The study by Kotsuji et al. on a new surgical technique for placenta praevia with accreta made an interesting read. It describes a transverse fundal incision during caesarean deliveries for women with placenta praevias with possible placenta accreta. It is an interesting description, but there are several technical details that need further consideration.
The authors have performed a transverse fundal incision in all of the patients who were suspected to have placenta accreta; however, 44% (15/34) of the patients did not have features of placenta accreta. So the validity of a fundal incision, which carries greater morbidity and mortality for women during the present and subsequent pregnancies, is questionable. As correctly stated by the authors, the accurate antenatal diagnosis of placenta accreta by means of magnetic resonance imaging or three-dimensional power Doppler should be increased. The authors try to highlight the effectiveness of the new technique by explaining the ability to observe the placenta directly beneath the surgical wound and the ability to apply sutures for haemostasis precisely with a fundal incision. The risk of uterine rupture is undoubtedly the main concern with this technique. Although it avoids going through the placenta, the thick muscular layer at the uterine fundus is likely to make the procedure a bit cumbersome, and uterine closure is likely to be difficult. The risk of uterine rupture as a result of a transverse fundal incision in a subsequent pregnancy is not known. The report by Palacios Jaraquemada et al. quoted by the authors had been on women who had a large resection in the anterior uterine wall, and not on women who had fundal incisions.
A more simplistic approach that could be applicable to day-to-day practice is described below. It involves the careful ultrasonic mapping of the placenta before surgery or during surgery after entering into the abdominal cavity. A high transverse incision in the upper uterine segment, just above the placental margin, can be performed rather than a fundal incision. This allows the surgery to be performed through a low transverse skin incision rather than a midline incision. This would still allow the direct observation of the placenta beneath the surgical wound and the precise placement of sutures for haemostasis if needed. Moreover, the placement of sutures would be easier, as the approach into the lower segment through a fundal incision is more difficult than the approach through a high transverse incision.
The technique described by Kotsuji et al., however, is more relevant to women who had placenta praevia broadly involving the anterior uterine wall. It is virtually impossible to plan and perform a randomised controlled trial to find out the best surgical technique to deal with women suspected to have placenta accreta because of its complex nature, the increased morbidity and mortality, and the ethical constraints.
The report by Kotsuji et al., however, gives valuable input to our existing knowledge on the surgical management of placenta accreta.