Bridging the Gap: Robotic Approach to Isthmocele Dehiscence

Abstract

<h3>Study Objective</h3> To describe a minimally invasive fertility preserving approach to emergent surgery in the setting of an isthmocele dehiscence. <h3>Design</h3> Narrated video of surgical technique with descriptions of key steps. <h3>Setting</h3> Uterine isthmoceles are usually asymptomatic but can cause abnormal uterine bleeding, pain, secondary infertility and have been associated with uterine rupture or cesarean scar dehiscence. There have been only a few case reports of isthmocele dehiscence following uterine instrumentation. Often in cases of acute bleeding, an abdominal hysterectomy is performed. We present the case of a 36-year-old G2P1001 patient who underwent dilation & evacuation at 14 weeks for holoprosencephaly which was complicated by post-operative hypotension and vaginal bleeding. Emergent laparoscopic exploration revealed concealed bleeding leading to hematoma formation at the site of isthmocele dehiscence. The hematoma was evacuated and the isthmocele was resected and repaired, allowing for a uterine preserving procedure. <h3>Patients or Participants</h3> One patient was included in this case report. <h3>Interventions</h3> Robotic assisted laparoscopic hematoma evacuation and isthmocele repair was performed with 5 key interventions: 1. Bladder mobilization using sharp dissection and cautery 2. Dilute vasopressin injected circumferentially around isthmocele 3. Monopolar cautery used to refresh dilated edges of isthmocele 4. Uterine sound introduced into endometrial cavity to delineate anatomy 5. Defect repair with 2-0 barbed suture in multiple layers <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> In patients with a history of cesarean delivery, it is important to consider isthmocele dehiscence in the setting of post-procedural bleeding or hemodynamic instability. In cases of isthmocele dehiscence, specifically when there is concealed bleeding into the isthmocele, one could consider a uterine sparing minimally invasive approach. Hemodynamic stability of the patient, access to necessary resources, efficiency of ancillary staff, and surgeon experience are key factors for success in such surgical emergencies.