Innovative Robotic Approach to Second-Trimester Placenta Accreta Spectrum Excision

Abstract

OBJECTIVE Placenta accreta spectrum (PAS) involves varying degrees of placental invasion into the myometrium and uterine serosa. Its incidence has increased, which correlates with higher cesarean delivery rates. Risk factors include prior uterine surgeries, multiple cesarean sections, and placenta previa.[1] The International Federation of Gynecology and Obstetrics recommends primary peripartum hysterectomy at delivery to prevent severe bleeding associated with PAS. However, hysterectomy may not be suitable for patients wishing to retain fertility and can negatively impact pelvic floor, bowel, and physical functions. In some cultures, undergoing a hysterectomy may affect a woman’s social standing and can influence her sense of personal well-being.[2] Minimally invasive techniques offer better cosmetic outcomes, quicker recovery, shorter hospital stays, and fewer wound and major postoperative complications compared to conventional open surgical routes for obstetric and gynecological procedures. Robotic surgery further enhances traditional laparoscopy by reducing tremors, providing 3D visualization, and enabling 360° instrument rotation.[3] Emerging evidence also suggests its efficacy in complex gynecological surgeries. This video presents a case of second-trimester placenta accreta managed with uterine artery embolization and robotic placenta accreta excision, showcasing a novel surgical approach. DESIGN Video presentation demonstrating step-by-step robot-assisted excision of second-trimester placenta accreta. PATIENT A 31-year-old G4P2 L2A1 at 14 weeks and 4 days of gestation with a history of failed medical termination of pregnancy, two previous full-term lower-segment cesarean sections, and a spontaneous abortion followed by curettage, with concerns for PAS on present imaging. INTERVENTIONS Examination revealed stable vitals with a relaxed uterus corresponding to 14 weeks gestation. Ultrasound showed a single-live intrauterine fetus with anterior placental thickening. MRI confirmed a 14-week fetus with evidence of placenta accreta at the scar site. The patient underwent uterine artery embolization followed by robotic placenta accreta excision. Key surgical steps included adhesiolysis and bladder separation, identification of the invaded myometrium, vasopressin injection, dissection of the invading placenta, resection of the invasive placenta, full-thickness myometrial closure, and specimen retrieval [Figure 1].Figure 1: Fetus and placenta positioned over the uterus within the abdominal cavity following excision of the uterine segment affected by placenta accreta.http://www.apagemit.com/page/video/show.aspx?num=1367&kind=2&page=1RESULTS The robotic-assisted surgery was successfully performed with minimal blood loss and without complications. The patient experienced an uneventful postoperative recovery, with minimal scarring and a rapid return to normal activities. CONCLUSION This case demonstrates the feasibility and effectiveness of robotic-assisted surgery in managing second-trimester placenta accreta. The approach allowed for precise excision with minimal blood loss, smooth postoperative recovery, and minimal scarring. These outcomes highlight robotic-assisted surgery as a viable, less invasive alternative to traditional laparotomy, offering benefits such as reduced surgical trauma, faster return to normal activities, and potential preservation of fertility for patients with PAS. Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent form. In the form, the patients have given her consent for their images and other clinical information to be reported in the journal. The patients understand that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Author contributions AB, SG, GS, a