A minimal invasive approach in management of symptomatic post–cesarean section isthmocele: a video case report.

courtesy: researchgate.net 

The cesarean section scar defect, also known as an isthmocele, is a reservoir-like pouch defect on the anterior wall of the uterus, located at the site of a previous cesarean delivery scar. It exact incidence is unknown because of scarcity of data about the condition.

It is commonly found on ultrasound examination (24%-88%). It could range from just thinning of the uterine myometrium to large defects leading to complete absence of myometrium.

It could present with abnormal uterine bleeding(AUB), pelvic pain and infertility in post-operative period. Several obstetric complications such as scar dehiscence, placenta accreta, and ectopic scar pregnancy are increasingly reported along with rising cesarean rates.

It is commonly repaired by vaginal surgery, operative hysteroscopic, combined laparoscopic-vaginal, or minimal invasive laparoscopic approach.  In absence of randomized studies, the efficacy of these approaches or superiority of one over another is not known.

A review of data showed that hysteroscopy is able to correct the scar defect but does not increase the uterine wall thickness, whereas laparoscopy is able to increase the uterine wall thickness.  

This video case report by Aimi G. et al. published in June issue of Fertility and Sterility describes a minimal invasive laparoscopic approach for correcting the scar defect.

A 36-year-old woman with history of 2 previous section presented with persistent postmenstrual spotting and chronic pelvic pain. A transvaginal sonography identified a 20.0 × 15.6 mm defect at the place of previous scar with a 2.6 mm remaining myometrial thickness over the defect.

In this case Isthmocele excision and myometrial repair was performed laparoscopically. After mobilization of the bladder, the isthmocele was identified by transrectal intraoperative sonography. Once identified, the isthmocele pouch was excised and contents drained. The cesarean section scar is excised with the help of cold scissors till healthy myometrium is visible. The defect was closed with a single layer of interrupted 2-0 Vycril sutures. A Hegar dilator was placed in cervix to maintain the continuity of uterus with the cervix.  Finally, visceral peritoneum was closed. Total operative time was 70 minutes.

Post operatively the patient made an uneventful recovery and was discharged home on 2 post-op day. A follow up sonography at 40 days after surgery with transvaginal and transabdominal route showed a complete repair of defect. At 3 months follow-up, postmenstrual spotting and chronic pelvic pain also resolved completely.

The authors concluded that, a laparoscopic approach is procedure of choice when repairing large isthmocele with severe myometrial thinning.  

Here is the video of the surgery