Table 3

Novel techniques for cesarean hysterectomy in patients with placenta accreta spectrum disorders

Author(s)TechniqueDescription of modification
Selman28 Posterior retrograde hysterectomy via pouch of Douglas
  1. After closure of hysterotomy, uterus is exteriorized, round ligaments are divided, retroperitoneal is space dissected parallel to ureters and pelvic side wall vessels, utero-ovarian ligaments are divided bilaterally.

  2. Posterior vaginal fornix exposed with sponge stick into vagina and opened transversely below cervicovaginal junction.

  3. Vagina circumscribed with clamps, divided, and ligated.

  4. Ureters identified, dissected, and preserved though anterior bladder pillar.

  5. Cervix grasped, pulled up behind uterus.

  6. Cardinal ligaments, uterosacrals, and bladder pillars are sequentially divided.

  7. Vesicouterine space is developed until bladder detached from anterior aspect of uterus or cystotomy and resection of posterior bladder wall if placental invasion.

Shamshirsaz et al29 Modified radical hysterectomy technique and use of bipolar cautery device
  1. Retroperitoneum accessed lateral to round ligaments, ureters, internal iliac vessels identified.

  2. Ureterolysis performed if required.

  3. Uterus separated from support structures with wide margin on broad ligament to avoid clamping fragile/unsupported vessels and or/thinned myometrium.

  4. Stepwise devascularization of lower uterine segment.

  5. If required, identification and ligation of superior vesical arteries.

  6. Intentional cystotomy and excision of bladder if invasion.

Belfort et al30 Linear cutting staple device for hysterotomy
  1. Midline abdominal incision, uterus exteriorized, and site of hysterotomy identified high on upper uterine segment of fundus.

  2. Uterine wall grasped to create fold of uterus.

  3. Placement of four full-thickness sutures in ‘box’ pattern to create unperfused area of upper uterine segment.

  4. Create initial entry in ‘box’ with cautery.

  5. Membranes dissected away from uterine wall digitally to create space for stapler.

  6. Linear cutting staple device inserted and deployed 1–3 times as required to create hysterotomy.

Rossetti et al31 Use of vessel-sealing devices for peripartum hysterectomy1. Vessel-sealing device used to facilitate surgery.