Laparoscopic repair of a symptomatic post-cesarean section isthmocele: a video case report

OBJECTIVE: To describe our technique for laparoscopic management of post-cesarean section isthmocele. DESIGN: Surgical video article. Local Institutional Review Board approval for the video reproduction has been obtained. SETTING: University hospital. PATIENT(S): A 36-year-old patient with a history of two previous cesarean deliveries. She complained of persistent postmenstrual spotting and chronic pelvic pain. At transvaginal ultrasound examination, a cesarean scar defect of 20.0 × 15.6 mm was identified, with a residual myometrial thickness over the defect of 2.6 mm. MAIN OUTCOME MEASURE(S): Repair of isthmocele and relief of pain. INTERVENTION(S): Isthmocele excision and myometrial repair was performed laparoscopically. The first step of the procedure was the cautious mobilization of the bladder from its adhesions with the site of the previous cesarean scar. Subsequently, the isthmocele site was identified with the aid of intraoperative transrectal ultrasonography. Transrectal ultrasonographic assistance is particularly important when a bulge of the cesarean scar is not laparoscopically visible. Once identified, the isthmocele pouch was incised and its pitchy content drained. Then the cesarean scar was excised with cold scissors, avoiding cauterization to reduce the risk of tissue necrosis. This step is considered completed when the whitish scar tissue of the isthmocele site margins are no longer present and reddish healthy myometrium is visualized. Before suturing the defect, a Hegar dilator was placed into the cervix with the aim of maintaining the continuity between the cervical canal and the uterine cavity. Then, the myometrial repair was performed with the use of a single layer of interrupted 2-0 Vycril sutures. To limit tissue ischemia, we prefer not to add a second layer of sutures. Finally, the visceral peritoneum defect was closed, with the aim of restoring the physiologic uterine anatomy. In this case, multiple peritoneal endometriotic implants were also identified and excised. RESULT(S): Operating time was 70 minutes. The postoperative course was uneventful and the patient was discharged on postoperative day 2. At 40-day postoperative follow-up, transvaginal and transabdominal ultrasonography showed complete anatomic repair of the uterine defect. At 3-month follow-up, the patient reported resolution of postmenstrual spotting and chronic pelvic pain. CONCLUSION(S): Good reproductive outcomes have been reported after hysteroscopic treatment of uterine isthmocele. However, laparoscopy has the advantage over hysteroscopy of allowing thorough repair of the uterine defect, thus restoring a normal myometrial thickness. Therefore, as demonstrated in this case, a laparoscopic approach might be considered to be the procedure of choice for the repair of a large uterine isthmocele with extreme thinning of the residual myometrium.