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Single-incision laparoscopic repair of a cesarean scar defect
VIDEO
Single-incision laparoscopic repair of a cesarean scar defect Yingchun Ma, M.D., Ph.D.,a Jaden Kohn, M.D.,b Yiming Zhang, M.D., Ph.D.,c Zhenkun Guan, B.S.,d Ting Zhou, M.D.,a and Xiaoming Guan, M.D., Ph.D.b a
Department of Obstetrics and Gynaecology, Shandong Provincial Qianfoshan Hospital, Jinan, People's Republic of China; Minimally Invasive Surgery, Baylor College of Medicine, Houston, Texas; c Division of Reproductive Medicine, Jinan Central Hospital Group, Jinan City, People's Republic of China; and d Guangzhou Medical University, Guangzhou, People's Republic of China b
Objective: To evaluate the feasibility of laparoscopic single-incision repair for a cesarean scar defect (CSD). Design: Step-by-step explanation of surgery using an instructive video, with Institutional Review Board approval. Setting: University Hospital, Shandong Province, People's Republic of China. Patient(s): A 36-year-old G2P1011 woman presented with postmenstrual spotting and pelvic pain that was resistant to medical management. Transvaginal ultrasound revealed a CSD measuring 1.08 0.71 cm with a residual myometrial thickness of 1.5 mm. She desired to preserve fertility and had cosmetic concerns related to surgery. Intervention(s): We performed single-incision laparoscopic CSD repair. After abdominal entry, the overlying peritoneum and bladder adhesion were dissected using a monopolar hook, cold scissors, and a grasper. Diagnostic hysteroscopy was performed to identify CSD boundaries. Cold scissors were used to resect the scar tissue, avoiding the use of thermal energy to prevent injury that would impair wound healing. Closure was performed using 2/0 Ethibond suture (Ethicon); the first layer was a running full-thickness vertical suture, and the second layer was a horizontal mattress suture to reduce incisional tension. Single-incision intracorporeal knot tying was successfully accomplished by forming a triangle with the straight laparoscopic forceps and the articulated instrument. Main Outcome Measure(s): Successful repair of CSD via single-incision laparoscopic surgery. Result(s): Operative time was 50 minutes; blood loss was 50 mL. At the postoperative visit, the umbilical wound had properly healed with excellent cosmetic results. Abdominal ultrasound demonstrated that the CSD had disappeared. Cyclic menses resumed without postmenstrual spotting or pelvic pain. Conclusion(s): Our case suggests that single-incision laparoscopic repair is a feasible approach to treat CSD that can provide excellent cosmetic results. Additional studies should investigate the clinical utility of single-incision laparoscopic CSD repair in a larger sample to compare the outcomes with the vaginal and hysteroscopic approaches. (Fertil SterilÒ 2019;111:607–8. Ó2018 by American Society for Reproductive Medicine.) Use your smartphone El resumen está disponible en Español al final del artículo. Key Words: Single-site laparoscopic surgery, cesarean scar defects Discuss: You can discuss this article with its authors and other readers at https:// www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/41462-25718
NOW AVAILABLE ON YOUTUBE
2.
https://youtu.be/ck1ROwQmULg
SUGGESTED READING 1.
Tulandi T, Cohen A. Emerging manifestations of cesarean scar defect in reproductive-aged women. J Minim Invasive Gynecol 2016;23:893–902.
3.
Bij de Vaate AJ, van der Voet LF, Naji O, Witmer M, Veersema S, Brolmann HA, et al. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. Ultrasound Obstet Gynecol 2014;43:372–82. Huanxiao Z, Shuqin C, Hongye J, Hongzhe X, Gang N, Chengkang X, et al. Transvaginal hysterotomy for cesarean scar pregnancy in
Received February 1, 2018; revised and accepted November 27, 2018. Y.M. has nothing to disclose. J.K. has nothing to disclose. Y.Z. has nothing to disclose. Z.G. has nothing to disclose. T.Z. has nothing to disclose. X.G. is a speaker for Applied Medical, Rancho Santa Margarita, California. Reprint requests: Xiaoming Guan, M.D., Ph.D., Baylor College of Medicine, Minimally Invasive Gynecology Surgery, 6651 Main Street, 10th floor, Houston, Texas 77030 (E-mail: [email protected]).
to scan this QR code and connect to the video for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
40 consecutive cases. Gynecol Surg 2015; 12:45–51. 4. Xie W, Cao D, Yang J, Yu M, Shen K, Zhao L. Single-port vs multiport laparoscopic hysterectomy: a meta-analysis of randomized controlled trials. J Minim Invasive Gynecol 2016;23:1049–56. 5. Kliethermes C, Blazek K, Ali K, Nijjar JB, Kliethermes S, Guan X. Postoperative pain after single-site versus multiport hysterectomy. JSLS 2017;21. 6. Guan X, Liu J, Wang Y, Gisseman J, Guan Z, Kleithermes C. Laparoscopic single-incision supracervical hysterectomy for an extremely large uterus with bag tissue extraction. J Minim Invasive Gynecol 2018; 25:768.
Fertility and Sterility® Vol. 111, No. 3, March 2019 0015-0282/$36.00 Copyright ©2018 American Society for Reproductive Medicine, Published by Elsevier Inc. https://doi.org/10.1016/j.fertnstert.2018.11.039 VOL. 111 NO. 3 / MARCH 2019
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VIDEO Reparacion laparoscopica mediante incision unica de un defecto de cicatriz de la ces area nica para un defecto de cicatriz de la cesarea (CSD). Objetivo: Evaluar la viabilidad de la reparaci on laparoscopica mediante incisi on u ~o: Explicaci Disen on paso a paso de la cirugía mediante un video instructivo, con la aprobaci on del Consejo Institucional de Revisiones. Entorno: Hospital Universitario, provincia de Shandong, Rep ublica Popular China. Paciente(s): Una mujer G2P1011 de 36 a~ nos de edad que presentaba spotting postmenstrual y dolor pelvico resistente al tratamiento medico. La ecografía transvaginal revel o un CSD que medía 1.08 x 0.71 cm con un grosor miometrial residual de 1.5 mm. Deseaba preservar fertilidad y tenía preocupaciones esteticas relacionadas con la cirugía. nica del CSD. Tras la entrada abdominal, se diseccionaron Intervencion(es): Realizamos reparaci on laparoscopica mediante incisi on u el revestimiento peritoneal y la adhesi on vesical utilizando un asa monopolar, tijeras frías y una pinza. Se realiz o histeroscopia diagn ostica para identificar los límites del CSD. Se utilizaron tijeras frías para resecar el tejido cicatricial, evitando el uso de energía termica para prevenir lesiones que dificultarían la cicatrizacion. El cierre se realiz o mediante sutura de Ethibond 2/0 (Ethicon); La primera capa era una sutura vertical de espesor completo, y la segunda capa era una sutura de colch on horizontal para reducir la tensi on de la incisi on. nica formando un triangulo con las pinzas laparosc Se logr o realizar con exito nudo intracorp oreo de incisi on u opicas rectas y el instrumental articulado. nica. Principales medidas de resultado: Reparaci on exitosa del CSD mediante cirugía laparosc opica de incisi on u Resultados: El tiempo operatorio fue de 50 minutos; La perdida de sangre fue de 50 mL. En la visita postoperatoria, la herida umbilical se había curado adecuadamente con excelentes resultados esteticos. La ecografía abdominal demostr o que el CSD había desaparecido. Las menstruaciones cíclicas se reanudaron sin spotting postmenstruales o dolor pelvico. nica es un enfoque factible para tratar la CSD que puede Conclusion: Nuestro caso sugiere que la reparaci on laparosc opica de incisi on u nica con reparaci dar excelentes resultados esteticos. Estudios adicionales deberían investigar la utilidad clínica de la incisi on u on laparosc opica de CSD en una muestra mayor para comparar los resultados con los abordajes vaginales e histerosc opicos.
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VOL. 111 NO. 3 / MARCH 2019
Single-incision laparoscopic repair of a cesarean scar defect Yingchun Ma, M.D., Ph.D.,a Jaden Kohn, M.D.,b Yiming Zhang, M.D., Ph.D.,c Zhenkun Guan, B.S.,d Ting Zhou, M.D.,a and Xiaoming Guan, M.D., Ph.D.b a
Department of Obstetrics and Gynaecology, Shandong Provincial Qianfoshan Hospital, Jinan, People's Republic of China; Minimally Invasive Surgery, Baylor College of Medicine, Houston, Texas; c Division of Reproductive Medicine, Jinan Central Hospital Group, Jinan City, People's Republic of China; and d Guangzhou Medical University, Guangzhou, People's Republic of China b
Objective: To evaluate the feasibility of laparoscopic single-incision repair for a cesarean scar defect (CSD). Design: Step-by-step explanation of surgery using an instructive video, with Institutional Review Board approval. Setting: University Hospital, Shandong Province, People's Republic of China. Patient(s): A 36-year-old G2P1011 woman presented with postmenstrual spotting and pelvic pain that was resistant to medical management. Transvaginal ultrasound revealed a CSD measuring 1.08 0.71 cm with a residual myometrial thickness of 1.5 mm. She desired to preserve fertility and had cosmetic concerns related to surgery. Intervention(s): We performed single-incision laparoscopic CSD repair. After abdominal entry, the overlying peritoneum and bladder adhesion were dissected using a monopolar hook, cold scissors, and a grasper. Diagnostic hysteroscopy was performed to identify CSD boundaries. Cold scissors were used to resect the scar tissue, avoiding the use of thermal energy to prevent injury that would impair wound healing. Closure was performed using 2/0 Ethibond suture (Ethicon); the first layer was a running full-thickness vertical suture, and the second layer was a horizontal mattress suture to reduce incisional tension. Single-incision intracorporeal knot tying was successfully accomplished by forming a triangle with the straight laparoscopic forceps and the articulated instrument. Main Outcome Measure(s): Successful repair of CSD via single-incision laparoscopic surgery. Result(s): Operative time was 50 minutes; blood loss was 50 mL. At the postoperative visit, the umbilical wound had properly healed with excellent cosmetic results. Abdominal ultrasound demonstrated that the CSD had disappeared. Cyclic menses resumed without postmenstrual spotting or pelvic pain. Conclusion(s): Our case suggests that single-incision laparoscopic repair is a feasible approach to treat CSD that can provide excellent cosmetic results. Additional studies should investigate the clinical utility of single-incision laparoscopic CSD repair in a larger sample to compare the outcomes with the vaginal and hysteroscopic approaches. (Fertil SterilÒ 2019;111:607–8. Ó2018 by American Society for Reproductive Medicine.) Use your smartphone El resumen está disponible en Español al final del artículo. Key Words: Single-site laparoscopic surgery, cesarean scar defects Discuss: You can discuss this article with its authors and other readers at https:// www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/41462-25718
NOW AVAILABLE ON YOUTUBE
2.
https://youtu.be/ck1ROwQmULg
SUGGESTED READING 1.
Tulandi T, Cohen A. Emerging manifestations of cesarean scar defect in reproductive-aged women. J Minim Invasive Gynecol 2016;23:893–902.
3.
Bij de Vaate AJ, van der Voet LF, Naji O, Witmer M, Veersema S, Brolmann HA, et al. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. Ultrasound Obstet Gynecol 2014;43:372–82. Huanxiao Z, Shuqin C, Hongye J, Hongzhe X, Gang N, Chengkang X, et al. Transvaginal hysterotomy for cesarean scar pregnancy in
Received February 1, 2018; revised and accepted November 27, 2018. Y.M. has nothing to disclose. J.K. has nothing to disclose. Y.Z. has nothing to disclose. Z.G. has nothing to disclose. T.Z. has nothing to disclose. X.G. is a speaker for Applied Medical, Rancho Santa Margarita, California. Reprint requests: Xiaoming Guan, M.D., Ph.D., Baylor College of Medicine, Minimally Invasive Gynecology Surgery, 6651 Main Street, 10th floor, Houston, Texas 77030 (E-mail: [email protected]).
to scan this QR code and connect to the video for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
40 consecutive cases. Gynecol Surg 2015; 12:45–51. 4. Xie W, Cao D, Yang J, Yu M, Shen K, Zhao L. Single-port vs multiport laparoscopic hysterectomy: a meta-analysis of randomized controlled trials. J Minim Invasive Gynecol 2016;23:1049–56. 5. Kliethermes C, Blazek K, Ali K, Nijjar JB, Kliethermes S, Guan X. Postoperative pain after single-site versus multiport hysterectomy. JSLS 2017;21. 6. Guan X, Liu J, Wang Y, Gisseman J, Guan Z, Kleithermes C. Laparoscopic single-incision supracervical hysterectomy for an extremely large uterus with bag tissue extraction. J Minim Invasive Gynecol 2018; 25:768.
Fertility and Sterility® Vol. 111, No. 3, March 2019 0015-0282/$36.00 Copyright ©2018 American Society for Reproductive Medicine, Published by Elsevier Inc. https://doi.org/10.1016/j.fertnstert.2018.11.039 VOL. 111 NO. 3 / MARCH 2019
607
VIDEO Reparacion laparoscopica mediante incision unica de un defecto de cicatriz de la ces area nica para un defecto de cicatriz de la cesarea (CSD). Objetivo: Evaluar la viabilidad de la reparaci on laparoscopica mediante incisi on u ~o: Explicaci Disen on paso a paso de la cirugía mediante un video instructivo, con la aprobaci on del Consejo Institucional de Revisiones. Entorno: Hospital Universitario, provincia de Shandong, Rep ublica Popular China. Paciente(s): Una mujer G2P1011 de 36 a~ nos de edad que presentaba spotting postmenstrual y dolor pelvico resistente al tratamiento medico. La ecografía transvaginal revel o un CSD que medía 1.08 x 0.71 cm con un grosor miometrial residual de 1.5 mm. Deseaba preservar fertilidad y tenía preocupaciones esteticas relacionadas con la cirugía. nica del CSD. Tras la entrada abdominal, se diseccionaron Intervencion(es): Realizamos reparaci on laparoscopica mediante incisi on u el revestimiento peritoneal y la adhesi on vesical utilizando un asa monopolar, tijeras frías y una pinza. Se realiz o histeroscopia diagn ostica para identificar los límites del CSD. Se utilizaron tijeras frías para resecar el tejido cicatricial, evitando el uso de energía termica para prevenir lesiones que dificultarían la cicatrizacion. El cierre se realiz o mediante sutura de Ethibond 2/0 (Ethicon); La primera capa era una sutura vertical de espesor completo, y la segunda capa era una sutura de colch on horizontal para reducir la tensi on de la incisi on. nica formando un triangulo con las pinzas laparosc Se logr o realizar con exito nudo intracorp oreo de incisi on u opicas rectas y el instrumental articulado. nica. Principales medidas de resultado: Reparaci on exitosa del CSD mediante cirugía laparosc opica de incisi on u Resultados: El tiempo operatorio fue de 50 minutos; La perdida de sangre fue de 50 mL. En la visita postoperatoria, la herida umbilical se había curado adecuadamente con excelentes resultados esteticos. La ecografía abdominal demostr o que el CSD había desaparecido. Las menstruaciones cíclicas se reanudaron sin spotting postmenstruales o dolor pelvico. nica es un enfoque factible para tratar la CSD que puede Conclusion: Nuestro caso sugiere que la reparaci on laparosc opica de incisi on u nica con reparaci dar excelentes resultados esteticos. Estudios adicionales deberían investigar la utilidad clínica de la incisi on u on laparosc opica de CSD en una muestra mayor para comparar los resultados con los abordajes vaginales e histerosc opicos.
608
VOL. 111 NO. 3 / MARCH 2019