University of Maryland School of Medicine, Baltimore, MD, USA.
J Matern Fetal Neonatal Med. 2021 Jul;34(13):2061-2070. doi: 10.1080/14767058.2019.1656194. Epub 2019 Aug 27.
Cesarean hysterectomy for the treatment of placenta accreta spectrum (PAS) disorders has the potential to be associated with significant blood loss, massive transfusion, and operative morbidity. Two major contributors to blood loss are the hysterotomy and the bladder dissection. We introduce a new surgical technique and hypothesize that developing the hysterotomy with a linear cutter and mobilization of the bladder using a vessel sealing system (VSS) before clamping uterine arteries will lead to a total reduction in blood loss and transfusion rates.
This was a case series, which presents clinical outcomes according to our described surgical technique. The following surgical outcomes were collected: operation time (minutes), estimated blood loss (EBL), intraoperative complications, need for reoperation before discharge, and transfusion rates. Our surgical technique utilizes a linear cutter to create a bloodless hysterotomy and a VSS to dissect the vesicouterine tissue. The VSS cauterizes and transects the small vesicouterine and placental-vesical vascular anastomoses that are prone to bleeding. Once the bladder is mobilized below the level of the cervix, the uterine arteries are ligated to complete the key components of the hysterectomy.
Of the 23 cases, the median EBL was 1500 cubic centimeters and patients received a median of 1 unit of packed red blood cells. Eleven of the 23 cases did not require any blood transfusion and no patients required massive transfusion. The EBL did not differ between procedures that were performed emergently versus scheduled and it also did not differ between patients that had placenta increta versus placenta percreta, as diagnosed by histopathology.
Use of a linear cutter and closure of the lower anastomosis with VSS prior to clamping uterine artery during cesarean hysterectomy can significantly reduce blood loss and transfusion rates. This technique is applicable in emergent and nonemergent settings as well as for the most challenging procedures complicated by placenta percreta.
治疗胎盘植入谱系（PAS）疾病的剖宫产子宫切除术有可能导致大量出血、大量输血和手术并发症。出血的两个主要原因是子宫切开术和膀胱分离术。我们介绍了一种新的手术技术，并假设在夹闭子宫动脉之前，使用线性切割器进行子宫切开术，并使用血管密封系统（VSS）移动膀胱，这将导致总失血量和输血率的全面降低。
这是一个病例系列，根据我们描述的手术技术呈现临床结果。收集了以下手术结果：手术时间（分钟）、估计失血量（EBL）、术中并发症、出院前再次手术的需要以及输血率。我们的手术技术使用线性切割器进行无血子宫切开术，使用 VSS 进行膀胱-子宫组织分离。VSS 烧灼和横断易出血的小膀胱-胎盘血管吻合支。一旦膀胱向下移动到宫颈水平以下，就结扎子宫动脉以完成子宫切除术的关键部分。
在 23 例病例中，中位 EBL 为 1500 立方厘米，患者平均输注 1 单位浓缩红细胞。23 例中有 11 例不需要输血，也没有患者需要大量输血。紧急手术与计划手术之间的 EBL 没有差异，也没有在组织病理学诊断为胎盘植入与胎盘穿透之间存在差异。
在剖宫产子宫切除术中，使用线性切割器并在夹闭子宫动脉之前使用 VSS 闭合下部吻合口，可以显著降低失血量和输血率。这种技术适用于紧急和非紧急情况，以及由胎盘穿透引起的最具挑战性的手术。
