Gynecology
7 min read

Laparoscopic Repair of a Cesarean Scar Defect and Round Ligament Suspension

Title card for the video "Laparoscopic Repair of a Cesarean Scar Defect and Round Ligament Suspension"

Table of Contents

Video Description

In this video we present a laparoscopic excision of a cesarean scar defect under hysteroscopic guidance. Our objectives are to review surgical indications and patient counselling and to demonstrate our surgical approach. The case involves a 40-year-old G4P3 female with a large cesarean scar defect, retroverted uterus, and 1mm of residual myometrial thickness. She had already experienced one cesarean scar pregnancy. After thorough counselling she wished to proceed with laparoscopic repair. We review the 5 key steps to the procedure: 1) bladder dissection; 2) delineation of the defect; 3) excision of the defect; 4) repair of the defect; and 5) round ligament suspension. Our surgical technique is demonstrated in detail. Laparoscopic repair is the treatment of choice for women with symptomatic cesarean scar defects with residual myometrial thickness <3mm who desire future pregnancy. While the literature suggests promising reproductive outcomes following laparoscopic repair, the evidence is limited and evolving.

Presented By

Dr. Lacey Brennan
 
Dr. Peter Thiel
Dr. Ally Murji

Affiliations

Mount Sinai & Women’s College Hospital, University of Toronto

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What is Repair of a Cesarean Scar Defect and Round Ligament Suspension?

An evidence-led approach to the surgical treatment of Cesarean scar defects and round ligament suspension emphasizes using the latest scientific research and clinical evidence to guide decisions in managing the condition surgically. Here’s how it works in practice:

  • Patient-Centered Decision-Making: Surgeons consider each patient’s unique symptoms, severity, and quality of life, customizing surgical plans based on proven outcomes rather than a one-size-fits-all approach.

  • Minimally Invasive Techniques: Guided by evidence on effective and less risky procedures, laparoscopic surgery, which involves small incisions and a camera, is preferred for precision and faster recovery.

  • Focus on Comprehensive Excision: The procedure includes careful removal of the defect with monopolar energy, ensuring complete excision while avoiding damage to adjacent uterine structures such as the uterine arteries.

  • Use of Imaging and Diagnostic Advances: Advanced imaging techniques like ultrasound and sonohysterogram (Sono-HSG) are used to evaluate the defect pre- and postoperatively, aiding in precise diagnosis and outcome assessment.

  • Consideration of Hormonal Impact: Hormonal changes affecting uterine healing are considered, and the repair aims to improve myometrial thickness and restore the anatomical positioning of the uterus to support future pregnancies.

  • Outcomes Monitoring and Adjustment: Postoperative monitoring includes a sonohysterogram at six weeks to assess myometrial thickness and defect closure, with additional early ultrasound recommended in subsequent pregnancies to ensure optimal outcomes.

This approach aims to improve reproductive outcomes following laparoscopic repair.

What are the Risks of Repairing a Cesarean Scar Defect and Round Ligament Suspension?

While an evidence-led approach to repairing a Cesarean scar defect and round ligament suspension is beneficial in many ways, it does carry certain risks, including:

  1. Complexity of Comprehensive Excision: The procedure involves delicate excision of the scar tissue with monopolar electrosurgery, which requires precision to avoid damage to surrounding tissues, such as the uterine arteries. Complete excision of the defect while ensuring uterine integrity is technically demanding.

  2. Possible Recurrence: Despite the goal of reducing the size of the defect and increasing myometrial thickness, there is always a risk of recurrence, particularly if the initial surgery does not achieve a perfect repair or if the patient experiences additional stresses during pregnancy.

  3. Anesthesia-Related Risks: Like any surgery, the approach requires anesthesia, which carries risks like allergic reactions, respiratory issues, and, rarely, life-threatening complications.

  4. Surgical Complications: Minimally invasive surgeries still carry risks such as bleeding, infection, and damage to nearby organs or nerves, particularly in advanced cases.

  5. Post-Operative Pain and Adhesion Formation: Patients may experience post-operative pain, and there is a risk of adhesion formation, particularly with complex pelvic surgeries like this one. Adhesions can lead to chronic pain and complications in future pregnancies or surgeries.

  6. Limited Efficacy in Advanced Cases: In women with significant defects or advanced scarring, the surgery may have limited success. The residual myometrial thickness and the degree of uterine damage may make the repair less effective, potentially leading to future complications or unsuccessful pregnancies.

  7. Long-Term Hormonal Side Effects: While the surgery aims to restore uterine anatomy for future pregnancies, there are potential long-term hormonal impacts, such as alterations in fertility or menstrual cycles, especially if the surgery affects the uterine environment or function.

  8. Financial and Emotional Costs: The procedure may require multiple consultations, imaging, and follow-up care. There are also emotional costs associated with the uncertainty of future pregnancies, the risk of complications, and the need for extended recovery periods. Patients may experience anxiety or stress regarding the outcome, especially given the limited evidence on long-term success rates.

These risks emphasize the importance of thorough patient counseling and consideration of the potential benefits and limitations of the procedure.

Video Transcript: Laparoscopic Repair of a Cesarean Scar Defect and Round Ligament Suspension

In this video, we will present a Laparoscopic Repair of a Caesarean Scar Defect and Round Ligament Suspension. Our objectives are to review the surgical indications, review patient counselling, and demonstrate our surgical approach. Our case involves a 40-year-old G4P3 female strongly desiring another pregnancy. History is significant for three prior caesarean sections and a Type 1 Caesarean Scar Pregnancy. Imaging revealed a retroverted uterus, a large Caesarean Scar Defect, and a residual myometrial thickness of only one millimetre.

Uterine retroversion is a well-documented risk factor for Caesarean Scar Defects. Retroversion is thought to result in tensile forces on the healing uterine incision, leading to defect formation. We call this the broken uterus. The literature supports repair of large Caesarean Scar Defects in symptomatic women who desire future pregnancy. When the residual myometrial thickness is less than three millimetres, a laparoscopic repair is recommended over hysteroscopic remodelling.

It is important to note that while literature suggests promising reproductive outcomes following repair, evidence is limited and evolving. Therefore, thorough patient counselling is essential and should reflect these risks and limitations. There will always be a niche. The goal is to make it smaller, increase the residual myometrial thickness, and improve patient symptoms. The procedure can be broken down into five key steps. The goal of the procedure is to not only repair the defect but also to restore the anatomy, such that the uterine axis will promote healing.

Upon entry, inspection of the pelvis revealed a broken uterus that was retroverted and appeared to buckle posteriorly when unsupported. The first step is to open the vesicouterine peritoneum and reflect the bladder down beyond the defect. A lateral-to-medial approach for bladder dissection was used, as the area of densest scarring was located medially. Monopolar electrosurgery is used to cut dense midline adhesions. With the bladder reflected inferiorly, an area of complete dehiscence was identified.

The second step is to delineate the niche. Hysteroscopically, the niche can be visualised with abnormal vasculature in the anterior isthmus. Looking back laparoscopically, transillumination with the hysteroscope was used to help delineate the borders of the defect. The third step is removal of the niche. Here, we use monopolar energy to completely excise the defect. Care is taken not to go too far laterally into the territory of the uterine arteries. A uterine sound is used to visually appreciate the margins of the defect prior to closure.

The fourth step is to repair the defect. Equal bites of myometrium were taken inferiorly and superiorly to ensure appropriate approximation of the myometrium and prevent large niche recurrence. We find individual interrupted sutures to provide the most symmetrical re-approximation. Following closure of the first layer, we looked back hysteroscopically to appreciate that the defect had been closed. Gentle tapping confirms the location of the suture line. We then performed a second imbricating layer using a barbed suture. When cinching, we were careful to apply [unclear] traction to the suture to avoid tearing myometrium.

The final step is Round Ligament Suspension. The round ligaments were plicated using an O-Biosyn suture in an accordion fashion. Caesarean scar defects are often accompanied by a retroverted uterus. Suspension of the round ligaments is thought to decrease the tensile forces on the healing closure site. Round ligament plication was then repeated on the other side. Following repair, the defect had been excised, myometrium re-approximated, and the uterine axis was restored to a more anatomic position. The uterus was no longer broken.

Postoperatively, we routinely perform a sonohysterogram at six weeks. While evidence on optimal time to pregnancy is limited, we counsel patients to wait at least three to six months. Given the ongoing risk for caesarean scar pregnancy of 1 to 2%, an early ultrasound is essential in subsequent pregnancies. Planned caesarean section is advised.

On her post-op sono-HSG we can see excellent residual myometrial thickness and an imperceptible niche.

In conclusion, laparoscopic repair with hysteroscopic guidance is the treatment of choice for women with a symptomatic Caesarean Scar Defect with residual myometrial thickness less than three millimetres who desire future pregnancy. Studies suggest promising reproductive outcomes following laparoscopic repair, but further research is required.