Placenta Accreta Spectrum Disorders: A. Chohan Continuous Squeezing Suture (ACCSS) for Controlling Haemorrahge From Lower Uterine Segment at Caesarean Section

Placenta accreta spectrum has opened up a new era in the history of PPH, as forcible separation of adherent placenta leads to massive bleeding from placental bed . Peripartum hysterectomy has emerged as gold standard treatment for this variety of PPH (3 folds rise over uterine atony) with its overall morbidity of 40-50%, and mortality of 7-10% in case of placenta percreta . The fear of placental bed bleeding has led to the development of conservative management like "leaving the placenta in situ approach" with its wide range of mild to severe, and serious morbidities . The conservative surgical techniques (The triple P procedure, one step conservative surgery approach) have also used the concept of non-separation of placenta and have instead adopted resection of myometrium with placenta in situ . These surgeries involve devascularisation of deep pelvic / major abdominal vessels and ligation of complex arterial anastomosis making the procedure technically difficult. Moreover, the devascularisation is done under extensive and expensive interventional radiological equipment which places the procedures out of reach for the routine setups particularly in the under developed countries. Another conservative surgical technique (stepwise surgical approach) , which described separation of placenta also mainly relied upon devascularisation of pelvic organs by bilateral ligation of anterior branch of internal iliac artery rather than elaborating the details of technique of controlling haemorrhage at the actual bleeding site.

Rationale of ACCSS ACCSS is a novel suturing technique addresses the management of placenta praevia and PAS following the orthodox approach of separation of placenta, taking the challenge of controlling massive haemorrhage. The rational of ACCSS is; i. Placental bed is the ultimate area of concern in women with placenta praevia and PAS, and it generally spreads over the whole inner surface of lower uterine segment, but the placental attachment and bleeding area upon its separation does not extend onto the internal os and into the vagina.

ii. Lower uterine segment is thin, flexible, squeezable and holds the suture well.

iii. Internal cervical os is a fixed structure, and has a ring with sufficient strength to function as anchor to the suture.

iv. Taking half thickness of internal cervical os into suture does not alter the anatomy and uterine drainage remains unaffected.