Objective: We previously described a technique for repair of the myometrial defect at repeat Caesarean section which increases residual myometrial thickness thereby potentially reducing future niche-related complications. Here we describe how this technique can be modified for use for placenta accreta spectrum disorders. Design: Comparison of surgical performance of the modified technique with peripartum hysterectomy in women having repeat Caesarean delivery for placenta accreta Setting: A two year retrospective case control study at a tertiary unit in Singapore. Population: All women with placenta accreta spectrum disorder between December 2019 and October 2021. Methods: After delivery through the isthmocele women either underwent the modified technique which comprised uterine exteriorisation, systematic placental removal initiated from the posterior uterine wall, identification, mobilization and apposition of the boundaries of myometrial defects and repair or peripartum hysterectomy. Main Outcome Measures: Operating time, estimated blood loss and complication rate. Results: Ten women had Caesarean hysterectomy and ten had Caesarean section using the modified approach. Age and gestational age at delivery were similar for the two groups. Women in the modified technique group had had fewer prior Caesarean sections and had a lower body mass index. Operating time, estimated blood loss and need for transfusion were lower in the myometrial repair group but without statistical significance and there were no visceral injuries. There was one bladder injury in the hysterectomy group. Conclusion: The modified approach provides an effective alternative to peripartum hysterectomy with favourable surgical profile and allows uterine conservation with restoration of myometrial thickness.