Modified cesarean hysterectomy technique for management of cases of placenta increta and percreta at a tertiary referral hospital in Egypt

  • Ahmed M. Hussein
  • Ahmed KamelEmail author
  • Ayman Raslan
  • Dina M. R. Dakhly
  • Ali Abdelhafeez
  • Mohamed Nabil
  • Mohamed Momtaz
Maternal-Fetal Medicine



To evaluate the effect of a modified type II radical hysterectomy on maternal morbidities and mortality in cases with abnormally invasive placenta (AIP).


63 cases with AIP were managed at one of the largest referral centers in Egypt in a prospective study design. This technique entails devascularization of the uterus laterally on both sides and to clamp the uterus at the lowest possible point just below the level of the placenta while sparing the ureters.


The difference between pre- and post-operative hemoglobin was only about 1 gm/dl, and the mean blood loss was 1673 ± 958 ml. There was a significant drop in the post-operative need for blood and blood product replacement, packed red blood cells (p = 0.013), fresh red blood cells (p < 0.001), and plasma units (p = 0.012). Operative time (skin to skin) averaged 190 ± 58.2 min as the technique is slow and utilizes meticulous hemostatic steps. ICU admission was 4.8% with a mean total hospital stay of 8.6 ± 3.6 days. Histopathological examination revealed 58 cases of placenta increta and five percreta cases. We also had 16 bladder injuries (25.4%) and two ureteric injuries, and no maternal mortalities.


This technique reduces maternal morbidity and mortality while performing cesarean hysterectomy for cases with AIP.


Abnormally invasive placenta (AIP) Accreta Placenta accreta spectrum (PAS) disorders Increta Percreta Maternal morbidity Maternal mortality Modified cesarean hysterectomy 



Abnormally invasive placenta


Placenta accreta spectrum


Packed red blood cells


Red blood cells



We would like to thank Dr. Hesham Torad M.D. (team’s on-call urologist), and Dr. Ahmed Hosny M.D. (team’s on-call vascular surgeon) for their hard work and continuous support throughout the duration of the study, and for their skills and dedication during the operative procedures when called upon.

Author contributions

AMH: Protocol/project development, obstetrics and gynecological surgery, data analysis, manuscript writing/editing. AK: Protocol/project development, obstetrics and gynecological surgery, data analysis, manuscript writing/editing. AR: Obstetrics and gynecological surgery, data collection or management, manuscript writing/editing. DMD: Obstetrics and gynecological surgery, data collection or management, manuscript writing/editing. AA: Obstetrics and gynecological surgery, data collection or management, manuscript writing/editing. MN: Obstetrics and gynecological surgery, data collection and management, data analysis, manuscript writing/editing. MM: Obstetrics and gynecological surgery, data analysis, manuscript writing/editing.


This research did not receive any specific grant from any funding agency in the public, commercial or nonprofit sector.

Compliance with ethical standards

Conflict of interest

The authors of this study declare no conflict of interest and no competing interests with respect to the research, authorship and publication of this article.

Supplementary material

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Video 1: Identification of the avascular plane in the posterior leaflet of the broad ligament (MOV 8039 kb) (11.1 mb)
Video 2: Dissecting the posterior leaflet of the broad ligament in the avascular plane (MOV 11376 kb) (3.6 mb)
Video 3: Identification of the ureter (MOV 3677 kb) (8 mb)
Video 4: Demarcation of the level of placenta and clamping just below it. Videos 1 and 2 were filmed by A.K, videos 3 and 4 were filmed by M.N (MOV 8193 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Obstetrics and Gynecology, Faculty of MedicineCairo UniversityGizaEgypt

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