Laparoscopic Repair of a Deep Cesarean Scar Defect Guided by Hysteroscopy: Surgical Technique

Abstract

<h3>Study Objective</h3> To show a uterus-preserving surgical technique in a patient with a deep cesarean scar defect. <h3>Design</h3> A technical video showing a laparoscopic isthmoplasty guided by hysteroscopy. <h3>Setting</h3> A tertiary referral hospital. For surgery, the patient was placed in dorsal modified lithotomy position. The surgeon was on the patient's left side, the first assistant on the right, and the second assistant between the patient's legs to perform the hysteroscopy. <h3>Patients or Participants</h3> A 41-year-old woman, with a history of two cesarean sections, was referred to our gynecological department for symptomatic isthmocele with abnormal uterine bleeding and abdominal pain. At MRI examination, it was identified a cesarean scar defect of 34 mm length x 34mm depth x 48mm of transverse diameter, with a residual myometrial thickness of 1.7 mm. <h3>Interventions</h3> The procedure started with the resection of adhesions between the uterus and the abdominal wall, followed by cautious mobilization of the bladder below the external cervical os. The cesarean scar was excised until healthy myometrium was identified, guided by transillumination with hysteroscopy. Afterwards, an hysterometer was used to facilitate the myometrial repair, which was performed with two layers of interrupted 2-0 absorbable multifilament suture. An hysteroscopic control was done, using physiological solution with methylene blue as distensor media, which ensured, with a laparoscopic view, that there were no leaks. Finally, the uterine plastic was covered by a peritoneal flap. <h3>Measurements and Main Results</h3> Operating time was of 140 minutes. The postoperative course was uneventful, and the patient was discharged on the first postoperative day. The patient reported resolution of postmenstrual spotting and abdominal pain. <h3>Conclusion</h3> Laparoscopic repair of a deep cesarean scar defect guided by hysteroscopy, is a feasible surgery and it should be considered as an alternative to hysterectomy in women who want to preserve the uterus.