
==== Front
Gynecol Oncol Rep
Gynecol Oncol Rep
Gynecologic Oncology Reports
2352-5789
Elsevier

S2352-5789(24)00045-6
10.1016/j.gore.2024.101366
101366
Surgical Film
Cesarean hysterectomy for placenta accreta spectrum: 3-2-1 approach
Vallejo Andrew a
Mona Guo X. a
Neuman Monica K. a
Youssefzadeh Ariane C. b
Roman Lynda D. ac
Matsuo Koji koji.matsuo@med.usc.edu
ac⁎
a Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
b Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
c Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
⁎ Corresponding author at: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA 90033, USA. koji.matsuo@med.usc.edu
22 3 2024
6 2024
22 3 2024
53 1013669 3 2024
11 3 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Given the high risk of complications associated with cesarean hysterectomy for placenta accreta spectrum (PAS), any surgical approach and technique can yield utility in reducing the surgical morbidity. Here, we propose the 3-2-1 approach as a schema to be implemented in the proper setting for the surgical management of a PAS cesarean hysterectomy. The 3-2-1 approach begins with the surgical dissection of three anatomical landmarks that ultimately facilitate a safe surgical site for the ligation and transection of the uterine vessels. First-step is identification of the three anatomical landmarks which are (i) posterior lower uterine segment peritoneum de-serosalization, (ii) identification of the ureters laterally, and (iii) anterior bladder dissection. Posterior-to-anterior progression avoids encountering dense adhesions and hypervascularity in the anterior lower uterine segment early in the surgery. Further, allows better mobilization of the uterus to identify the anatomical landmarks laterally and anteriorly. Second-step is to deploy the 2-hand technique where the surgeon places one hand anteriorly and the other hand posteriorly in the lower uterine segment below the placental bed. The surgeon brings both hands together with flexed fingers perpendicular to the uterine tissue and gently elevates the uterus and placenta out of the pelvis and ensures safe anatomical distance to surrounding structures. Third-step is the consideration of a supracervical hysterectomy. In summary, this 3-2-1 approach to reflect the anatomy of enlarged lower uterine segment in PAS is a stepwise schema that can aid surgeons in the completion of a cesarean hysterectomy, with the goal to improve surgical outcomes.

Keywords

Placenta accreta spectrum
Cesarean hysterectomy
Lower uterine segment
Surgical technique
==== Body
pmc1 Introduction

Placenta accreta spectrum (PAS) involves the pathologic attachment of the placenta to uterine myometrial layer that results in failure of normal placental detachment at delivery (Society of Gynecologic O et al., 2018, Einerson et al., 2023). As many as one in 313 cesarean deliveries have a diagnosis of PAS in the recent United States with continued increasing in the incidence (Matsuzaki et al., 2021). Pregnant patients with PAS frequently undergo cesarean delivery followed by immediate hysterectomy. This surgical procedure is associated with significant maternal morbidity and mortality, including hemorrhage, shock, coagulopathy, urinary tract injury, intensive care unit admission, and prolonged hospitalizations (Matsuzaki et al., 2021, Silver and Branch, 2018). The risk of death among cases of severe forms of PAS is as high as one in 71 patients (Matsuzaki et al., 2021). Thus, any surgical approach to reduce maternal morbidity and mortality is utmost importance in the management of pregnant patients with PAS (Kingdom et al., 2020).

This significant surgical morbidity and mortality associated with cesarean hysterectomy for PAS primarily attributed to abnormal placental implantation in the lower uterine segment leading to hypervascularity, thin uterine wall, and possible disrupted anatomical architecture (Matsuo et al., 2022, Matsuo et al., 2023). One major difference is seen in the application of the surgical clamps when ligating the uterine vessels. Application at the uterine isthmus seen in an ordinary hysterectomy would be located above the placenta in a PAS surgery (Fig. 1). This leads to serial progression down the lower uterine segment below the placenta increasing risk of severe blood loss due to hypervascularity from the placenta’s presence in the lower uterine segment from inevitable disruption of the thin uterine wall (Matsuo et al., 2022, Matsuo et al., 2023). Here, we propose the 3-2-1 approach for cesarean hysterectomy to address this characteristic anatomical abnormality in the lower uterine segment of PAS to safely proceed hysterectomy and improve surgical outcomes (Matsuo et al., 2022, Matsuo et al., 2023).Fig. 1 Lower uterine segment appearance without 2-hand technique.

2 Surgical steps

We utilize this 3-2-1 method in the context of usual preparedness for PAS center-of-excellence approach: (i) interdisciplinary team including members from maternal-fetal medicine specialist, general obstetrician gynecologist, experienced pelvic surgeon, anesthesiologist, acute care shock trauma surgeon, and interventional radiologist, (ii) blood bank services with massive transfusion protocol capability, and (iii) intensive care unit care (Einerson et al., 2023). Following midline vertical laparotomy, placenta-sparing hysterotomy, delivery of the fetus via cesarean, additional consideration for the PAS hysterectomy includes tranexamic acid injection, diagnostic cystoscopy and ureteral stent placement, and intraoperative uterine artery embolization in selected cases as was described in this video content.

The cesarean hysterectomy is then completed using the 3-2-1 approach over three sequential steps (Table 1). The first-step is to identify and create the three anatomical landmarks: (i) posterior lower uterine segment peritoneum de-serosalization (posterior aspect). (ii) ureteral identification (lateral aspect), and (iii) bladder dissection (anterior aspect) (Fig. 2). The posterior-to-anterior surgical progression avoids encountering dense adhesions and hypervascularity in the anterior lower uterine segment early in the surgery. Further, allows better mobilization of the uterus to identify the anatomical landmarks laterally and anteriorly.Table 1 The 3-2-1 Approach Schema.

First-step: Identify the 3 anatomical landmarks.	
Posterior cul-de-sac: de-serosalize the posterior lower uterine segment beyond the placental bulge, allowing the surgeon to reach below the placental edge.	
Lateral ureters: enter retroperitoneal space to identify and lateralize the ureters.	
Anterior bladder: Carry down to the level of the endopelvic fascia of the cervix, most easily identified laterally instead of anterior due to adhesive disease.
Modest fluid distention of the urinary bladder with normal saline can help identify the bladder edge.
Gentle traction with dry lap is preferred in lieu of clamps due to the increased friability in a gravid uterus susceptible to avulsion and shearing.	
Second-step: Deploy the 2-hand technique.	
The surgeon hands, on the contra-lateral side, are placed antero-posteriorly at the lower uterine segment, meeting at the cardinal ligament below the placental bed at the level of the upper cervix or vagina.	
Surgeon fingers are flexed (approximately 90 degrees) and perpendicular to the uterine tissue. Fingertips palpating contralateral hands with minimal tissue in between to confirm no placental tissue is in between.	
Two hands gently elevate the placenta-containing lower uterine segment out of the pelvis, safely isolating the cardinal ligament from the surrounding structures (ureters, bladder, and rectum).	
Third-step: Supracervical hysterectomy, 1 consideration.	
Place clamps beneath caudally from fingertips and confirm safe anatomical distance from surrounding organs and structures.	
Complete hysterectomy: supracervical hysterectomy can minimize surgical morbidity and time.	
Individualized considerations must be taken with a patient’s cervical dysplasia history.	

Fig. 2 Identification of 3 anatomical land marks.

The second-step is to deploy the 2-hand technique (Fig. 3). The surgeon places one hand anteriorly and the other hand posteriorly in the lower uterine segment below the placental bed. The surgeon brings both hands together with flexed fingers perpendicular to the uterine tissue and gently elevates the uterus and placenta out of the deep pelvis. The prior peritoneal de-serosalization process enable smooth elevation of placenta-containing lower uterine segment leaving the ureters in place. Confirming that there is adequate distance from both ureters / bladder prior to ligation and identification of the proper site for clamp placement to transect the cardinal ligaments, surgeons proceed hysterectomy (Fig. 4). In the third-step, supracervical hysterectomy is a possible consideration to reduce surgical morbidity weighing patient risk factor (Fig. 5).Fig. 3 Deploying 2-hand technique.

Fig. 4 Application of surgical clamp following 2-hand technique.

Fig. 5 Lower uterine segment appearance with 2-hand technique.

3 Conclusion

In summary, this simple, reproducible, and anatomy-based 3-2-1 approach is a stepwise schema that can aid surgeons in the completion of a cesarean hysterectomy for PAS, with the goal to improve surgical outcomes.

Ensign Endowment for Gynecologic Cancer Research (K.M.). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Informed consent

Signed informed consents were obtained from the patients.

Transparency: The manuscript’s corresponding author (K.M.) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Tweetable statement: This simple and reproducible 3-2-1 approach to reflect the abnormally enlarged lower uterine segment in placenta accreta spectrum may be useful for cesarean hysterectomy.

Meeting presentation: Society of Gynecologic Oncology 2024 Annual Meeting on Women’s Cancer, San Diego, CA, March 16–18, 2024.

Declaration of AI and AI-assisted technologies in the writing process: Not applicable.

CRediT authorship contribution statement

Andrew Vallejo: Data curation, Formal analysis, Investigation, Project administration, Software, Visualization, Writing – original draft. X. Mona Guo: Data curation, Investigation, Methodology, Resources, Writing – review & editing. Monica K. Neuman: Investigation, Resources, Writing – review & editing. Ariane C. Youssefzadeh: Investigation, Resources, Writing – review & editing. Lynda D. Roman: Funding acquisition, Investigation, Resources, Supervision, Writing – review & editing. Koji Matsuo: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft.

Declaration of competing interest

Lynda D. Roman served as consultant for Cardiff Oncology and Nutcracker, and participates in the Steering Committee for the Global Coalition of Adaptive Research. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary material

The following are the Supplementary data to this article:Supplementary video 1

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.gore.2024.101366.
==== Refs
References

Einerson B.D. Gilner J.B. Zuckerwise L.C. Placenta accreta Spectrum Obstet. Gynecol. 142 1 2023 31 50 37290094
Kingdom J.C. Hobson S.R. Murji A. Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020 Am. J. Obstet. Gynecol. 223 3 2020 322 329 32007492
Matsuo K. Miller H. Licon E. Proposal of a simple 2-hand technique at cesarean hysterectomy for placenta accreta spectrum Arch. Gynecol. Obstet. 305 1 2022 1 5 34609593
Matsuo K. Sangara R.N. Matsuzaki S. Placenta previa percreta with surrounding organ involvement: a proposal for management Int. J. Gynecol. Cancer. 33 10 2023 1633 1644 37524496
Matsuzaki, S., Mandelbaum, R.S., Sangara, R.N., et al., 2021. Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States. Am. J. Obstet. Gynecol. 225(5):534 e531-534 e538.
Silver R.M. Branch D.W. Placenta accreta Spectrum N. Engl. J. Med. 378 16 2018 1529 1536 29669225
Society of Gynecologic O, American College of O, Gynecologists, et al. Placenta Accreta Spectrum. Am. J. Obstet. Gynecol. 219(6):B2-B16.
