B-Lynch Plus: A Technique in Uterine Conservative Surgery in Asymmetric Uteri with Atony

Postpartum massive uncontrolled hemorrhage is a main cause of maternal mortality and morbidity, accounting for 25-30% of all maternal deaths. Uterine atony is the most common cause of this serious problem (75-90%). Early diagnosis and teamwork are very important. Intravenous fluid resuscitation and use of blood products, uterine massage, uterotonics, uterine tamponade procedures and selective radiological embolization of the bleeding vessel all play potentially successfully roles during management of uterine atony.With failure of conservative managements, surgical intervention is necessary. The choice of surgical intervention technique to be used depends on the experience of the surgeon, parity of the patient and the desire for preservation capacity, the amount of the hemorrhage, and the general condition of the patient.The B-Lynch suturing technique is a conservative surgical treatment to this problem. It was developed by Christopher B-Lynch and first described in 1997 and has been widely adopted where postpartum hemorrhage is due to uterine atony. Often the classical B-Lynch suturing technique can stop postpartum hemorrhage without the need for additional surgery and allows preserving fertility. However, when the uterus is asymmetrical in shape, such in the presence of uterine fibroids or congenital uterine anomalies such as unicornuate uterus, proper placement of vertical brace sutures may not be possible and one of the vertical brace sutures tends to slip laterally toward the broad ligament. In this situation, if the two ends of the suture below the cesarean incision are pulled too tight to try and maintain their position around the asymmetric uterus, the suture may tear, or can unduly damage the uterus e.g. the sutures can cut through the uterine wall and embed in the myometrium or cause ischemic necrosis In order to solve of this problem, we describe an additional step in association with classic B-Lynch suturing technique. After caesarian section, in an atonic uterus, the classical B-Lynch suturing procedure starts. After completing all steps of the original B-Lynch suturing technique and before manually compressing the uterus, another free thread is passed under the pair of vertical brace sutures at the level of the fundus and its two ends are held by an assistant, While the uterus is being compressed, the two lengths of suture below the cesarean incision are pulled tight, the principal surgeon placing surgeon knots to secure tension.Two ends of the horizontal loop at the fundus are then tied with mild tension, bringing the vertical braces suture closer together. The lower transverse uterine incision is now closed in the routine manner. This additional step described above is simple, does not lead to further puncturing of the uterus, and adds minimal time to the procedure. It allows achievement of the primary goal of the procedure to compress the uterus without occluding the uterine arteries or uterine cavity

Keywords:

Postpartum hemorrhage , B-Lynch suture , uterine atony