an obstetric-surgical training audience and requires its own training. The surgical qualification of the surgeon must enable them to know the anatomical structures with certainty. The extra-peritoneal approach requires the first identification of the umbilico-prevesical artery, and of the triangle in which the hysterotomy will take place on the lower segment. In addition, they must be able to recognize and repair a visceral lesion during their learning phase (basically, a bladder wound). Finally, the surgeon must be familiar with extractions and obstetrical mechanics.
Mentoring is strongly recommended, at least on the first cases, in order to clearly identify the anatomy and the principles of this intervention. The systematic realization of a vertical paramedic fascial incision during intra-peritoneal cesareans also makes it possible to become familiar with this approach. The identification with the finger of the intervesico-uterine pouch and therefore of the left para-vesical approach could also be performed at this time. The suture of the uterus can be learned during conventional cesareans.
The 7 surgeons who practiced this technique on a regular basis were all surgically trained, had performed at least 100 cesareans using conventional techniques, and were completely autonomous and comfortable with fetal extractions. Learning curve of the technique was clearly correlated to the level of experience of each surgeon and to it skills, taking less than five cesareans to become autonomous with this technique for a gynecologist with more than 15 years of gynecological surgical practice, and twenty cesareans for 2 young gynecologists finishing their gynecology-obstetrics internship. Two gynecologists at the beginning of the post-internship needed less than five cesareans while accompanied and oral counseling for particular situations in less than a dozen cases.
Our team is keen to train any qualified colleague who requests it.
Here is the (non-exhaustive) list of practitioners who have been trained and regularly practice the FAUCS extra-peritoneal cesareans:
Dr Olivier Ami
4 rue de Sontay
75116 Paris
Tél : 01 45 00 78 12
Web : docteurolivierami.fr
mail : dr.olivierami@gmail.com
Dr Denis Fauck
71 Avenue Jean Jaurès
78500 Sartrouville
Tel : 01 30 86 29 00
Dr Richard Benhamou
58 Rue Eugène Eichenberger
92800 Puteaux
Tel : 01 49 06 17 42
Dr Mathieu Fauck
28 Avenue F de Kergorlay
14800 Deauville
Tel : 02 31 14 33 00
Mail : cabinetgynecologiedeauville@gmail.com
Dr Alexandre Lazard
6 rue Rocca
13008 Marseille
Tel : 04 91 75 86 70
Site : gynecomarseille.com
gyneco.rocca@gmail.com
Dr Bénédicte Simon
76 Avenue de Paris
78000 Versailles
Tel : 01 39 50 58 05
web : docteurbenedictesimon.com/
Dr Luka Velemir
22ter Boulevard Dubouchage
06000 Nice
Tel : 04 93 79 68 55
Site : www.drvelemir.fr/
Dr Israel Hendler
Department of Obstetrics and Gynecology
Sheba Medical Center
Ramat-Gan
Israel
Sackler medical school tel aviv university israel
Tel : +972 52 6666 409
web : www.hendler-md.co.il
Pr Kaouther Dimassi
MEDUOG / WATOG / CAVELPA
Department of obstetrics and gynecology
Mongi Slim University Hospital
Route De La Soukra 2046 Sidi Daoud La Marsa
Tunisia
University Tunis El Manar, Faculty of medicine Tunis
Tel : +216 99 715 268
Email : dan.mongislim@gmail.com
Dr Michel BORHOVEN
Gynécologue-obstétricien
1A , Bvd Pierre DUPONG
L-1430 LUXEMBOURG
Centre Hospitalier de Luxembourg
Tel : +352 25 20 01
Email : gyn@pt.lu