Robotic Assisted Laparoscopic Repair of Isthmocele

Abstract

Video Objective This video demonstrates the technique for a Robotic assisted laparoscopic repair of a large Isthmocele. Setting A 41-year-old G1P1 woman presented with secondary infertility and postmenstrual spotting. Her first spontaneous pregnancy ended by cesarean section delivery 5 years ago. She has a 3 years history of secondary infertility and failed Intracytoplasmic sperm injection (ICSI). Transvaginal ultrasound showed a wedge-shaped hypoechoic area in the myometrium at the level of the previous cesarean scar and Pelvic MRI confirmed the diagnosis of Isthmocele. Interventions Diagnostic hysteroscopy done prior to the Robotic assisted Laparoscopy for endometrial cavity assessment and localization of the cesarean scar defect showed an endometrium studded with black hemosiderin-like lesions, biopsy was taken. Then a Robotic assisted Laparoscopic surgery started with dissection of the vesicovaginal plane and resection of the isthmocele pouch. Complete excision of fibrotic tissues performed and a Hegar dilator was placed to maintain cervico-uterine patency. The defect was then repaired in 3 layers. For the first two layers 0-polyglactin (Vicryl®) was used for faster absorption of the suture material in contact with the endometrial cavity. The third layer was closed using 2-0 delayed absorbable barbed sutures (V-LocTM). An adhesion barrier was placed overlying the suture line. The operative time was 150 minutes and the patient had an uneventful postoperative recovery. Conclusion The pathology of the endometrial biopsy showed the unusual finding of endometrial glands filled with blood.The postoperative vaginal ultrasound confirmed a well re-approximated uterine wall, a myometrial thickness of 14 mm and a continuous and intact endometrial lining at 6 weeks postoperatively. At 3 months a flexible office hysteroscopy showed excellent repair, complete healing of the lower uterine defect and a normal endometrial cavity with resolution of the abnormal lesions.Post-operatively, the patient denied any post-menstrual spotting and conceived spontaneously 4 months after the repair. This video demonstrates the technique for a Robotic assisted laparoscopic repair of a large Isthmocele. A 41-year-old G1P1 woman presented with secondary infertility and postmenstrual spotting. Her first spontaneous pregnancy ended by cesarean section delivery 5 years ago. She has a 3 years history of secondary infertility and failed Intracytoplasmic sperm injection (ICSI). Transvaginal ultrasound showed a wedge-shaped hypoechoic area in the myometrium at the level of the previous cesarean scar and Pelvic MRI confirmed the diagnosis of Isthmocele. Diagnostic hysteroscopy done prior to the Robotic assisted Laparoscopy for endometrial cavity assessment and localization of the cesarean scar defect showed an endometrium studded with black hemosiderin-like lesions, biopsy was taken. Then a Robotic assisted Laparoscopic surgery started with dissection of the vesicovaginal plane and resection of the isthmocele pouch. Complete excision of fibrotic tissues performed and a Hegar dilator was placed to maintain cervico-uterine patency. The defect was then repaired in 3 layers. For the first two layers 0-polyglactin (Vicryl®) was used for faster absorption of the suture material in contact with the endometrial cavity. The third layer was closed using 2-0 delayed absorbable barbed sutures (V-LocTM). An adhesion barrier was placed overlying the suture line. The operative time was 150 minutes and the patient had an uneventful postoperative recovery. The pathology of the endometrial biopsy showed the unusual finding of endometrial glands filled with blood.The postoperative vaginal ultrasound confirmed a well re-approximated uterine wall, a myometrial thickness of 14 mm and a continuous and intact endometrial lining at 6 weeks postoperatively. At 3 months a flexible office hysteroscopy showed excellent repair, complete healing of the lower uterine defect and a normal endometrial cavity with resolution of the abnormal lesions.Post-operatively, the patient denied any post-menstrual spotting and conceived spontaneously 4 months after the repair.