Demonstration of Isthmocele Surgical Repair

Study ObjectiveTo describe the surgical treatment of a uterine isthmocele.DesignDemonstration laparoscopic technique with narrated video footage.SettingCesarean section rate has been increasing despite World Health Organization's recommendation maximum 15%, some countries reaching rates as high 50%. The choice delivery method is complex topic based on physical and psychologic health, social cultural context, quality maternity care. With number cesarean sections, new entity was recognized, isthmocele [1Gubbini G Casadio P Marra E Resectoscopic correction “isthmocele” in women postmenstrual abnormal bleeding secondary infertility.J Minim Invasive Gynecol. 2008; 15: 172-175Abstract Full Text PDF PubMed Scopus (98) Google Scholar]. A dilatation scar functions reservoir collecting blood during menstruation. Isthmocele prevalence ranges from 19% to 84%[2van der Voet LF Vervoort AJ Veersema S BijdeVaate Brölmann HA Huirne JA Minimally invasive therapy for gynaecological symptoms related niche caesarean scar: systematic review.BJOG. 2014; 121: 145-156Crossref (76) most frequent complaint relates intermittent (30%). can be cause infertility pelvic pain [3Tulandi T Cohen A. Emerging manifestations defect reproductive-aged women.J 2016; 23: 893-902Abstract (59) Interstitial pregnancy known complication mortality up 2.5%. diagnosis made by transvaginal ultrasound and/or magnetic resonance imaging but also hysteroscopy or hysterosalpingography. Treatment done controlling oral combined contraceptive (decreasing metrorrhagia) improving fertility [4Zhang X Yang M Wang Q Chen J Ding Hua K Prospective evaluation five methods used treat defects.Int Gynaecol Obstet. 134: 336-339Crossref (26) Scholar, 5Zhang Y. comparative study repair management patients previous defect.J 535-541Abstract (32) 6Schepker N Garcia-Rocha GJ von Versen-Höynck F Hillemanns Schippert C Clinical defects after non-pregnant women.Arch Gynecol 2015; 291: 1417-1423Crossref (42) 7Raimondo Grifone Raimondo D Seracchioli R Scambia Masciullo V Hysteroscopic symptomatic cesarean-induced isthmocele: prospective study.J 22: 297-301Abstract (56) seems improve whom workup did not find other [8Donnez O Donnez Orellana Dolmans MM Gynecological obstetrical outcomes series 38 women.Fertil Steril. 2017; 107: 289-296.e2Abstract (66) 9Enderle I Dion L Bauville et al.Surgical symptom relief fertility.Eur Obstet Reprod Biol. 2020; 247: 232-237Abstract (5) Surgical approach vaginal route hysteroscopy; abdominal laparoscopy, robotic laparotomy; through combine procedure both routes. Hysterectomy definitive treatment, those who want preserve fertility, offered. For surgery, several ways have described detect such Foley catheter, hysteroscopy, methylene blue, Hegar probe. When we do prefer concomitant use hysteroscopy. There trending opinion that smaller could treated hysteroscopically (2.5 mm according Jeremy al [10Jeremy B Bonneau Guillo al.Uterine ishtmique transmural hernia: results its fertility.Gynecol Fertil. 2013; 41: 588-596Crossref (24) Scholar] 3.0 Marotta [11Marotta ML Squifflet Jadoul Darii al.Laparoscopic post-cesarean diagnosed nonpregnant 20: 386-391Abstract (83) Scholar]). goal remove inflammatory infiltration endocervix, cutting superior inferior edges enabling normal evacuation uterus. By contrast, larger (with <2.5–3.0-mm residual myometrium) risk perforation better laparoscopy. This especially important interested because [12Vachon-Marceau Demers Bujold al.Single versus double-layer closure at cesarean: impact lower segment thickness next pregnancy.Am 217: 65.e1-65.e5Abstract (14) still no strong evidence hysteroscopic leads an increased ruptures compared myometrium greater correction. Myometrium independent factor rupture [13Bujold Jastrow Simoneau Brunet Gauthier RJ Prediction complete sonographic segment.Am 2009; 201: 320.e1-320.e6Abstract (109) Scholar], therefore, preferred over desire. Finally, isthmocele, recommend 6-month interval before attempting pregnancy.InterventionsLaparoscopic are symptomatic, thin endometrium, desire pregnancy. Key strategies (1) dissection vesicouterine pouch laterally avoid entering bladder wall; (2) transillumination (3) cut cold scissors avoiding thermal damage remaining myometrium; (4) suture figure 8 multiple layers. No using specific available.ConclusionSurgical good option infertile. Laparoscopic guided if <3 mm.