CONCLUSION
This surgical approach involving delivery of baby through the incised isthmocele, expeditious uterine exteriorization and systematic manual removal of the placenta from posterior uterine wall to anterior, combined with our previously described technique of myometrial defect repair, can optimally conserve the uterus while reducing the likelihood of future niche complications in cases of PASD. It is performed within the uterine boundary which reduces the risk of perioperative complications. As it is designed for use in high risk situations, where alternatives are equally fraught with risk, including life threatening bleeding, training, practice and experience in the technique is obligatory.