Abstract
<h3>Study Objective</h3> Discuss advantages of ethylene vinyl alcohol copolymer (EVAC) use for uterine arterio-venous malformation (AVM). Demonstrate technique for vascular control during robotic repair of isthmocele. <h3>Design</h3> Video documentation of the surgical procedure (instructive video). <h3>Setting</h3> University of California, San Francisco Hospital operating room with patient placed in dorsal lithotomy positioning. <h3>Patients or Participants</h3> A 37-year-old woman, status-post embolization of uterine AVM, presenting with a 3.5 × 2.5 cm uterine isthmocele. <h3>Interventions</h3> Discuss embolization of a uterine AVM. Then, present a case of AVM with isthmocele, review the patient's imaging, and show a stepwise approach to the procedure. Hysteroscopy is performed to identify the isthmocele location and visualize the cavity post-embolization. The robotic platform was chosen as the mode of surgery. Entry into the retroperitoneum with transient occlusion of the uterine arteries is planned due to proximity of isthmocele to left uterine artery as seen on MRI. Once the pararectal space is entered the ureter is localized on the medial leaf of the broad ligament. The uterine artery is then isolated and skeletonized. This procedure is performed bilaterally. Vascular clamps are then placed on the uterine arteries at their respective origins. The bladder is also backfilled to aid in creation of a bladder flap given the history of c-section. With firefly technology, the borders of the isthmocele are identified. This area is resected, the residual copolymer is removed from the defect, and the hysterotomy is repaired in two layers using unidirectional barbed suture. At the conclusion of the case, the vascular clamps are removed and vascular supply is restored. <h3>Measurements and Main Results</h3> Isthmocele resection and repair was achieved with an estimated blood loss of 25mL. The patient's symptoms resolved. <h3>Conclusion</h3> Evaluation of pathology on pre-operative imaging can impact surgical approach. Transient occlusion of the uterine arteries can aid in repair of isthmocele with minimal blood loss.
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