Laparoscopic uterine isthmus anastomosis

To demonstrate a laparoscopic surgical technique for reconstructing posttraumatic uterine isthmus separation in an adolescent patient, focusing on anatomical restoration and fertility preservation.

Stepwise surgical video case report with narrated audio.

A 16-year-old girl presented with oligomenorrhea and cyclic lower abdominal pain 1 year after a motor vehicle accident necessitating right lower limb amputation and partial pelvic resection. Transrectal ultrasound and computed tomography revealed complete separation between the uterine corpus and cervix at the isthmus level.

Before the procedure, the patient was fully informed about the potential obstetric risks, including cervical incompetence, miscarriage, preterm birth, abnormal placentation, uterine rupture, and the possible need for a cesarean section. The laparoscopic procedure commenced with adhesiolysis to expose the isthmic discontinuity. A uterine manipulator was introduced transvaginally to delineate the cervical anatomy. After transection of the round ligaments, the uterine fundus was retroverted to expose the superior rupture margin referring to uterine anatomy and scar tissue position. Vasopressin is then injected into the myometrium to reduce bleeding during ultrasonic removal of scar tissue. Blunt and sharp dissection of the vesicouterine peritoneum, guided by the landmarks provided by the uterine manipulator, revealed the inferior rupture opening of the uterine isthmus. Eight interrupted sutures were performed in a full-thickness pattern, and luminal patency was confirmed intraoperatively using a Foley catheter inserted transvaginally. Then, continuous suture reinforcement was performed at the site of the uterine isthmic rupture, and the right round ligament was resutured to complete the reconstruction. The procedure concluded with peritoneal closure and placement of an abdominal drain. This study was approved by the Ethics Committee of The First Affiliated Hospital, Sun Yat-sen University ([2025]258).

Restoration of uterocervical continuity, postoperative menstrual normalization, and preservation of fertility potential.

The procedure was completed in 160 minutes with an estimated blood loss of 100 mL. Restoration of uterocervical continuity was immediately confirmed intraoperatively using a Foley catheter. There were no bladder or bowel injuries. The abdominal drain was removed on postoperative day 2, and the patient was discharged on postoperative day 5 after an uncomplicated recovery. The intrauterine Foley catheter was left in place for 10 days to maximize the reduction of risks associated with uterine isthmus wound dehiscence and uterine isthmus stenosis while minimizing the risk of intrauterine infection. Menstruation resumed in the month after surgery.

The laparoscopic approach achieved successful anastomosis of the uterine isthmic rupture, restoring anatomical continuity between the uterine corpus and cervix. Postoperative assessment confirmed menstrual normalization and preservation of the patient's fertility potential, with no surgical complications observed. The procedure's minimally invasive nature provided magnified visualization critical for precise dissection and suture placement while minimizing adhesion formation compared with open techniques. These outcomes support the feasibility of laparoscopic uterine isthmic reconstruction in adolescents with posttraumatic isthmic separation, offering valuable insights for the surgical management of similar cases in the future.