**2.11 Specific considerations in placenta percreta**

• It is important to be aware that the blood supply to the lower uterine segment is extremely abnormal in the case of a placenta percreta. Frequently, the same bladder tissue supplies arterial blood to the placenta and drains venous blood through a network of tiny vessels that individually appear insignificant. However, the totality of the surface of these vessels exceeds that of the uterine artery itself. The interface between the bladder tissue and the uterus involved in a placenta percreta must be treated with the same caution as a pulsating artery or a distended vein. Usually, these new vessels have a thin muscular layer, and trying to cauterize them with a diathermocoagulator can cause problems. It is also contraindicated to perform a blunt dissection of the invasion areas because this maneuver can cause massive bleeding (**Figures 2** and **3**).

**Figure 2.** *Fundic incision in the face of a low placental insertion.*

**Figure 3.** *Subsequent breech extraction of the fetus.*

• Whenever possible, a careful and thorough dissection of the bladder tissue from the myometrium with a bipolar cautery device (LigaSure) is preferable in order to retain as much bladder wall as possible. The device allows to clamp small pieces of vascular tissue, to dry the tissue mass, and to separate the two interface zones. Using this technique, it is often necessary to support and suture the bladder wall after completing the hysterectomy due to significant bladder thinning and damage; sometimes, a cystotomy and excision of the attached piece of bladder are done. This approach is preferable to persistent bladder dissection attempts in cases of deep placental invasion (**Figure 4**).

**Figure 4.** *Placenta firmly adhering to the anterior aspect of the lower uterine segment (left) left in situ (right).*

**Figure 5.** *Fundus closure with placenta left in situ (left). Completion of the fundus suture (right).*

• Intraoperative arterial embolization of the placental bed (after a C-section but before hysterectomy) may be necessary when the placenta percreta involves the lateral pelvic walls and dissection seems too risky (**Figure 5**).

Figures of surgical steps.
