Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Multidisciplinary Surgical Approach to Invasive Placentation?
- What are the Risks of Multidisciplinary Surgical Approach to Invasive Placentation?
- Video Transcript
Video Description
This video presents the multidisciplinary preoperative, intraoperative, and postoperative management of invasive placentation at a single institution. It also outlines the surgical steps taken to safely perform this procedure.
Presented By
Affiliations
University of Toronto, Mount Sinai Hospital
Watch on YouTube
Click here to watch this video on YouTube.
What is Multidisciplinary Surgical Approach to Invasive Placentation?
A multidisciplinary surgical approach to invasive placentation involves a team of specialists coordinating to manage complex cases where the placenta abnormally adheres to the uterine wall. This condition, known as placenta accreta, increta, or percreta, poses significant risks during childbirth. Key Components of the Approach:
- Preoperative Planning: Utilizes detailed imaging like ultrasound and MRI to map placental attachment.
- Team Composition: Includes obstetricians, urologists, radiologists, anesthesiologists, and potentially other surgical specialists.
- Integrated Care: Focuses on surgical readiness, potential complications, and postoperative management to optimize maternal and fetal outcomes.
What are the Risks of Multidisciplinary Surgical Approach to Invasive Placentation?
The multidisciplinary surgical approach to invasive placentation, while critical for managing high-risk conditions like placenta accreta, increta, or percreta, carries specific risks:
- Surgical Complications: Despite the expertise of a specialized team, the surgery can lead to complications such as significant blood loss, bladder and bowel injury, or other organ damage due to the invasive nature of the placenta.
- Need for Hysterectomy: Often, a hysterectomy may be necessary to control bleeding and remove the invasive placenta, which can have long-term effects on a woman’s health and fertility.
- Anesthesia Risks: Extended surgery times and potential massive bleeding increase the risks associated with anesthesia.
- Postoperative Care: These patients may face longer recovery times, potential for infection, and the need for blood transfusions or intensive care.
- Coordination Challenges: Effective communication and coordination among the diverse specialists are crucial. Miscommunication or procedural delays can impact outcomes, especially in emergency scenarios.
Addressing these risks involves meticulous preoperative planning, skilled surgical execution, and comprehensive postoperative care to minimize complications and support recovery.
Video Transcript: Multidisciplinary Surgical Approach to Invasive Placentation
We present a video that describes a multidisciplinary surgical approach to women with invasive placentation. The video will focus on antenatal care, operating room setup and key surgical steps.
Patients are identified and managed antenatally by maternal foetal medicine and surgical gynaecology. Antenatal care involves diagnostic radiology with ultrasound and MRI, paediatric consultation for elective delivery at 34 to 36 weeks, anaesthesia consultation and coordination with perfusion medicine for intraoperative cell saver.
The patient meets for surgical gynaecology to discuss the procedure, including perioperative haemoglobin optimisation, and additional surgical services are consulted on a case-by-case basis.
The operating room setup requires careful orchestration between disciplines. The patient is in dorsal lithotomy, which facilitates intraoperative access to the vagina and provides space for an additional assistant. Maternal foetal medicine is present to perform perioperative ultrasound, to delineate the placental margin and perform the Caesarean section.
Anaesthesia routinely administers epidural anaesthesia. An art line is placed, four units of blood are available and tranexamic acid is administered routinely. Perfusion medicine operates the cell saver device, which helps to minimise heterologous blood transfusion. Nursing has set up the hysterectomy tray, vascular clips and the Breisky and Bookwalter retractors.
A three-way Foley catheter with methylene blue is set up to help with bladder delineation, and depending on the case, urology may be present for cystoscopy and ureteric stenting. Finally, paediatrics is present with a neonatal warmer and resuscitation equipment, prepared for the pre-term neonate.
We highlight six key steps in performing a Caesarean hysterectomy for invasive placentation. Step one, midline laparotomy. Step two, intraoperative ultrasound. Step three, classical hysterotomy. Step four, prophylactic internal iliac artery ligation. Step five, bladder dissection and ureterolysis. And step six, colpotomy at the cervical-vaginal junction.
Step one, midline laparotomy is performed, which his often supraumbilical to facilitate adequate access. Step two, intraoperative or preoperative ultrasound is performed to delineate the upper margin of the placenta. Step three, classical hysterotomy is performed above the placental margin. Bandage scissors are used to extend the incision away from the placenta, and the neonate is then delivered.
The cord is tied and replaced in the uterus. There is no attempt to remove the placenta, and uterotonics are not administered. All amniotic fluid is then evacuated from the field and the suction system is exchanged for the cell saver, which is used to capture maternal blood only. The hysterotomy is then closed quickly in a single layer to minimise blood loss from the uterine incision.
Step four is prophylactic bilateral internal iliac artery ligation. After transecting the round ligament, the peritoneum is opened cephalad, lateral and parallel to the infundibulopelvic ligament, and blunt dissection is used to open the space further. A narrow Deaver is placed in the space and retracted cephalad to expose the vessels.
Here, you can see the bifurcation of the common iliac artery into the external and internal iliac arteries, with the external iliac vein running in between. The ureter is seen on the medial leaf of the broad ligament, and can be seen vermiculating here. A Lauer is used to isolate the internal iliac artery before occluding the anterior division with large vascular clips approximately 3 cm below the bifurcation.
Step five, bladder dissection. Meticulous bladder dissection is a critical component of the surgery. To aid in delineating the bladder margins, it is retrograde filled with methylene blue through a three-way Foley catheter. The bladder margin becomes more apparent as it’s filled, helping to determine where to start the bladder dissection.
Next, we develop the paravesical spaced. With traction being applied to the round ligament, the avascular paravesical space is developed bluntly. This space is bordered by the bladder medially, the pelvic side wall laterally and the cardinal ligament cephalad.
Once both paravesical spaces are developed, we work from lateral to medial to dissect the adherent bladder off the placenta. The extensive network of vasculature behind the bladder is dissected using vascular clips or a pinch-burn technique. These large vessels must be reflected with the bladder. Identifying the correct plane is critical to avoid either bladder injury or significant placental bleeding.
At the level of the cardinal ligament, the ureter runs in close proximity to the uterine vessels. Ureterolysis is performed here to avoid inadvertent injury. Vessel loops can be passed under the ureter to aid in their identification and mobilisation. The anatomy is demonstrated nicely here. The uterine artery can then be safely clamped, cut and ligated without injury to the ureter or bladder.
Step six is the colpotomy. We place a Breisky retractor into the anterior vaginal fornix to help delineate the cervical-vaginal junction. Here, the Breisky demarcates the anterior fornix, superior to the bladder dome. The colpotomy can now be safely performed directly over top of the Breisky retractor. The colpotomy is often completed with Jorgenson scissors.
Standardised postoperative care includes observing the patient on labour and delivery for 24 hours, with an epidural in place. Following this, early mobilisation is encouraged, and most patients are discharged by postoperative day two to three.
In summary, we presented a multidisciplinary approach to invasive placentation. Each team member plays a critical role in caring for these complex patients from their antepartum to postpartum course, and this teamwork helps to facilitate safe and efficient care. Finally, we highlighted six key steps for Caesarean hysterectomy.