Laparoscopic Repair of Cesarean Scar Defect "Isthmocele"

To demonstrate the technique of laparoscopic repair of a large cesarean scar defect (isthmocele).

Case report (Canadian Task Force classification III).

Cesarean scar defect, also known as an isthmocele, is the result of incomplete healing of the isthmic myometrium after a low transverse uterine incision performed for cesarean section. Although mostly asymptomatic, it may cause menstrual abnormalities (typically postmenstrual spotting), chronic pelvic pain, and secondary infertility. Scar tissue dehiscence, scar pregnancy, and abnormally adherent placenta are some of the obstetric complications associated with this defect. No standardized treatment has yet been accepted. Hysteroscopy and laparoscopy are the minimally invasive approaches currently used to repair the defect.

A 40-year-old patient, G2P2, presented with postmenstrual spotting and secondary infertility for the past 2 years. She had a history of 2 previous cesarean deliveries. Transvaginal ultrasound revealed a large (2.5 × 1.5 cm) niche. Thickness of the myometrium over the defect was 3 mm. Laparoscopic repair of the uterine defect was performed. The bladder that was densely adherent to the lower uterine segment was freed by careful dissection. The defect was then localized with a sharp curette placed transcervically into the uterus. The curette was pushed anteriorly to delineate the margins of the defect and puncture the ceiling of the isthmocele cavity. The fibrotic tissue that formed the ceiling and the lateral borders of the defect was excised using laparoscopic scissors. Reapproximation of the edges was done with continuous nonlocking 3-0 V-Loc sutures. The procedure took 90 minutes, and there were no associated complications. Postoperative ultrasound performed in the second month after the operation showed a minimal defect measuring 0.5 cm, with a residual myometrial thickness of 7 mm. At the time of this writing, the patient was free of symptoms.

Laparoscopic repair, although not standardized, is a minimally invasive procedure that can be performed to treat uterine scar defects. Mobilization of the overlying bladder, resection of the isthmocele margins and secondary suturing of the remaining myometrial tissue appears to be an effective treatment option for affected patients.