Articles
Register for One step conservative surgery in anterior placenta percreta by Pfannenstiel incision (Bladder detachment; hemostasis, placental and invaded area removal and uterine repair)
Professor José M Palacios Jaraquemada MD PhD; Fernando Monge MD, Fernando
Paesani MD
J. J Naón Morphologic
Institute
School of Medicine
University of Buenos Aires, Argentina, and
CEMIC University
Hospital
jpalacios@fmed.uba.ar and jpalacios@ciudad.com.ar
Brief history:
In 1989, and as a consequence of a mother’s death secondary to placenta accreta, Dr. Palacios Jaraquemada began an integral study of this placental adhesive disorder with the aim to reduce its specific morbidity and mortality.
Once he finished his thesis on the collateral circulation of the pelvis, he has performed innumerable cadaveric arteriographies in order to control pelvic hemorrhages.
At the same time he began, in Argentina, to study placental adherence through nuclear magnetic resonance. At first, he analyzed the morphology of the invasion and, later, he tried to determine the application and use of this study in surgeries, and the possibility of complications. This led to the publication in 2005 of the most important casuistic work about this topic1.
Continuous anatomic research allowed the development of a new surgical technique which solved the problem of placental adherence and its technical complications in a single surgical act2.
Surgical observation of certain circulatory phenomena following hemostatic or embolization maneuvers called attention, as there is no correspondence in the literature or in scientific articles. Therefore, after ten years of study, a new anastomotic component of the uterus could be established, which has been recently presented at Harvard and Georgetown Universities. This article explains, among other issues, how the uterus maintains its vitality after occlusion of the uterine arteries, and even after the joint occlusion of both uterine arteries and of the superior ovarian anastomotic pedicle3.
Nowadays, for the treatment of placenta accreta/percreta, there is the possibility of hysterectomy, as well as that of leaving the placenta in situ with or without adding metotrexate. However, this latter conservative technique is accompanied by a high rate of reoccurrence in following pregnancies.
Due to the increase of cesarean surgeries around the world, as well as the rise in complications that these imply, the one-step uterine conservation technique with reconstruction is described in a video. This procedure has proved to be safe and to provide the best current result in case of future pregnancies.
1.- MRI in 300 cases of placenta accreta: Surgical correlation of new findings. Palacios Jaraquemada JM; Bruno CH. Acta Obstet Gynecol Scand 2005;84:719-727. Abstract 1
2.- Anterior placenta percreta: Surgical approach, hemostasis and uterine repair. Palacios Jaraquemada JM, Pesaresi M, Nassif JC; Hermosid S.Acta Obstet Gynecol Scand 2004;83:738-744. Abstract 2
3.- Lower uterine blood supply: Extrauterine anastomotic system and its application in the surgical devascularization techniques. Palacios Jaraquemada, JM; García Mónaco, R, Barbosa, NE, Ferle, L, Iriarte, H Conesa, H. Acta Obstet Gynecol Scand. 2007;86(2):228-34. Abstract 3
Abstract 1:
MRI in 300 cases of placenta accreta: Surgical correlation of new findings. Palacios Jaraquemada JM; Bruno CH. Acta Obstet Gynecol Scand 2005;84:719-727
Background. To establish the usefulness of placental magnetic resonance in patients with a diagnosis of placenta accreta through the correlation of diagnostic images and surgical findings. Methods. Three hundred patients with ultrasound signs of placenta accreta were studied. In 252 patients, magnetic resonance imaging (MRI) was performed in a closed 1.5 T resonator, and in 48 patients, open 0.23 T-set was used. T1 and T2 slices in the three planes were performed, and placental invasion was classified in depth levels and topographic areas in relation to the posterior vesical wall. The final degree of invasion was established during surgery according to clinical and anatomical criteria. The information obtained with MRI was analyzed, thus establishing its relevance to the change in surgical technique. Results. In 286 cases, MRI provided topographic information of placental invasion, and in 90 patients, it modified invasion levels. Undiagnosed parametrium extent was determined in 11 cases, and 11 other cases were reclassified as placenta previa. Changes in conduct following MRI study included: recommendation to modify surgery date at week 35, recommendation for prophylactic ureteral catheterization, recommendation for the use of intraoperative blood salvage, possibility of approach through Pfannenstiel incision, probability of segmental myometrial approach, probability of aortic clamping, need to investigate subclinical disseminated intravascular coagulation, need of posterior pelvic dissection, and the possibility of uterine conservation. Conclusions. Magnetic resonance imaging turned out to be essential to define the topography and area of placental invasion. New findings modified surgical tactic and technique, allowing a reduction in historical morbidity and a significant increase in conservative surgeries.
Abstract 2:
Anterior placenta percreta: Surgical approach, hemostasis and uterine repair. Palacios Jaraquemada JM, Pesaresi M, Nassif JC; Hermosid S.Acta Obstet Gynecol Scand 2004;83:738-744.
Background. To describe an accurate approach, hemostatic procedures and uterine repair in patients with anterior placenta percreta. Methods. A total of 68 patients with anterior placenta percreta were included. A large retrovesical and parametrial dissection was performed in all cases. Hemostasis was achieved with selective vascular ligature or with surgical myometrial compression. The anterior wall defect was repaired using a myometrial suture, fibrin glue and polyglycolic mesh. Finally, a nonadherent cellulose layer was applied over this reconstruction. Hysteroscopy and T2 magnetic resonance imaging (MRI) were performed as a reconstruction control at 90 days after discharge. Results. Elective surgery was performed in 49 patients and emergency surgery in 19. In 59 midline incisions were performed and in nine lower transverse incisions. Forty-nine patients underwent fundal hysterotomy and 19 transplacental segmental uterine approaches. The uteri of 50 patients with anterior placenta percreta were repaired. Of the 18 hysterectomies performed in this series, 16 were indicated due to massive destruction and two were secondary to coagulopathies. The following surgical complications developed: pelvic hemorrhage (one), coagulopathies (two), uterine infection (three), low ureteral ligations (two), iatrogenic foreign bodies (two) and collection (three). Uterine conservation was highly significant between the upper and lower invasion areas. Ten pregnancies were reported after the repair, resulting in uncomplicated cesarean delivery. Conclusion. This approach has allowed an adequate uterine repair in patients with anterior placenta percreta. Based on these results it is valid to assume that a functional and anatomic uterine repair has been successfully performed.
Abstract 3:
Lower uterine blood supply: Extrauterine anastomotic system and its application in the surgical devascularization techniques. Palacios Jaraquemada, JM; García Mónaco, R, Barbosa, NE, Ferle, L, Iriarte, H Conesa, H. Acta Obstet Gynecol Scand. 2007;86(2):228-34.
Background. To establish the arterial components that determine lower uterine blood supply, varieties and anastomoses that result in complications during selective devascularization procedures. Methods. Thirty-nine female cadaveric pelvises with latex repletion in pelvic arteries were used. All the material was studied through direct dissection, and dissection enlarged with a 90-diopter magnifying glass, establishing origin, course, and anastomoses of the genital arteries. Axial calibers of the uterine and the main vaginal arteries were compared. An anatomical and a historical compilation of the uterine artery was made, with special reference to anastomotic areas in the lower sector. Results. Three main pedicles were determined in the lower uterine blood supply: a cephalic one constituted by the uterine artery, a medial one made up by the cervical artery, and a distal one formed by the vaginal arteries. Different types of anastomoses were distinguished among the upper, middle, and lower pedicles. All types of anastomoses displayed similar features and were interconnected along the isthmic-vaginal borders, or as an intramural anastomotic network. In many cases, a transmedial interuterine anastomosis of axial caliber equivalent to the uterine artery itself could be observed. The bibliography consulted provided neither detailed descriptions of the cervical-segmental arterial system nor of the vaginal system or its anastomoses. In two cases, images were found in books that show this anastomotic system without further explanation. Conclusion. A not very well known anastomotic system was described between uterine and vaginal arteries. This system explains some reported failures, complications, and hemodynamic changes after uterine devascularization procedures.
