Transverse versus Vertical Incision in the Surgical Management of Placenta Accreta Spectrum

Austin Oberlin; Katherine Yoh; Eve Overton; Whitney A. Booker; John G. Ilagan; Dib Sassine; Alexandra Diggs; Sherelle Laifer-Narin; Adela Cimic; Laurence E. Ring; Maria Sheikh; Caryn St. Clair; June Hou; Alexandre Buckley De Meritens; Jason D. Wright; Mary D'Alton; Chia-Ling Nhan Chang; Mirella Mourad; Fady Khoury-Collado

doi:10.1055/a-2479-2604

American Journal of Perinatology, Table of Contents

Am J Perinatol
DOI: 10.1055/a-2479-2604

Original Research

Transverse versus Vertical Incision in the Surgical Management of Placenta Accreta Spectrum

Austin Oberlin

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Katherine Yoh

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Eve Overton

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Whitney A. Booker

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

John G. Ilagan

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Dib Sassine

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Alexandra Diggs

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Sherelle Laifer-Narin

²Department of Diagnostic Radiology, Columbia University, New York, New York

,

Adela Cimic

³Department of Anatomic Pathology, Columbia University, New York, New York

,

Laurence E. Ring

⁴Department of Anesthesiology, Columbia University, New York, New York

,

Maria Sheikh

⁴Department of Anesthesiology, Columbia University, New York, New York

,

Caryn St. Clair

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

June Hou

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Alexandre Buckley De Meritens

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Jason D. Wright

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Mary D'Alton

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Chia-Ling Nhan Chang

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Mirella Mourad

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

,

Fady Khoury-Collado

¹Department of Obstetrics and Gynecology, Columbia University, New York, New York

› Author Affiliations

Abstract

Objectives Traditionally, midline vertical skin incisions have been utilized during surgery for placenta accreta spectrum (PAS), as it is considered to maximize exposure and allow for a uterine incision to avoid the placenta. However, literature directly comparing outcomes of vertical versus transverse incisions in PAS is sparse. Our objective was to compare maternal outcomes between patients who underwent a vertical versus a transverse skin incision for PAS.

Study Design Retrospective review of patients with pathologically confirmed PAS undergoing scheduled surgery at our institution between September 2019 and November 2023. Starting in October 2021, select patients were offered a transverse skin approach. Patients were eligible if the surgery was scheduled, and the placenta was not entirely covering the anterior uterine wall. The transverse skin incision was approximately 18 to 20 cm and used the patient's prior scar. Primary outcomes included the rate of maternal transfusion >4 units of packed red blood cells (PRBCs), the incidence of surgical complications, and the need for conversion to general anesthesia (GETA).

Results Seventy patients underwent scheduled surgery for PAS. Thirty-three patients had a vertical skin incision, and 37 had a transverse incision. After initiation of the transverse incision approach, 37/43 (86%) had a transverse incision and none required conversion to a vertical incision intraoperatively. The two groups were similar with regard to age, body mass index (BMI; kg/m²), and severity of PAS. There was no difference in the rate of transfusion of >4 units of PRBCs (vertical 12% vs. transverse 22%, p = 0.29), or in the rate of intraoperative complications (i.e., cystotomy; vertical 3% vs. transverse 14%, p = 0.20). In patients with a transverse incision, a significantly lower number of patients required conversion to GETA intraoperatively (vertical 70% vs. transverse 24%, p < 0.001).

Conclusion In appropriately selected patients, a transverse skin incision was associated with lower conversion to GETA without any difference in intraoperative outcomes.

Key Points

Transverse incision for PAS has equivalent surgical outcomes.
Fewer patients require GETA with a transverse incision.
Transverse incision for PAS may need fewer narcotics.

Keywords

placenta accreta spectrum - incision - anesthesia - operative - hysterectomy

Full Text

References

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