Transverse versus vertical incision in the surgical management of placenta accreta spectrum

Austin Oberlin; Katherine Yoh; Eve Overton; Whitney Alexandra Booker; John Ilagan; Dib Sassine; Alexandra Diggs; Sherelle Laifer-Narin; Adela Cimic; Laruence 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

Transverse versus vertical incision in the surgical management of placenta accreta spectrum

Am J Perinatol. 2024 Nov 20. doi: 10.1055/a-2479-2604. Online ahead of print.

Authors

Austin Oberlin¹, Katherine Yoh¹, Eve Overton², Whitney Alexandra Booker³, John Ilagan², Dib Sassine¹, Alexandra Diggs¹, Sherelle Laifer-Narin⁴, Adela Cimic⁵, Laruence Ring⁶, Maria Sheikh⁶, Caryn St Clair⁷, June Hou³, Alexandre Buckley de Meritens⁸, Jason D Wright³, Mary D'Alton¹, Chia-Ling Nhan Chang², Mirella Mourad⁹, Fady Khoury Collado⁸

Affiliations

¹ Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, United States.
² Maternal Fetal Medicine, Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, United States.
³ Obstetrics and Gynecology, Columbia University Medical Center, New York, United States.
⁴ Radiology, Columbia University Medical Center, New York, United States.
⁵ Anatomic Pathology, Columbia University Irving Medical Center, New York, United States.
⁶ Anesthesiology, Columbia University Irving Medical Center, New York, United States.
⁷ Obstetrics and Gynecology/Gynecologic Oncology, Columbia University, New York, United States.
⁸ Gynecologic Oncology, Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, United States.
⁹ Obstetircs and Gynecology, NewYork-Presbyterian Hospital, New York, United States.

PMID: 39566520
DOI: 10.1055/a-2479-2604

Abstract

Objective(s): 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 09/2019 and 11/2023. Starting in 10/2021, 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 18-20cm and used the patient's prior scar. Primary outcomes included rate of maternal transfusion >4 units of packed red blood cells (PRBC), 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 (86.0%) had a transverse incision and none required conversion to a vertical incision intraoperatively. The two groups were similar with regard to age, BMI, and severity of PAS. There was no difference in the rate of transfusion of >4 units of PRBC (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.