Performing the hysterectomy
A complete review of all surgical techniques for managing PAS is beyond the scope of this article. However, we briefly cover important procedural steps and offer suggestions on how to minimize the risk of bleeding.
In our experience. The areas with the highest risk of massive bleeding that can be difficult to control include the pelvic sidewall when there is lateral extension of the PAS, the vesicouterine space, and placenta previa vaginally. Be mindful of these areas at risk and have a plan in place in case of bleeding.
Uterine incision
Avoid the placenta when making the uterine incision, which is typically done in the fundal part of the uterus. Cut and tie the cord and return it to the uterine cavity. Close the incision in a single layer. Use of a surgical stapler can be used for the hysterotomy and can decrease the amount of blood loss.8
Superior attachments of the uterus
The superior attachments of the uterus include the round ligament, the utero-ovarian ligament, and the fallopian tubes. With meticulous dissection, develop an avascular space underneath these structures and, in turn, individually divide and suture ligate; this is typically achieved with minimal blood loss.
In addition, isolate the engorged veins of the broad ligament and divide them in a similar fashion.
In our experience. Use of a vessel-sealing device can facilitate division of all the former structures. Simply excise the fallopian tubes with the vessel-sealing device either at this time or after the uterus is removed.
Pelvic sidewall
Once the superior attachments of the uterus have been divided, the next step involves exposing the pelvic sidewall structures, that is, the ureter and the pelvic vessels. Expose the ureter from the pelvic brim to the level of the uterine artery. The hypogastric artery is exposed as well in this process and the pararectal space developed.
When the PAS has extended laterally, perform stepwise division of the lateral attachments of the placenta to the pelvic sidewall using a combination of electrocautery, hemoclips, and the vessel-sealing device. In laterally extended PAS cases, it often is necessary to divide the uterine artery either at its origin or at the level of the ureter to allow for the completion of the separation of the placenta from the pelvic sidewall.
In our experience. During this lateral dissection, significant bleeding may be encountered from the neovascular network that has developed in the pelvic sidewall. The bleeding may be diffuse and difficult to control with the methods described above. In this situation, we have found that placing hemostatic agents in this area and packing the sidewall with laparotomy pads can achieve hemostasis in most cases, thus allowing the surgery to proceed.
Steps in managing a cesarean delivery with placenta accreta spectrum
1. Stop and collect your multidisciplinary team. If required resources are not available at your institution and the patient is stable, consider transferring her to the nearest center of expertise
2. Prepare for resuscitation: Have blood products available in the operating room and optimize IV access and arterial line
3. Optimize exposure of the surgical field: place in lithotomy position, extend fascial incision, perform hysterotomy to avoid the placenta, and expose pelvic sidewall and ureters
4. Be mindful of likely sources of massive bleeding: pelvic sidewall, bladder/vesicouterine space, and/or placenta previa vaginally
5. Proceed with meticulous dissection to minimize the risk of hemorrhage, retrograde fill the bladder, be mindful of the utility of packing
6. Be prepared to move to an expeditious hysterectomy in case of massive bleeding
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