Placenta Accreta Spectrum Cesarean Hysterectomy

Table of Contents

• Procedure Summary
• Authors
• Youtube Video
• What is a Placenta Accreta Spectrum Cesarean Hysterectomy?
• What are the Risks of Placenta Accreta Spectrum Cesarean Hysterectomy?
• Video Transcript

Video Description

This video presents a stepwise approach to managing placenta accreta spectrum through cesarean hysterectomy, offering practical surgical tips and highlighting innovations for improved maternal and fetal outcomes.

Presented By

Affiliations

University of British Columbia

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What is a Placenta Accreta Spectrum Cesarean Hysterectomy?

Placenta Accreta Spectrum Cesarean Hysterectomy is a specialized surgical procedure performed to manage cases where the placenta abnormally attaches to or invades the uterine wall, posing significant risks to maternal and fetal health. Here’s what it involves:

• Stepwise Surgical Approach: The procedure starts with a cesarean delivery of the fetus, followed by leaving the placenta in place to minimize bleeding. The uterus is then surgically removed (hysterectomy) to prevent further complications.
• Hemorrhage Control: Key techniques include bilateral internal iliac artery dissection to reduce blood loss, careful separation of the bladder from the uterus, and meticulous closure of all bleeding sites to ensure hemostasis.
• Incision and Delivery Planning: Placental mapping helps determine the type of incision and hysterotomy. High-risk cases often require a midline incision for better access and reduced complications, while less complex cases may allow for lower abdominal incisions.
• Multidisciplinary Care: This complex surgery involves a team of specialists, including obstetricians, anesthesiologists, and sometimes urologists, ensuring coordinated care for optimal maternal and fetal outcomes.

This procedure is critical in high-risk pregnancies, offering a structured and innovative approach to addressing the life-threatening challenges of placenta accreta spectrum.

What are the Risks of a Placenta Accreta Spectrum Cesarean Hysterectomy ?

Video Transcript: Placenta Accreta Spectrum Cesarean Hysterectomy

Placenta Accreta Spectrum Cesarean Hysterectomy, a stepwise approach to management. The authors have no direct conflicts of interest. Placenta accreta spectrum disorders have increased more than fiftyfold since the 1950s, with the largest risk factor being placenta previa in those with prior cesarean sections. With a high risk of morbidity and even mortality, the literature shows that highly specialized, multidisciplinary teams often deliver the best patient outcomes.

Over the past few years we have collaborated nationally and internationally, learning from each other, sharing ideas and techniques that have culminated in the making of this video. This stepwise approach is not the property of the authors, but act as a tribute to the pioneers before us.

The main objective of this video is to present a stepwise approach to placenta accreta spectrum cesarean hysterectomy, with concrete tips at every step to maximize safety and success. We have phased out various older methods. For example, we abandoned the routine use of internal iliac balloon occlusion by IR due to risks such as vessel rupture and insufficient balloon occlusion, and abandoning GIA staplers for hysterotomy, as they took longer, and did not improve hemostasis.

Other aspects that have been phased out include delivering early at 34 to 36 weeks for uncomplicated pregnancies, using large umbilical or supraumbilical incisions, and having a strict 24-hour intensive post-op monitoring. These changes were made in light of better diagnostics, a drive to improve maternal and fetal outcomes, and expedite recovery. Our current approach includes bilateral internal iliac artery dissection prior to development at the vesicle uterine space to reduce risk of hemorrhage, planning for delivery at 36 weeks in uncomplicated pregnancies for optimal fetal growth, a subumbilical midline incision for high-risk cases to expedite recovery and reduce pain, and having 12 hours or less of intensive post-op monitoring for routine cases.

General tips for surgical planning include placental mapping, which is helpful in determining both the type of incision, as well as the hysterotomy location. For example, lower or intermediate-risk cases may warrant a Pfannenstiel or Maylard incision, while high-risk cases require a midline incision. A lithotomy position is recommended to monitor for vaginal bleeding throughout the case, as blood loss via this route can sometimes be unrecognized, but significant.

It is prudent to clear as much amniotic fluid as possible before switching to the cell saver for the rare potential risk of fluid embolism. And finally, having DVT prophylaxis in the form of SCDs intra-op, with transition to low molecular weight heparin post-op. We present our stepwise approach to highly suspected placenta accreta case in someone who has completed fertility.

Step zero, anaesthesia set up with concurrent placental mapping and cystoscopy. Here’s a typical OR setup. Anaesthesia is at the head of the bed, inserting extra lines with cell saver and packed RBC on standby. L and D staff are at one side of the patient, monitoring fetal heart rate, while one member of the accreta team is at the other side performing a presurgical confirmation of placental location. The surgical equipment can be seen to one side, and the patient can be seen at dorsal lithotomy, ready to be draped for concurrent cystoscopy, and insertion of ureteric catheters. This setup optimizes efficiency, and all members of the team work simultaneously but cohesively in their own space.

A typical cystoscopy setup includes five French whistle tip ureteric catheters, a three-way foley catheter for routine installation of methylene blue, a foley bag, as well as 30-degree cystoscope. We also have a reusable angiocath needle without a safety lock for threading our ureteric catheters into the foley. Once inside the bladder, the ureteric orifices can be found slightly distal to the trigone, and ureteric catheters are advanced to about 25 centimetres. We routinely perform this ourselves, rather than Urology, for improved efficiency.

Step one, laparotomy and delivery of the fetus. Placental mapping medially pre-op helps us determine the site of laparotomy and hysterotomy. For an anterior placenta we often make a vertical incision close to the fundus, then apply caudal traction on the uterus, and extend the incision cephalad using bandage scissors. Steps two and three. Hysterotomy closure with placenta in situ, and concurrent salpingectomy with ligation of upper pedicles. To increase deficiency, steps two and three may be performed simultaneously. One surgeon can start closing the hysterotomy site after clamping at the cord with a running suture, while the other surgeon starts the salpingectomy and ligation of upper pedicles on their side using an advanced bipolar device such as LigaSure impact.

Once the utero variant round ligaments are ligated, the retroperitoneum is open, and we move on to step four, dissection of bilateral internal iliac artery. Start by extending the perineal incision lateral to the IP ligament, then palpating the psoas muscle. The external iliac artery lies along its medial border. This is entry cephalad to the bifurcation of the common iliac, and the internal iliac artery is identified medially and posteriorly, and walked down caudally 3.5 to five centimetres from the bifurcation. To optimize visualisation, maintain good cephalad and lateral traction for exposure of the area. It also helps with the system to maintain medial traction of both the uterus and ureter, which is easy to identify and palpate by its stent.

We prefer to elevate the internal iliac artery with Russian forceps, while dissecting carefully parallel to the vessel using a combination of peanut and LaRoe or right-angle forceps. Care must be taken to avoid injuring the internal iliac vein, which lies immediately underneath. Once a plane is developed under the internal iliac artery, a vessel loop or suture may be passed under the vessel. This allows for prompt ligation in case of hemorrhage, if required. Some may prefer to use vessel clips instead. However, the benefit of internal iliac ligation may last as little as 15 to 20 minutes before collateral circulation causes ongoing bleeding, and therefore ligating the vessels too early may not be helpful.

Step five, development of vesicouterine space for bladder flap. The premise of internal iliac dissection is a setup for vessel ligation as needed if there is increasing hemorrhage. Most times a majority of blood loss occurs with development of the vesicouterine space in trying to separate the bladder from the uterus. Always start lateral and cephalad, and respect tissue planes. The key is to find the path of least resistance, and consider exploring new planes if dissection is not easy. This may mean working back and forth in different areas to continue progress. We partially backfill the bladder with methylene blue dye to help delineate its borders, and the perivesical spaces should be used as needed.

Step six, uterine artery ligation, colpotomy, and vaginal cuff closure. Once the bladder is separated from the pubocervical fascia, a vaginal retractor such as a Breisky or a narrow malleable in the anterior vaginal fornix may be used to find the level of the colpotomy, so that it is clear exactly how low the uterine artery ligation needs to be carried out. The rest of the hysterectomy is routine, with the completion of uterine artery ligation, colpotomy directly onto the vaginal retractor, followed by cuff closure.

Step seven, irrigation checking for hemostasis. It is important now to ensure that all pedicles are dry. This includes a retroperitoneum where the internal iliac dissection were carried out. Sometimes simple pressure with laparotomy sponges may go a long way in tamponading small oozing vessels. Other times additional sutures or haemostatic agents may be needed. In summary, we presented a stepwise approach to placenta accreta spectrum cesarean hysterectomy, with practical tips at every step to maximize safety and success. Thank you for viewing this video, and thank you to all of our colleagues across Canada for their contribution knowledge in the area of placenta accreta spectrum.