A feasible procedure for laparoscopic cesarean scar defect repair

In 1995, Morris first described cesarean scar defect as an "isthmocele" by macroscopy following hysterectomy in women with prior cesarean delivery. Cesarean scar defect is associated with gynecological symptoms such as abnormal uterine bleeding, secondary infertility, pelvic pain, and obstetrical complications such as cesarean scar pregnancy, placenta accreta, and uterine rupture. Surgical treatment techniques include hysteroscopic resection, transabdominal repair (laparotomy, laparoscopic, and robotic), and vaginal repair. If the residual myometrial thickness is <3 mm and a patient is symptomatic, consideration is made for defect repair from above rather than hysteroscopic resection. The advantages of laparoscopic repair include anatomic restoration of myometrial thickness, correction of uterine retroflexion, exploration of other causes of infertility and pelvic pain, and pathological diagnosis of scar tissue with endometriosis. Cesarean scar defect often cannot be visualized on the side of the abdominal cavity; therefore, it is difficult to identify the extent of the defect laparoscopically. Herein, we introduce laparoscopic cesarean scar defect repair through a surgical video with narration. This technique uses a uterine manipulator to distend and help delineate the defect, and a laparoscopic support suture within the defect as a "handle" to place the scar tissue on tension to ensure complete resection of the fibrotic tissue. Temporary uterine artery occlusion can be included to reduce bleeding in the surgical field to support visualization for complete fibrotic tissue removal and to achieve good apposition with a double-layer suture to promote proper anatomic wound healing. Symptom relief was achieved, and the patient became pregnant one year postoperatively. This video demonstrated a feasible, safe, effective procedure for laparoscopic cesarean scar defect repair in the patient.