Expose the entire gravid uterus gently and visually confirm and grade the external features of this disease.

Perform hysterotomy to deliver the fetus using an incision placed to avoid the placenta, usually toward the fundus. This incision may be placed vertically, and the placenta localized by ultrasound to guide optimal location.

No attempt to remove the adherent placenta should be made.

Close the hysterotomy to minimize blood loss: use a uterine stapler if the myometrium is suitably thin or elevate the uterine edges with a series of clamps followed by an efficient single layer closure.

Release and ligate the round ligaments and utero-ovarian pedicles bilaterally.

Use traditional methods or a bipolar sealing device, taking care to advance incrementally, perpendicular to the vessels, within the optimal sealing width of the blades.

The principal risk of bleeding is from excessive upward traction on the uterus by lateral straight clamps, rather than by manual elevation.

The uterus is skeletonized down to the cardinal ligaments and the paravesical spaces are opened, using electrodissection.

May also include a cephalad pelvic sidewall dissection, medial to the psoas muscles, to locate the bifurcation of the common iliac arteries, the external iliac vein, and the medially located proximal ureters.

This adjunct step leads to exposure of the anterior divisions of the internal iliac arteries and can be followed by ureterolysis in a distal direction to establish the spatial relationship of the ureters to the cardinal ligaments.

Separation of the hypervascular bladder wall away from the extremely thin lower uterine segment with associated adhesions often is prolonged.

Meticulous lateral-to-medial dissection of this plane on each side, including dividing the engorged blood vessels, adhesions, and adipose layer down with the bladder.

This step is concluded when there is sufficient inferior dissection of the bladder wall down to the level of the anterior vaginal fornix.

Filling the bladder with 100–300 mL of methylene blue in normal saline may be helpful in identifying the superior bladder wall margin, particularly in difficult cases.

In rare instances with bladder invasion, confirmation and localization by cystoscopy is advised; this step is then modified to include intentional cystotomy and resection of the affected portion of the posterior bladder wall with the uterus, followed by bladder repair.

In rare instances in which parametrial placental invasion is found, more extensive retroperitoneal dissection is required to excise the specimen and secure hemostasis, or alternatively a subtotal hysterectomy is performed, thereby omitting the final step.

Once adequate exposure for vault entry is created, the main uterine artery pedicles are ligated, followed by securing the vaginal angles, each containing well-developed branches of the vaginal and internal pudendal arteries.

Colpotomy, followed by a circumferential incision around the cervicovaginal margin, results in removal of the uterus.

The incised edges are clamped incrementally as the vault is opened, to minimize blood loss from the margins, followed by suturing of the vault in a usual fashion.