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.