Bladder dissection
The next critical part of the surgery involves developing the vesicovaginal space to mobilize the bladder. Prior to initiating the bladder dissection, we routinely retrograde fill the bladder with 180 to 240 mL of saline mixed with methylene blue. This delineates the superior edge of the bladder and indicates the appropriate level to start the dissection. Then slowly develop the vesicouterine space using a combination of electrocautery and a vessel-sealing device until the bladder is mobilized to the level of the anterior vaginal wall. Many vascular connections are encountered at that level, and meticulous dissection and patience is required to systematically divide them all.
In our experience. This part of the surgery presents several challenges. The bladder wall may be invaded by the placenta, which will lead to an increased risk of bleeding and cystotomy during the dissection. In these cases, it might be preferable to create an intentional cystotomy to guide the dissection; at times, a limited excision of the involved bladder wall may be required. In other cases, even in the absence of bladder wall invasion, the bladder may be densely adherent to the uterine wall (usually due to a history of prior CDs), and bladder mobilization may be complicated by bleeding from the neovascular network that has developed between the placenta and bladder.
Uterine arteries and cervix
Once the placenta is separated from its lateral attachments and the bladder is mobilized, the next steps are similar to those in a standard abdominal hysterectomy. If the uterine arteries were not yet divided during the pelvic sidewall dissection, they are clamped, divided, and suture ligated at the level of the uterine isthmus. The decision whether to perform a supracervical or total hysterectomy depends on the level of cervical involvement by the placenta, surgeon preference, anatomic distortion, and bleeding from the cervix and anterior vaginal wall.
Responding to massive bleeding
Not uncommonly, and despite the best efforts to avoid it, massive bleeding may develop from the areas at risk as noted above. If the bleeding is significant and originates from multiple areas (including vaginal bleeding from placenta previa), we recommend proceeding with an expeditious hysterectomy to remove the specimen, and then reassess the pelvic field for hemostatic control and any organ damage that may have occurred.
The challenge of PAS
Surgical management of PAS is one the most challenging procedures in pelvic surgery. Successful outcomes require a multidisciplinary team approach and an experienced team dedicated to the management of this condition.9 By contrast, proceeding “as usual” in the face of an unexpected PAS situation can lead to disastrous consequences in terms of maternal morbidity and mortality. ●