Robotic Assisted Laparoscopic Resection of Uterine Isthmocele

Abstract

Video Objective Uterine isthmoceles are pouchlike defects in the anterior uterine wall, at the site of a prior cesarean section scar. Its prevalence has increased in direct relation to the increase in cesarean rates worldwide. Isthmoceles cause abnormal uterine bleeding, secondary infertility, and pain. There is no standard treatment for isthmoceles. This video demonstrates a robotic assisted laparoscopic approach to the resection of a uterine isthmocele. Setting The patient is a 36 year old with a history of one cesarean section with abnormal uterine bleeding. She was diagnosed with an isthmocele by transvaginal ultrasound performed in preparation for embryo transfer. The patient was treated at a tertiary care centre in Brooklyn, New York. Interventions The risks, benefits, and alternatives of a robotic assisted laparoscopic resection of a uterine isthmocele were discussed with the patient and consent was obtained. The robot was docked and simultaneous hysteroscopy was performed. The fenestrated bipolar and monopolar scissors were used to perform lysis of adhesions and dissection of the bladder off the uterine isthmus and cervix. Robotic fluorescence imaging was used to identify the isthmocele defect via the “lantern sign” where the hysteroscopic light shines through the tissue similar to a lantern. The isthmocele was excised and the defect was reapproximated with an absorbable monofilament suture. A barbed suture was then used for a second imbricating layer, with excellent hemostasis. Fluorescence imaging was used again and the hysteroscopic light could no longer be identified, as the isthmocele had been resected and repaired. Conclusion Uterine isthmoceles are increasing in relation to the increased rate of cesarean sections. Symptomatic and asymptomatic women who desire future pregnancy should be offered surgical treatment. Robotic assisted laparoscopic management of uterine isthmoceles can be associated with increased patient satisfaction with faster recovery times, and decreased length of hospitalization, and should be considered when possible.