2144 Robotic Isthmocele Repair of a Big Cesarean Scar Defect - A Feasible Technique

Abstract

Video Objective Describe a robotic isthmocele repair of a big cesarean section scar defect. Setting Isthmocele is a reservoir, pouchlike defect, at the site of a previous cesarean section, normally resulted of a cesarean scar defect or dehiscence. Its prevalence may be underestimated. A rare, but important repercussion, is cervical scar pregnancy, one of the rarest forms of ectopic pregnancy, with a high risk of uterine rupture and haemorrhage. Half of the cases occurs to patients who had only one prior caesarea. Isthmocele's treatment must be chosen among different alternatives (hysteroscopic, vaginal, laparotomic, laporoscopic), considering symptoms, plans for future conception, and the size of the defect. Isthmocele resection with myometrium myoplastia must be considered if the residual myometrium thickness is less than 3 mm. Interventions A 38-year old woman, with 1 previous cesarean section and 1 cervical scar ectopic pregnancy treated with methotrexate 8 months ago, preparing to concieve, presented with a large isthmocele. Preoperative MRI exhibited a 26 × 22 mm defect, with a 1 mm remaining myometrium. A robotic approach was used to identify the cervical niche, using a uterine manipulator with its tip balloon placed downwards, right above the internal cervical orifice. After correct identification, the bladder was caudally dissected and the uterine isthmus limits were completed exposed. The isthmocele was resected. All connective tissue was enucleated until vivid myometrium was seem all over its circumference. The defect was closed in two layers with 2.0 vicryl interrupted sutures. Conclusion Robotic isthmocele repair is a feasible technique when correctly chosen. Due to the raising number of cesarean sections, gynecologists will face this problem more frequently and must be aware of its indications as well as different approaches.