Surgical Team: Jos M Palacios Jaraquemada MD Ph.D; Mario Pesaresi MD Ph.D, Juan Carlos Nassif MD, Susana Hermosid MD; Rodrigo Zlatkes; Silvina Bozzini; Mara Laura Sueldo MD. Surgical Assistant: Natalia Mara Casoetto.
Place of work: Durand Hospital, Obgyn Department; Buenos Aires, Argentina
This series describe an innovative approach for anterior placenta percreta surgery. The procedure has been developed in Argentina and is intended to limit obstetric bleeding and hysterectomy incidence. Though definite results will be reported later, a uterine preservation rate of about 90% with a mean transfusion need of 1000 ml has been achieved.
Patient selection, based on risk from repeated cesarean section, and uterine procedures and surgery, was the obstetrician's responsibility. In these cases, a comprehensive preoperative assessment, including abdominal and transvaginal ultrasonogram, placentary magnetic resonance imaging, and coagulation tests, was performed.
After placenta percreta was diagnosed, if no contraindications were found, surgery during the 35th week was planned. The surgical team decided the appropriate strategy.
An median infra-umbilical incision with a small supra-umbilical extension, allowed to bring forward the uterus and perform a fundic hysterectomy. After the baby was delivered, the infrarenal abdominal aorta was isolated and a loop was placed (proximal vascular control). Subsequently, all newly formed vessels between the uterus and placenta were isolated and ligated to completely release both vesicouterine and vesicocervical spaces. The aortic loop was secured and the placenta removed. Uterine arteries were selectively ligated. After the uterine cavity was cleared, the anterior wall was repaired using a reabsorbable mesh, collagen, and fibrin glue. Finally, the uterus and bladder were set apart by an anti-adhesive layer. The aortic loop was removed, the pelvis was drained, and the abdominal wall was closed.
Long-term postoperative results were excellent, with optimal tissue repair. Patients have been able to bear other children uneventfully. Protracted ileum (3-4 days) was the most frequent postoperative complication.
Additional figures show other dissection stages and predisposing factors (uterine segment injury secondary to repeated cesarean section).
Also by Jos M Palacios Jaraquemada MD Ph.D
Differential Diagnosis of the Placental Adhesive Disorders by Contrasted Nuclear Magnetic Resonance & Ultrasound - Placenta Accreta and Percreta