Nieto-Calvache Albaro Jose, Ramasauskaite Diana, Palacios-Jaraquemada Jose Miguel, Hussein Ahmed M, Jauniaux Eric, Ubom Akaninyene Eseme Bernard, Rivera-Torres Luisa F, Nunes Ines, Schlembach Dietmar, Beyeza-Kashesya Jolly, Wright Alison
Departamento de Ginecología y obstetricia, Fundación Valle del Lili, Cali, Colombia.
Faculty of Health Sciences, Universidad ICESI, Cali, Colombia.
Int J Gynaecol Obstet. 2025 Mar;168(3):987-998. doi: 10.1002/ijgo.16094. Epub 2025 Jan 4.
The incidence of cesarean section is dramatically increasing worldwide, whereas the training opportunities for obstetrician/gynecologists to manage complex cesarean section appear to be decreasing. This may be attributed to changing working hours directives and the increasing use of laparoscopy for gynecological surgical procedures, including in gynecological oncology. Various situations can create surgical difficulties during a cesarean section; however, two of the most frequent are complications from previous cesarean (myometrial defects, with or without placental intrusion and peritoneal adhesions) and the high risk of postpartum hemorrhage (uterine overdistension, abnormal placentation, uterine fibroids). Careful surgical dissection, with safe mobilization of the bladder and exposure of the anterior and lateral surfaces of the uterus, are pivotal steps for resolving the technical difficulties inherent in performing a complex cesarean section. We propose a standardized surgical protocol for women at risk of complex cesarean, including the antenatal identification of increased surgical risk, paramedian access to the pelvis, bladder dissection and mobilization, and the selection of a bleeding control strategy, considering uterine anatomy and the arterial pedicles involved in blood loss, which should be tailored to the individual case. We propose preoperative surgical planning to include consideration of the most common situations encountered during a complex cesarean, which facilitates anticipating an appropriate response for common possible scenarios, and can be adapted for low-, middle-, and high-resource settings. This protocol also highlights the importance of self-evaluation, continuous learning, and improvement activities within surgical teams.
剖宫产的发生率在全球范围内急剧上升，而妇产科医生处理复杂剖宫产的培训机会却似乎在减少。这可能归因于工作时间指令的变化以及腹腔镜在妇科手术（包括妇科肿瘤手术）中的使用增加。剖宫产过程中会出现各种导致手术困难的情况；然而，最常见的两种情况是既往剖宫产的并发症（子宫肌层缺陷，伴或不伴有胎盘植入及腹膜粘连）和产后出血的高风险（子宫过度扩张、胎盘异常、子宫肌瘤）。仔细的手术解剖，安全地游离膀胱并暴露子宫前表面和侧表面，是解决复杂剖宫产固有技术难题的关键步骤。我们为有复杂剖宫产风险的女性提出了一种标准化手术方案，包括产前识别手术风险增加、经旁正中入路进入骨盆、膀胱解剖和游离以及选择出血控制策略，要考虑子宫解剖结构和失血涉及的动脉蒂，应根据具体情况进行调整。我们建议术前进行手术规划，包括考虑复杂剖宫产过程中最常见的情况，这有助于对常见可能场景预期适当的应对措施，并且可适用于低、中、高资源环境。该方案还强调了手术团队内部自我评估、持续学习和改进活动的重要性。
