Laparoscopic Management of Type 2 Cesarean Scar Pregnancies - Planning and Procedural Execution

Abstract

<h3>Study Objective</h3> With increasing caesarean deliveries, Caesarean scar pregnancies CSP are also on the rise. We report our experience from successful laparoscopic management of type 2 exogenic CSPs which invades deep, projects into the vesicouterine fold and has the dangerous potential for rupture and massive hemorrhage. <h3>Design</h3> NA. <h3>Setting</h3> tertiary referral center. <h3>Patients or Participants</h3> four women confirmed to have type 2 cesarean scar pregnancy. <h3>Interventions</h3> MRI was done for preoperative planning to clearly define the sac, note dehiscence of scar and adherence of uterine corpus to anterior abdominal wall. This spatial resolution gave a good mental picture. At Laparoscopy, first adhesions are released and round ligaments divided temporarily, giving better access to lower uterine segment for surgery and suturing. Prior to making an incision on the uterus, the complete scar with sac inside is exposed till the anterior cervix. Careful controlled dissection avoids excessive bleeding and staining, which could result in loss of anatomic orientation and even panic. Bilateral uterine artery occlusion and Local injection of vasopressin are interventions used for decreasing bleeding from otherwise highly vascular gravid uterus. After complete resection and removal of the products, Full thickness, equidistant repair of LUS defect is aided by barbed suture. A Hegar's dilator placed in situ during the suturing phase prevents accidental approximation of uterine walls. Here we humbly acknowledge that we have managed laparoscopically one of the most advanced CSP reported so far at 16 weeks gestational age. <h3>Measurements and Main Results</h3> all four women had procedures accomplished laparoscopically, with complete resection of the type 2 CSPs and satisfactory reconstruction of defect, also received the benefits of the minimally invasive surgery such as less pain, less scar and rapid return to work. <h3>Conclusion</h3> Laparoscopy here is proven safe and effective, in view of excellent visualization, complete removal of pathology, good reconstruction of the defect, and should be the choice where facilities exist.