Discussion:
We present a step-by-step surgical protocol to preserve the uterus for patients with PAS overlying the cesarean scar. Any possible bleeding area including the placenta bed can be perfectly compressed with ideal efflux canal. Additionaly, with immediate blockage of hemorrhage rightly after delivery, and dissection of very thin part of the involved area, this protocol allowed for thorough clean of the placenta tissue. Finally, most surgeries was accomplished on the previous cesarean scar, a long attitude incision which was needed to deliver the baby without touching the placenta, can be avoided.
With this technique, make sure to do sutures without damaging the ureter by pushing the bladder downward and outward from the anterior lower uterine segment and cervix. To achieve hemostasis in the uterus, large step sutures are suggested. With large step sutures, hemostasis can be achieved within a shorter time by covering larger area and decreasing the uterine volume, the possiblility of local ischemic necrosis is also minimized. Enough blood preparation before surgery, timely infusion of blood products according to EBL is also essential to fulfill the process. Without timely supply, instant blood loss will lead to uterine inertia and intractable bleeding, and suspending sutures will be the only effective procedure to cut this vicious cycle.
Preoperative aortic balloon has been proved to be effective to reduce bleeding and shorter surgical time.7 In this cohort, in the 44 patients determined to be severe, the EBL in the balloon group was not significantly lower than those without balloon. The reason maybe that following this protocol, the immediate blockage of hemorrhage with hand and oval clamps resembled the effect of blockage of the aortic balloon. Considering the complications of the balloon technique, such as aortic rupture, ischemia and thrombosis in the lower extremities, reperfusion injury, the choose of balloon should be more conservative.13
The limitations of this research lies in its retrospective nature, and the shortage of standard diagnostic criteria on the severity of placenta invasion.