A Resident's Guide to Laparoscopic Isthmocele Repair

STUDY OBJECTIVE: The objective is to demonstrate laparoscopic repair of a c-section scar isthmocele using hysteroscopic guidance. DESIGN: N/A SETTING: 40yo G1P1 with secondary infertility was found to have fluid within her c-section scar. Pelvic ultrasound revealed a fluid-filled 11 × 9 × 17mm defect spanning the width of the cervix, consistent with a c-section scar isthmocele. Informed consent was obtained for laparoscopic repair with hysteroscopic guidance; however, she was counseled on the risk of recurrence, infertility, uterine rupture and need for future c-section. Hysteroscopy demonstrated a narrow diverticulum along the anterior aspect of the upper cervix with scar tissue. On laparoscopy there were dense uterine to abdominal wall adhesions. PATIENTS OR PARTICIPANTS: N/A INTERVENTIONS: The case begins with lysis of abdominal wall adhesions using the harmonic scalpel. The bladder is mobilized past the level of the cervical-uterine junction. A hysteroscopy is performed concurrently during which the cephalad and caudal borders of the isthmocele are transilluminated and marked with the harmonic scalpel. Dilute vasopressin is injected into the area of resection. The harmonic scalpel excises the scar, using the prior marks as a guide and taking care to avoid the uterine vessels. The defect is closed in three layers, which involves interrupted sutures to reapproximate the endocervical canal, then two barbed imbricating layers in a running fashion. Once hemostasis is assured the bladder flap is reapproximated. MEASUREMENTS AND MAIN RESULTS: At her postoperative visit, the patient felt well without pain or abnormal bleeding. She has not been seen for imaging due to the COVID-19 pandemic, however as of May 2020 she is attempting to conceive again. CONCLUSION: C-section scar isthmoceles are amenable to laparoscopic excision with primary repair. The concurrent use of hysteroscopy facilitates identification of the isthmocele borders. Patients should be counseled regarding the risk of uterine rupture and need for future c-sections.