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.

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

Vagina circumscribed with clamps, divided, and ligated.

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

Cervix grasped, pulled up behind uterus.

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

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

Retroperitoneum accessed lateral to round ligaments, ureters, internal iliac vessels identified.

Ureterolysis performed if required.

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

Stepwise devascularization of lower uterine segment.

If required, identification and ligation of superior vesical arteries.

Intentional cystotomy and excision of bladder if invasion.

Midline abdominal incision, uterus exteriorized, and site of hysterotomy identified high on upper uterine segment of fundus.

Uterine wall grasped to create fold of uterus.

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

Create initial entry in ‘box’ with cautery.

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

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