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Author's Response: Which cesarean scar defect should be treated; by which technique and by whom?
Accepted Manuscript In Reply: Which cesarean scar defect should be treated; by which technique and by whom? M. Api PII:
S1553-4650(16)00082-0
DOI:
10.1016/j.jmig.2016.02.003
Reference:
JMIG 2785
To appear in:
The Journal of Minimally Invasive Gynecology
Received Date: 3 February 2016 Accepted Date: 4 February 2016
Please cite this article as: Api M, In Reply: Which cesarean scar defect should be treated; by which technique and by whom?, The Journal of Minimally Invasive Gynecology (2016), doi: 10.1016/ j.jmig.2016.02.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT In Reply: Which cesarean scar defect should be treated; by which technique and by whom?
RI PT
Api M1 1 Department of Obstetrics and Gynecology (Dr. Api), Zeynep Kamil Women and Children Diseases Training and Research Hospital
EP
TE D
M AN U
SC
We read with great interest the letter of Grace and Nezhat, in which they indorsed the recommendation of repairing the large uterine defects by our proposed technique, which completely restores the uterine wall preferentially via laparoscopy (1). The cesarean scar defect represents a wide spectrum of healing disorders from small indentation on the anterior uterine wall at the isthmic level to a rather large defect acting as a reservoir within the uterine wall and even a fistula formation. The symptoms seem most likely to be related to the severity of the defect. The reservoir at the defect which contains mucus, old blood, debris and inflammatory cells could be responsible from the clinical symptoms such as intermenstrual bleeding, dysmenorrhea, dyspareunia and infertility. There is an ongoing debate about the required size of the defect to cause these clinical symptoms and about the most appropriate treatment for repairing of the defect. Although successful hysteroscopic shaving of the reservoir entrance has been reported (2), large uterine defects accompanied with thin residual myometrial thickness cannot be restored via hysteroscopy. An utero- peritoneal fistula formation is the most severe form of cesarean scar defect, which can only be restored by an abdominal approach as stated by the authors (3). Laparoscopy seems to be a reasonable opportunity for better visualization and surgical correction of the defect. For complete restoration, all of the fistula tract or the reservoir wall has to be excised first and the healthy wound edges should be reapproximated by sutures. In a recent video presentation (4) where the surgeons have repaired a large and symptomatic cesarean scar defect which was consequently found to be recurred according to the ultrasonographic persistence of the defect and the patient’s clinical symptoms. The possible causes of failure of treatment were discussed with the surgeons and were proposed to be linked to excision of the thin anterior wall of the large reservoir base and approximation of the wound edges without removing the whole defect (personal communication with permission of Urman B & Taskiran C). In our view, the defect needs to be clearly demarcated preoperatively and for this purpose, a Hegar dilator placed into the endometrial cavity may help to guide the surgeon during the excision and repair of the whole defect (1). Our suggestions for treatment of a cesarean scar defect are as follows: 1.Asymptomatic patients should not be treated. 2.If the patient is symptomatic, the sonographic appearance of the defect or the “reservoir” should be large enough to explain the clinical symptoms. 3.If the residual myometrial thickness is thick enough, hysteroscopic repair can be the treatment of choice. 4.If the defect is large and the residual myometrial thickness is thin, laparoscopic repair should be preferred.
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ACCEPTED MANUSCRIPT 5.In case of a large and severe defect or a fistula formation, whole lesion should be excised and repaired by experienced surgeons.
RI PT
References 1. Api M, Boza A, Gorgen H, Api O. Should Cesarean Scar Defect Be Treated Laparoscopically? A Case Report and Review of the Literature. J Minim Invasive Gynecol. 2015;22(7):1145-52. 2. Raimondo G, Grifone G, Raimondo D, Seracchioli R, Scambia G, Masciullo V.Hysteroscopic treatment of symptomatic cesarean-induced isthmocele: a prospective study. J Minim Invasive Gynecol. 2015;22(2):297-301.
SC
3. Jacobson MT, Osias J, Velasco A, Charles R, Nezhat C.Laparoscopic repair of a uteroperitoneal fistula. JSLS. 2003;7(4):367-9.
EP
TE D
M AN U
4.https://www.youtube.com/watch?v=06tNMl8LhPM
AC C
50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66
2
S1553-4650(16)00082-0
DOI:
10.1016/j.jmig.2016.02.003
Reference:
JMIG 2785
To appear in:
The Journal of Minimally Invasive Gynecology
Received Date: 3 February 2016 Accepted Date: 4 February 2016
Please cite this article as: Api M, In Reply: Which cesarean scar defect should be treated; by which technique and by whom?, The Journal of Minimally Invasive Gynecology (2016), doi: 10.1016/ j.jmig.2016.02.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT In Reply: Which cesarean scar defect should be treated; by which technique and by whom?
RI PT
Api M1 1 Department of Obstetrics and Gynecology (Dr. Api), Zeynep Kamil Women and Children Diseases Training and Research Hospital
EP
TE D
M AN U
SC
We read with great interest the letter of Grace and Nezhat, in which they indorsed the recommendation of repairing the large uterine defects by our proposed technique, which completely restores the uterine wall preferentially via laparoscopy (1). The cesarean scar defect represents a wide spectrum of healing disorders from small indentation on the anterior uterine wall at the isthmic level to a rather large defect acting as a reservoir within the uterine wall and even a fistula formation. The symptoms seem most likely to be related to the severity of the defect. The reservoir at the defect which contains mucus, old blood, debris and inflammatory cells could be responsible from the clinical symptoms such as intermenstrual bleeding, dysmenorrhea, dyspareunia and infertility. There is an ongoing debate about the required size of the defect to cause these clinical symptoms and about the most appropriate treatment for repairing of the defect. Although successful hysteroscopic shaving of the reservoir entrance has been reported (2), large uterine defects accompanied with thin residual myometrial thickness cannot be restored via hysteroscopy. An utero- peritoneal fistula formation is the most severe form of cesarean scar defect, which can only be restored by an abdominal approach as stated by the authors (3). Laparoscopy seems to be a reasonable opportunity for better visualization and surgical correction of the defect. For complete restoration, all of the fistula tract or the reservoir wall has to be excised first and the healthy wound edges should be reapproximated by sutures. In a recent video presentation (4) where the surgeons have repaired a large and symptomatic cesarean scar defect which was consequently found to be recurred according to the ultrasonographic persistence of the defect and the patient’s clinical symptoms. The possible causes of failure of treatment were discussed with the surgeons and were proposed to be linked to excision of the thin anterior wall of the large reservoir base and approximation of the wound edges without removing the whole defect (personal communication with permission of Urman B & Taskiran C). In our view, the defect needs to be clearly demarcated preoperatively and for this purpose, a Hegar dilator placed into the endometrial cavity may help to guide the surgeon during the excision and repair of the whole defect (1). Our suggestions for treatment of a cesarean scar defect are as follows: 1.Asymptomatic patients should not be treated. 2.If the patient is symptomatic, the sonographic appearance of the defect or the “reservoir” should be large enough to explain the clinical symptoms. 3.If the residual myometrial thickness is thick enough, hysteroscopic repair can be the treatment of choice. 4.If the defect is large and the residual myometrial thickness is thin, laparoscopic repair should be preferred.
AC C
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49
1
ACCEPTED MANUSCRIPT 5.In case of a large and severe defect or a fistula formation, whole lesion should be excised and repaired by experienced surgeons.
RI PT
References 1. Api M, Boza A, Gorgen H, Api O. Should Cesarean Scar Defect Be Treated Laparoscopically? A Case Report and Review of the Literature. J Minim Invasive Gynecol. 2015;22(7):1145-52. 2. Raimondo G, Grifone G, Raimondo D, Seracchioli R, Scambia G, Masciullo V.Hysteroscopic treatment of symptomatic cesarean-induced isthmocele: a prospective study. J Minim Invasive Gynecol. 2015;22(2):297-301.
SC
3. Jacobson MT, Osias J, Velasco A, Charles R, Nezhat C.Laparoscopic repair of a uteroperitoneal fistula. JSLS. 2003;7(4):367-9.
EP
TE D
M AN U
4.https://www.youtube.com/watch?v=06tNMl8LhPM
AC C
50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66
2