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Laparoscopic Isthmocele Repair with Hysteroscopic Assistance
Accepted Manuscript Title: Laparoscopic Isthmocele Repair with Hysteroscopic Assistance Author: Elena Suarez Salvador, Cecilia Haladjian, Melissa Bradbury, Montserrat Cubo- Abert, Laura Manalich Barrachina, Eva Vila Escude, Oriol Puig Puig, Antonio Gil Moreno PII: DOI: Reference:
S1553-4650(17)31228-1 https://doi.org/doi:10.1016/j.jmig.2017.10.005 JMIG 3301
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
19-9-2017 3-10-2017 5-10-2017
Please cite this article as: Elena Suarez Salvador, Cecilia Haladjian, Melissa Bradbury, Montserrat Cubo- Abert, Laura Manalich Barrachina, Eva Vila Escude, Oriol Puig Puig, Antonio Gil Moreno, Laparoscopic Isthmocele Repair with Hysteroscopic Assistance, The Journal of Minimally Invasive Gynecology (2017), https://doi.org/doi:10.1016/j.jmig.2017.10.005. 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.
TITLE Laparoscopic isthmocele repair with hysteroscopic assistance AUTHORS 1. Suarez Salvador, Elena MD, Department of minimally invasive Gynecology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 2. Haladjian, Cecilia MD, Department of minimally invasive Gynecology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 3. Bradbury, Melissa MD, Vall d’Hebron Research Institute, Barcelona, Spain [email protected] 4. Cubo- Abert, Montserrat MD, Department of minimally invasive Gynecology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 5. Manalich Barrachina, Laura MD, Department of minimally invasive Gynecology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 6. Vila Escude, Eva MD, Department of minimally invasive Gynecology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 7. Puig Puig, Oriol MD, Department of surgery Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 8. Gil Moreno, Antonio MD, PhD, Department of Gynecology Oncology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] Corresponding autor Cecilia Haladjian [email protected] IRB Our institutional review board ruled that approval was not required for this study. Written and oral informed consent was obtained for surgery and case publication.
Page 1 of 5
Disclosure Dr. Haladjian has nothing to disclose.
Key words: cesarean scar defect, niche, residual myometrium thickness, complication of cesarean section
Objective To show our experience with the hysteroscopic assistance in the laparoscopic repair of an isthmocele.
Design Surgical video article. Canadian task force III
Setting University hospital
Intervention A 42-year-old patient, with previous caesarean section, presented as an emergency with a large overinfected isthmocele. Once infection was cured with antibiotics sonography revealed a 23*14mm isthmocele with 1.4mm residual myometrium thickness. She had been having for several years postmenstrual spotting and dysmenorrhea. She had previous dyspareunia worsened after caesarean section. As she had a symptomatic isthmocele with thin residual myometrium and childbearing desire laparoscopic repair was offered. Firstly, bladder was dissected to expose the isthmus. Uterine arteries were dissected. Hysteroscopic guidance and transillumination showed the defect’s edges. The
Page 2 of 5
isthmocele and fibrotic tissue were excised with cold scissors minimizing cauterization. A hysterometer was placed in the uterine cavity to respect the cervical canal and posterior uterine wall, the myometrium was then closed in two layers. Surgical time was 120 minutes. The postoperative period was uneventful. Two months after surgery sonography confirmed restoration, myometrium thickness was 8.3mm. She was asymptomatic, except for dyspareunia. Six months after surgery hysteroscopy was normal. We recommended not attempting pregnancy for nine months.
Conclusion Hysteroscopic simultaneous assistance during laparoscopic isthmocele repair can be of great help to identify the defect’s edges, especially in large cavities and in the first cases as limits could not be clear. It’s important to resect all the fibrotic tissue but respecting healthy myometrium. Excessive cauterization and ischemic sutures could prevent myometrium’s correct healing.
References
Marotta M L, Donnez J, Squifflet J, Jadoul P, Darii N, Donnez O. Laparoscopic repair of post-cesarean section uterine scar defects diagnosed in nonpregnant women. J Minim Invasive Gynecol. 2013 Aimi G, Buggio L, Berlanda N, Vercellini P. Laparoscopic repair of a symptomatic postcesarean section isthmocele: a video case report. Fertil Steril. 2017 Nezhat C, Grace L, Soliemannjad R, Meshkat Razavi G, Nezhat A. Cesarean scar defect: What is it and how should it be treated? OBG Manag. 2016 Donnez MD et al. Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of 38 women. Fertility and Sterility, 2017
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Nirgianakis K, Oehler R, Mueller M. The Rendez-vous technique for treatment of caesarean scar defects: a novel combined endoscopic approach. Surg Endosc. 2016
Page 4 of 5
video still.jpg
Page 5 of 5
S1553-4650(17)31228-1 https://doi.org/doi:10.1016/j.jmig.2017.10.005 JMIG 3301
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
19-9-2017 3-10-2017 5-10-2017
Please cite this article as: Elena Suarez Salvador, Cecilia Haladjian, Melissa Bradbury, Montserrat Cubo- Abert, Laura Manalich Barrachina, Eva Vila Escude, Oriol Puig Puig, Antonio Gil Moreno, Laparoscopic Isthmocele Repair with Hysteroscopic Assistance, The Journal of Minimally Invasive Gynecology (2017), https://doi.org/doi:10.1016/j.jmig.2017.10.005. 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.
TITLE Laparoscopic isthmocele repair with hysteroscopic assistance AUTHORS 1. Suarez Salvador, Elena MD, Department of minimally invasive Gynecology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 2. Haladjian, Cecilia MD, Department of minimally invasive Gynecology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 3. Bradbury, Melissa MD, Vall d’Hebron Research Institute, Barcelona, Spain [email protected] 4. Cubo- Abert, Montserrat MD, Department of minimally invasive Gynecology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 5. Manalich Barrachina, Laura MD, Department of minimally invasive Gynecology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 6. Vila Escude, Eva MD, Department of minimally invasive Gynecology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 7. Puig Puig, Oriol MD, Department of surgery Vall d’Hebron University Hospital, Barcelona, Spain [email protected] 8. Gil Moreno, Antonio MD, PhD, Department of Gynecology Oncology, Vall d’Hebron University Hospital, Barcelona, Spain [email protected] Corresponding autor Cecilia Haladjian [email protected] IRB Our institutional review board ruled that approval was not required for this study. Written and oral informed consent was obtained for surgery and case publication.
Page 1 of 5
Disclosure Dr. Haladjian has nothing to disclose.
Key words: cesarean scar defect, niche, residual myometrium thickness, complication of cesarean section
Objective To show our experience with the hysteroscopic assistance in the laparoscopic repair of an isthmocele.
Design Surgical video article. Canadian task force III
Setting University hospital
Intervention A 42-year-old patient, with previous caesarean section, presented as an emergency with a large overinfected isthmocele. Once infection was cured with antibiotics sonography revealed a 23*14mm isthmocele with 1.4mm residual myometrium thickness. She had been having for several years postmenstrual spotting and dysmenorrhea. She had previous dyspareunia worsened after caesarean section. As she had a symptomatic isthmocele with thin residual myometrium and childbearing desire laparoscopic repair was offered. Firstly, bladder was dissected to expose the isthmus. Uterine arteries were dissected. Hysteroscopic guidance and transillumination showed the defect’s edges. The
Page 2 of 5
isthmocele and fibrotic tissue were excised with cold scissors minimizing cauterization. A hysterometer was placed in the uterine cavity to respect the cervical canal and posterior uterine wall, the myometrium was then closed in two layers. Surgical time was 120 minutes. The postoperative period was uneventful. Two months after surgery sonography confirmed restoration, myometrium thickness was 8.3mm. She was asymptomatic, except for dyspareunia. Six months after surgery hysteroscopy was normal. We recommended not attempting pregnancy for nine months.
Conclusion Hysteroscopic simultaneous assistance during laparoscopic isthmocele repair can be of great help to identify the defect’s edges, especially in large cavities and in the first cases as limits could not be clear. It’s important to resect all the fibrotic tissue but respecting healthy myometrium. Excessive cauterization and ischemic sutures could prevent myometrium’s correct healing.
References
Marotta M L, Donnez J, Squifflet J, Jadoul P, Darii N, Donnez O. Laparoscopic repair of post-cesarean section uterine scar defects diagnosed in nonpregnant women. J Minim Invasive Gynecol. 2013 Aimi G, Buggio L, Berlanda N, Vercellini P. Laparoscopic repair of a symptomatic postcesarean section isthmocele: a video case report. Fertil Steril. 2017 Nezhat C, Grace L, Soliemannjad R, Meshkat Razavi G, Nezhat A. Cesarean scar defect: What is it and how should it be treated? OBG Manag. 2016 Donnez MD et al. Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of 38 women. Fertility and Sterility, 2017
Page 3 of 5
Nirgianakis K, Oehler R, Mueller M. The Rendez-vous technique for treatment of caesarean scar defects: a novel combined endoscopic approach. Surg Endosc. 2016
Page 4 of 5
video still.jpg
Page 5 of 5