8442 Isthmocele Repair in Unusual Presentations

Abstract

<h3>Study Objective</h3> To demonstrate unusual clinical presentations and surgical management of isthmocele. <h3>Design</h3> Surgical video. Two cases are presented of women with unusual presentations undergoing isthmocele repair. One video demonstrates a robot-assisted and hysteroscopic repair, while the other is a laparoscopic and hysteroscopic repair. <h3>Setting</h3> Academic tertiary care hospital. <h3>Patients or Participants</h3> A 30-year-old G1P1and a 33-year-old G1P1 were referred to a minimally invasive gynecologic surgeon for pelvic pain and abnormal uterine bleeding. <h3>Interventions</h3> The first patient was referred for evaluation of dysmenorrhea and dyspareunia. She had a known history of an emergent cesarean delivery. MRI demonstrated findings concerns for isthmocele. She underwent a hysteroscopy, robotic-assisted excision of endometriosis and isthmocele repair. The second patient was referred 3 months after her delivery for abnormal uterine bleeding. She presented with persistent abnormal uterine bleeding. Her cesarean was complicated by a left extension and postoperative hemorrhage leading to IR coiling of her left uterine artery and a take-back exploratory laparotomy for hemoperitoneum. MRI report described myometrial blood products continuous with the endometrial lining. She underwent a concomitant hysteroscopy and laparoscopic isthmocele repair. Given the left lateral location of her defect near the uterine insertion of the uterine artery, the left uterine artery was clipped at its origin during the surgery as a precautionary measure. The clip was later removed upon completion of the repair. During her surgery, an endometrioma was noted to overly the c-section scar defect. Both patients had full recoveries and were cleared for pregnancy 6 months after the repair. <h3>Measurements and Main Results</h3> Office hysteroscopy after both the procedures demonstrated no further appreciable defects. <h3>Conclusion</h3> Isthmocele presentations vary. Isthmoceles should remain high on a differential when working up a patient with post-partum pelvic pain and abnormal bleeding. Concomitant use of hysteroscopy during laparoscopic or robotic repair of isthmocele is recommended.