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Laparoscopic repair of a symptomatic post–cesarean section isthmocele: a video case report
VIDEO
Laparoscopic repair of a symptomatic post–cesarean section isthmocele: a video case report Giorgio Aimi, M.D., Laura Buggio, M.D., Nicola Berlanda, M.D., and Paolo Vercellini, M.D. Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a Carattere Unita degli Studi di Milano, Milan, Italy Scientifico Ca’ Granda Ospedale Maggiore Policlinico and Universita
Objective: To describe our technique for laparoscopic management of post–cesarean section isthmocele. Design: Surgical video article. Local Institutional Review Board approval for the video reproduction has been obtained. Setting: University hospital. Patient(s): A 36-year-old patient with a history of two previous cesarean deliveries. She complained of persistent postmenstrual spotting and chronic pelvic pain. At transvaginal ultrasound examination, a cesarean scar defect of 20.0 15.6 mm was identified, with a residual myometrial thickness over the defect of 2.6 mm. Main Outcome Measure(s): Repair of isthmocele and relief of pain. Intervention(s): Isthmocele excision and myometrial repair was performed laparoscopically. The first step of the procedure was the cautious mobilization of the bladder from its adhesions with the site of the previous cesarean scar. Subsequently, the isthmocele site was identified with the aid of intraoperative transrectal ultrasonography. Transrectal ultrasonographic assistance is particularly important when a bulge of the cesarean scar is not laparoscopically visible. Once identified, the isthmocele pouch was incised and its pitchy content drained. Then the cesarean scar was excised with cold scissors, avoiding cauterization to reduce the risk of tissue necrosis. This step is considered completed when the whitish scar tissue of the isthmocele site margins are no longer present and reddish healthy myometrium is visualized. Before suturing the defect, a Hegar dilator was placed into the cervix with the aim of maintaining the continuity between the cervical canal and the uterine cavity. Then, the myometrial repair was performed with the use of a single layer of interrupted 2-0 Vycril sutures. To limit tissue ischemia, we prefer not to add a second layer of sutures. Finally, the visceral peritoneum defect was closed, with the aim of restoring the physiologic uterine anatomy. In this case, multiple peritoneal endometriotic implants were also identified and excised. Result(s): Operating time was 70 minutes. The postoperative course was uneventful and the patient was discharged on postoperative day 2. At 40-day postoperative follow-up, transvaginal and transabdominal ultrasonography showed complete anatomic repair of the uterine defect. At 3-month follow-up, the patient reported resolution of postmenstrual spotting and chronic pelvic pain. Conclusion(s): Good reproductive outcomes have been reported after hysteroscopic treatment of uterine isthmocele. However, laparoscopy has the advantage over hysteroscopy of allowing thorough repair of the uterine defect, thus restoring a normal myometrial thickness. Therefore, as demonstrated in this case, a laparoscopic approach might be considered to be the procedure of choice for the repair of a large uterine isthmocele with extreme thinning of the residual myometrium. (Fertil SterilÒ 2017;-:-–-. Ó2017 by American Society for Reproductive Medicine.) Key Words: Isthmocele, cesarean scar defect, laparoscopy, complication of cesarean, cesarean section, niche Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/ 16110-fertility-and-sterility/posts/15835-23737
NOW AVAILABLE ON YOUTUBE https://youtu.be/o3fnvUvSqyg
SUGGESTED READING 1.
Donnez O, Donnez J, Orellana R, Dolmans MM. Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in
a series of 38 women. Fertil Steril 2016;107: 289–96.e2. 2. Nezhat C, Falik R, Li A. Surgical management of niche, isthmocele, uteroperitoneal fistula, or
Received January 17, 2017; revised April 5, 2017; accepted April 6, 2017. G.A. has nothing to disclose. L.B. has nothing to disclose. N.B. has nothing to disclose. P.V. has nothing to disclose. e della Ricerca to Fondazione Istituto di Ricovero e Cura Supported by Italian fiscal contribution ‘‘51000’’ from the Ministero dell’Istruzione, dell’Universita a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy. Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a CarReprint requests: Laura Buggio, M.D., Unita degli Studi di Milano, Via Commenda, 12, Milan 20122, Italy (E-mail: attere Scientifico Ca’ Granda Ospedale Maggiore Policlinico and Universita [email protected]). Fertility and Sterility® Vol. -, No. -, - 2017 0015-0282/$36.00 Copyright ©2017 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2017.04.004 VOL. - NO. - / - 2017
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VIDEO
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cesarean scar defect: a critical rebirth in the medical literature. Fertil Steril 2016;107:69–71. ski K, Romanek K, Filipczak A, Rechberger T. When and Futyma K, Ga1czyn how should we treat cesarean scar defect—isthmocoele? Gynekol Pol 2016;87:664–8. Urman B, Arslan T, Aksu S, Taskiran C. Laparoscopic Repair of cesarean scar defect ‘‘isthmocele’’. J Minim Invasive Gynecol 2016;23: 857–8.
5. 6.
7.
Tulandi T, Cohen A. Emerging manifestations of cesarean scar defect in reproductive aged women. J Minim Invasive Gynecol 2016;23:893–902. 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;22:1145–52. Gubbini G, Centini G, Nascetti D, Marra E, Moncini I, Bruni L, et al. Surgical hysteroscopic treatment of cesarean-induced isthmocele in restoring fertility: prospective study. J Minim Invasive Gynecol 2011;18:234–7.
VOL. - NO. - / - 2017
Laparoscopic repair of a symptomatic post–cesarean section isthmocele: a video case report Giorgio Aimi, M.D., Laura Buggio, M.D., Nicola Berlanda, M.D., and Paolo Vercellini, M.D. Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a Carattere Unita degli Studi di Milano, Milan, Italy Scientifico Ca’ Granda Ospedale Maggiore Policlinico and Universita
Objective: To describe our technique for laparoscopic management of post–cesarean section isthmocele. Design: Surgical video article. Local Institutional Review Board approval for the video reproduction has been obtained. Setting: University hospital. Patient(s): A 36-year-old patient with a history of two previous cesarean deliveries. She complained of persistent postmenstrual spotting and chronic pelvic pain. At transvaginal ultrasound examination, a cesarean scar defect of 20.0 15.6 mm was identified, with a residual myometrial thickness over the defect of 2.6 mm. Main Outcome Measure(s): Repair of isthmocele and relief of pain. Intervention(s): Isthmocele excision and myometrial repair was performed laparoscopically. The first step of the procedure was the cautious mobilization of the bladder from its adhesions with the site of the previous cesarean scar. Subsequently, the isthmocele site was identified with the aid of intraoperative transrectal ultrasonography. Transrectal ultrasonographic assistance is particularly important when a bulge of the cesarean scar is not laparoscopically visible. Once identified, the isthmocele pouch was incised and its pitchy content drained. Then the cesarean scar was excised with cold scissors, avoiding cauterization to reduce the risk of tissue necrosis. This step is considered completed when the whitish scar tissue of the isthmocele site margins are no longer present and reddish healthy myometrium is visualized. Before suturing the defect, a Hegar dilator was placed into the cervix with the aim of maintaining the continuity between the cervical canal and the uterine cavity. Then, the myometrial repair was performed with the use of a single layer of interrupted 2-0 Vycril sutures. To limit tissue ischemia, we prefer not to add a second layer of sutures. Finally, the visceral peritoneum defect was closed, with the aim of restoring the physiologic uterine anatomy. In this case, multiple peritoneal endometriotic implants were also identified and excised. Result(s): Operating time was 70 minutes. The postoperative course was uneventful and the patient was discharged on postoperative day 2. At 40-day postoperative follow-up, transvaginal and transabdominal ultrasonography showed complete anatomic repair of the uterine defect. At 3-month follow-up, the patient reported resolution of postmenstrual spotting and chronic pelvic pain. Conclusion(s): Good reproductive outcomes have been reported after hysteroscopic treatment of uterine isthmocele. However, laparoscopy has the advantage over hysteroscopy of allowing thorough repair of the uterine defect, thus restoring a normal myometrial thickness. Therefore, as demonstrated in this case, a laparoscopic approach might be considered to be the procedure of choice for the repair of a large uterine isthmocele with extreme thinning of the residual myometrium. (Fertil SterilÒ 2017;-:-–-. Ó2017 by American Society for Reproductive Medicine.) Key Words: Isthmocele, cesarean scar defect, laparoscopy, complication of cesarean, cesarean section, niche Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/ 16110-fertility-and-sterility/posts/15835-23737
NOW AVAILABLE ON YOUTUBE https://youtu.be/o3fnvUvSqyg
SUGGESTED READING 1.
Donnez O, Donnez J, Orellana R, Dolmans MM. Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in
a series of 38 women. Fertil Steril 2016;107: 289–96.e2. 2. Nezhat C, Falik R, Li A. Surgical management of niche, isthmocele, uteroperitoneal fistula, or
Received January 17, 2017; revised April 5, 2017; accepted April 6, 2017. G.A. has nothing to disclose. L.B. has nothing to disclose. N.B. has nothing to disclose. P.V. has nothing to disclose. e della Ricerca to Fondazione Istituto di Ricovero e Cura Supported by Italian fiscal contribution ‘‘51000’’ from the Ministero dell’Istruzione, dell’Universita a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy. Operativa Dipartimentale Ginecologia Chirurgica e Endometriosi, Fondazione Istituto di Ricovero e Cura a CarReprint requests: Laura Buggio, M.D., Unita degli Studi di Milano, Via Commenda, 12, Milan 20122, Italy (E-mail: attere Scientifico Ca’ Granda Ospedale Maggiore Policlinico and Universita [email protected]). Fertility and Sterility® Vol. -, No. -, - 2017 0015-0282/$36.00 Copyright ©2017 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2017.04.004 VOL. - NO. - / - 2017
e1
VIDEO
3.
4.
e2
cesarean scar defect: a critical rebirth in the medical literature. Fertil Steril 2016;107:69–71. ski K, Romanek K, Filipczak A, Rechberger T. When and Futyma K, Ga1czyn how should we treat cesarean scar defect—isthmocoele? Gynekol Pol 2016;87:664–8. Urman B, Arslan T, Aksu S, Taskiran C. Laparoscopic Repair of cesarean scar defect ‘‘isthmocele’’. J Minim Invasive Gynecol 2016;23: 857–8.
5. 6.
7.
Tulandi T, Cohen A. Emerging manifestations of cesarean scar defect in reproductive aged women. J Minim Invasive Gynecol 2016;23:893–902. 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;22:1145–52. Gubbini G, Centini G, Nascetti D, Marra E, Moncini I, Bruni L, et al. Surgical hysteroscopic treatment of cesarean-induced isthmocele in restoring fertility: prospective study. J Minim Invasive Gynecol 2011;18:234–7.
VOL. - NO. - / - 2017