Belfort Michael A, Shamshiraz Alireza A, Fox Karin
Texas Children's Percreta Center and Baylor College of Medicine, Section of Maternal Fetal Surgery, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Houston, TX.
Texas Children's Percreta Center and Baylor College of Medicine, Section of Maternal Fetal Surgery, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Houston, TX.
Am J Obstet Gynecol. 2017 Jan;216(1):78.e1-78.e2. doi: 10.1016/j.ajog.2016.10.030. Epub 2016 Oct 27.
Preventing blood loss at the time of a cesarean delivery during a scheduled, nonemergent cesarean hysterectomy for placenta percreta may reduce the need for crystalloid and blood product transfusion. Commonly a classical hysterotomy is created and this can result in as much as a 500-800 mL blood loss before the hysterotomy is closed. Our technique involves placement of 4 full-thickness interrupted sutures in a box pattern to create an unperfused area of upper uterine segment. Diathermy is used to open the uterus to the membranes in the center of the "box" without blood loss. A finger is then inserted between the membranes and uterus to create a space into which 1 side of an 80-mm linear cutting stapler is introduced. The other side of the stapler is then attached and clamped closed, and the stapler is activated. Forward motion of the lever lays down 2 rows of staples, and backward movement of the lever divides the uterine muscle between the 2 staple lines. The stapler is removed and reloaded and reintroduced 1 or 2 times as needed to create an avascular hysterotomy large enough to atraumatically deliver the baby. The membranes are then opened and the baby is delivered. Following this the umbilical cord is clamped and cut without any attempt to remove the placenta, replaced in the uterine cavity, and the hysterotomy is closed with a running locked suture that incorporates the membrane edges. The hysterectomy then proceeds. In most cases there is minimal blood loss (usually <20 mL) from the cesarean delivery.
对于胎盘植入患者，在计划进行的非急诊剖宫产子宫切除术中，剖宫产时预防失血可能会减少晶体液和血液制品的输注需求。通常会做一个经典的子宫下段横切口，这可能导致在关闭子宫下段横切口之前失血多达500 - 800毫升。我们的技术包括以盒状模式放置4针全层间断缝线，以形成子宫上段的无灌注区域。使用电刀在“盒”中央打开子宫至胎膜处而不出血。然后将一根手指插入胎膜与子宫之间以形成一个空间，将80毫米线性切割吻合器的一侧插入该空间。然后连接吻合器的另一侧并夹紧关闭，启动吻合器。杠杆向前移动会钉下两排钉子，杠杆向后移动会在两排钉子之间切断子宫肌层。根据需要取出吻合器并重新装填，再重新插入1或2次，以形成一个足够大的无血管子宫下段横切口，以便无创伤地娩出胎儿。然后打开胎膜，娩出胎儿。此后，夹住并切断脐带，不试图取出胎盘，将胎盘放回子宫腔，并用连续锁边缝合关闭子宫下段横切口，缝合时将胎膜边缘包括在内。然后进行子宫切除术。在大多数情况下，剖宫产时失血极少（通常<20毫升）。
