PDF(Pubmed)
Abstract：
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.
摘要：
鉴于剖宫产子宫切除术治疗胎盘植入谱（PAS）的并发症风险较高，任何手术方法和技术都可以降低手术发病率。这里,我们建议将3-2-1方法作为一种模式,在适当的环境中实施PAS剖宫产子宫切除术.3-2-1方法从三个解剖标志的手术解剖开始，最终有助于子宫血管结扎和横切的安全手术部位。第一步是确定三个解剖标志，即（i）子宫下段腹膜后去血清化，(ii)侧面识别输尿管，和(iii)膀胱前剥离术。从后到前的进展避免了手术早期在子宫下段的致密粘连和血管过多。Further,允许更好地动员子宫，以识别横向和前部的解剖标志。第二步是部署双手技术，外科医生将一只手向前放置，另一只手向后放置在胎盘床下方的子宫下段中。外科医生将双手与弯曲的手指垂直于子宫组织，轻轻地将子宫和胎盘从骨盆中抬起，并确保与周围结构的安全解剖距离。第三步是考虑宫颈上子宫切除术。总之,这种3-2-1方法反映了PAS中子宫下段扩大的解剖结构，是一种逐步的模式，可以帮助外科医生完成剖宫产子宫切除术。以改善手术结果为目标。
