Is cesarean scar defect becoming history? The effect of uterotomy closure

Isthmocele or cesarean scar defect is a pouch-like defect in the myometrium at the isthmic level that is thought that it might occur as a result of the insufficient healing process of the uterine incision after cesarean section. It is important not to underestimate isthmocele and its preventive measures since it might cause serious gynecologic and obstetric complications. However, the best suturing technique suitable for the prevention of isthmocele formation is yet to be identified. The aim of this study was to compare the effects of three different uterine closure techniques applied during cesarean section on isthmocele formation.

In this prospective study, a total of 120 term (>37 weeks) pregnant women with no history of cesarean section and scheduled for primary cesarean section were randomized preoperatively to three different uterotomy closure techniques (baseball, single-locked, and single-unlocked groups).

In a total of 43 patients, postoperative third-month sonography revealed isthmocele as an anechoic triangular area with ≥1 mm depth at the scar site. Compared with the single-locked and single-unlocked groups, isthmocele development was significantly lower in the baseball-type closure group (47.5% in the single-locked, 46.2% in the single-unlocked, and 15.4% in the baseball-type closure group). The group with the highest residual myometrial thickness, that is, 5.7 mm, was again the patients who underwent baseball sutures.

Uterotomy closure with baseball-type suturing seems to be an advantageous method as compared to the traditional techniques in terms of preserving the residual myometrial thickness and preventing isthmocele formation.