Extraperitoneal vs. Transperitoneal Cesarean Section: A Systematic Literature Review of Safety and Outcomes

Background: This systematic review aimed to evaluate the safety and outcomes of extraperitoneal cesarean section (EPCS), including the French Ambulatory Cesarean Section (FAUCS), by comparing them to those of transperitoneal cesarean section (TCS). Data Sources: The search was conducted using the following electronic bibliographic databases: PubMed, Web of Science, and Scopus. Studies were included if they were observational or interventional and investigated EPCS, including FAUCS, as the primary intervention. Exclusion criteria were animal studies, reviews, editorials, and conference abstracts. Methods: Two reviewers independently assessed the risk of bias using RoB 2 for RCTs and ROBINS-I for retrospective studies. Studies were grouped into comparable categories, and data were synthesized in summary tables and by comparative descriptive analysis. Results: In comparative studies, EPCS was associated with significantly lower rates of postoperative complications, such as fever (4% vs. 16% for TCS) and elevated C-reactive protein or leukocytosis (0% vs. 16-20%). EPCS reduced postoperative pain, with lower VAS scores at 24 h (e.g., 2.5 vs. 4.0 in TCS, p < 0.001) and shorter analgesic use. Time to return of bowel function was faster in EPCS and modified EPCS (6-8 h vs. 18-24 h in TCS, p < 0.01). Hospital stays were shorter after EPCS (4.15 ± 0.89 days vs. 4.82 ± 1.34 days, p = 0.027). FAUCS enabled early discharge within 24-48 h in 86-93% of cases and reduced morphine use (0.8% vs. 38% in TCS). Neonatal outcomes, including Apgar scores and cord pH, were similar across all groups. Conclusions: EPCS offers several potential advantages over TCS, including less postoperative pain, faster recovery, and shorter hospital stays. EPCS and its FAUCS variant are also associated with quicker return of bowel function and lower analgesic needs. TCS, while enabling faster fetal delivery, is linked to greater postoperative discomfort and slower recovery. However, current evidence is limited, and further high-quality trials are needed to confirm these benefits and assess long-term outcomes.