Placenta accreta and beyond: Aesop's fables

Abstract

We have read with great interest the article by Matsubara et al. 1. The author has described measures and techniques of cesarean hysterectomy for placenta praevia accreta that he would like to be universally achievable. In our country, the rate of cesarean sections can reach almost 80% of deliveries and gynecologic surgery teams are often confronted with cases of placenta previa, accreta or percreta. In view of the lack of standardization of cesarean hysterectomy technique, and with building up of experience, we came to develop our own technique, which is safe and can be adapted to emergency cases. First of all, placement of ureteral stents is not always possible, especially during emergencies in cases with massive bleeding. What our team usually does after the longitudinal uterine fundal incision, delivering the baby and incision closure with Vicryl® “0” hepatic needle sutures (Ethicon, Johnson and Johnson Companies, Somerville, NJ, USA) 2, is to extend the laparotomy to the pubic bone and approach the retroperitoneum just lateral to the adnexal ligaments. This step is quite essential, particularly when the placenta fills the pelvis. Next is the ligation of the utero-adnexal “ligaments” as close as possible to the uterus. Double or even triple ligation sutures are placed, owing to the great engorgement of the vessels in the pregnant uterus. We do not agree with the author's “M cross” ligation technique using needles. Then, we thoroughly identify both hypogastric arteries and clamp them with “bulldogs”, surgical tools used to clamp off or close blood vessels (Platts & Nisbett, Sheffield, UK) 3, after which we dissect these arteries distally until we reach the uterine arteries.. These are in turn clipped using Hem-o-Lok® (Teleflex, Durham, NC, USA) 4, 5 and lifted up to expose the underlying uterine veins, which are then clipped as well. The logical following step is the dissection and un-roofing of both ureters (freeing the ureters from their crossing with the uterine arteries) by bringing the clipped uterine arteries towards the uterus. A recto-vaginal space dissection is then performed and vaginal incision is carried out with the help of a flat retractor placed in the posterior vaginal fornix. The bladder is then filled to help identify its separation site and the plane is cautiously dissected with the Bowie knife. If vesical invasion is previously noted on MRI or on site, excision of a bladder patch is performed. The bladder–vaginal interface is then exposed after the bladder is brought down and the anterior vaginal incision is achieved by placing the flat retractor in the anterior cul-de-sac. The operator's index and middle fingers are subsequently positioned through the posterior and the anterior vaginal incisions, lifting the uterus up and allowing placement of two clamps alongside the cervix after verifying that the ureters are at a distance. With this technique, we are able to accomplish a total hysterectomy with minimal morbidity and nearly absent ureteral risk. Ureteral lesion is still possible despite stenting 6. Thus, it is inconceivable to execute the maneuvers depicted above without identifying the ureters. Matsubara et al. failed to perform this identification and extrapolated the cesarean hysterectomy from standard hysterectomy. Furthermore, opening the anterior and posterior vagina allows lifting the uterus, lowering the ureters and raising the latero-cervical tissue to permit risk-free section. The authors' technique is not as safe and carries the risk of massive bleeding.