Cesarean Section Scar Ectopic: Laparoscopic and Hysteroscopic Surgical Management

Abstract

Study Objective To present a case of resection of cesarean section scar ectopic pregnancy with isthmocele repair using both laparoscopic and hysteroscopic techniques. Design N/A Setting Patient was positioned in the standard dorsal lithotomy position. Throughout the entirety of the video the patient is in Trendelenburg position. Patients or Participants A 25 yo G7P3124 who was diagnosed with a c-section scar ectopic pregnancy via 5w4d ultrasound after presenting with vaginal bleeding and abdominal pain. After being counseled on options for medical versus surgical management, she was initially treated with a dose of methotrexate. Upon further discussion the patient was transferred and opted for surgical management. Interventions In anticipation of potential significant blood loss, a laparoscopic tourniquet was placed at the lower uterine segment and the uterine arteries were skeletonized for easy ligation. A bladder flap was made at the level the vesicouterine peritoneum. The ectopic products of conception were removed hysteroscopically. The isthmocele was then resected and repaired laparoscopically. Finally, hysteroscopic inspection was used to confirm normal contour of the uterus and isthmocele repair. Measurements and Main Results Our patient underwent uncomplicated laparoscopic and hysteroscopic resection of cesarean section scar ectopic with isthmocele repair with minimal blood loss. She was discharged from PACU and was doing well at one week follow up. Conclusion There is currently no standard of care for management of cesarean section scar ectopic. When opting for surgical management it is important to anticipate possible complications, including dense adhesions and hemorrhage. In this video we provide a detailed combined hysteroscopic and laparoscopic approach to removal of cesarean scar ectopic. Techniques to minimize blood loss and reduce injury to surrounding organs are highlighted; including bladder distension, laparoscopic tourniquet, and uterine artery skeletonization. Anticipating and mitigating potential complications with these techniques leads to an optimal outcome.