Managing placenta accreta spectrum in low-resource settings using a novel dissection-free aorta clamp: Operative technique.

Abstract

Surgical management of Placenta accreta spectrum (PAS) is associated with profuse bleeding and increased risk of operative injury to the adherent pelvic structures. We propose using a novel aorta clamp that can occlude the abdominal aorta without retroperitoneal dissection, thereby making it easy for an obstetrician-gynecologist to use it. The novel Paily aorta clamp (PAC) is applied just above the bifurcation of the abdominal aorta. This was a retrospective study of 33 women with varying grades of histopathology-confirmed PAS, who were managed as an elective or emergency procedure in a tertiary center in India. Twenty-nine women with advanced grades of PAS underwent sub-total/total hysterectomies, while four women with low-grade PAS underwent a conservative procedure. The procedures were associated with median estimated intra-operative blood loss of 1000 ± 1500 ml, with only 21.2% (n= 7) requiring a transfusion of four or more units packed red blood cells. PAC was applied for a median of 55 ± 20min and was not associated with any perioperative aortic wall injury or distal thromboembolic phenomenon. Our experience using the novel PAC, in the current series and across multiple centers in India, demonstrates that the sizeable abdominal aorta can be clamped safely and effectively without retroperitoneal dissection-with no incidence of vascular injury so far. However, we would urge only designated centers with experienced obstetrician-gynecologists-backed by a urologist, adequate blood bank and intensive care facilities-to tackle PAS procedures using the PAC technique.