Presented by:
Madalina Maxim
Affiliations:
McGill University
Watch on YouTube
https://youtu.be/cOEv9ZSmK-k Click here to watch this video on YouTube.
What is Combined Laparoscopic-Hysteroscopic Isthmocele Repair?
Combined laparoscopic-hysteroscopic isthmocele repair is a minimally invasive procedure used to treat a cesarean scar defect, or isthmocele, in the lower uterine segment. In cases involving a failing cesarean scar ectopic pregnancy, the combined approach allows the surgeon to identify and remove pregnancy tissue while repairing the underlying scar defect under visualization from both inside and outside the uterus. Here’s what it involves:
- Preoperative Assessment: Ultrasound and other imaging are used to identify the cesarean scar defect, determine the location of the pregnancy, and assess the thickness of the surrounding myometrium.
- Laparoscopic Assessment: The pelvis and external surface of the lower uterus are inspected to evaluate the scar and its relationship to the bladder and surrounding structures.
- Hysteroscopic Evaluation: A hysteroscope is introduced into the uterine cavity to visualize the defect and pregnancy tissue from within the uterus.
- Bladder Dissection: The bladder is carefully mobilized away from the previous cesarean scar to expose the affected lower uterine segment.
- Removal of Pregnancy Tissue: Cesarean scar ectopic pregnancy tissue is carefully removed while controlling bleeding and preserving healthy uterine tissue.
- Isthmocele Excision: Fibrotic or deficient tissue at the cesarean scar defect is excised to create healthy margins for reconstruction.
- Uterine Reconstruction: The myometrium is carefully sutured to restore the thickness and integrity of the lower uterine segment.
- Hysteroscopic Confirmation: The uterine cavity can be reassessed hysteroscopically to confirm restoration of the cavity and appropriate repair.
- Final Inspection: The repaired uterus and surrounding structures are inspected for bleeding or injury before completing the procedure.
Using laparoscopy and hysteroscopy together provides visualization of both sides of the cesarean scar, allowing simultaneous treatment of the ectopic pregnancy and reconstruction of the underlying uterine defect.
What are the Risks of Combined Laparoscopic-Hysteroscopic Isthmocele Repair?
Repair can be technically challenging because cesarean scar defects are located in the lower uterine segment near the bladder and major blood vessels, and an ectopic pregnancy may make the area particularly vascular.
- Significant Hemorrhage: Cesarean scar pregnancies can be highly vascular, creating a risk of substantial bleeding during removal or scar excision.
- Bladder Injury: Previous cesarean delivery can cause the bladder to become densely adherent to the lower uterus, increasing the risk of injury during dissection.
- Uterine Perforation: Hysteroscopic instrumentation or dissection through a thin cesarean scar can result in perforation of the uterine wall.
- Incomplete Pregnancy Removal: Residual pregnancy tissue may cause persistent bleeding or hCG elevation and require additional treatment.
- Uterine Scar Complications: Incomplete healing or persistent thinning of the repaired lower uterine segment may occur despite reconstruction.
- Infection: Endometritis, pelvic infection, or infection of the repaired surgical site can develop following surgery.
- Intrauterine Adhesions: Surgical manipulation of the uterine cavity can lead to scar tissue formation that may affect menstruation or fertility.
- Future Pregnancy Complications: A history of cesarean scar pregnancy and uterine reconstruction may be associated with future risks involving the uterine scar or placental implantation and requires appropriate obstetric follow-up.
- Need for Additional Surgery: Uncontrolled bleeding, extensive tissue damage, or unsuccessful repair may require further surgical intervention.
- General Surgical Risks: Blood clots, anesthesia-related complications, fluid-related hysteroscopic complications, and injury to surrounding pelvic structures are possible.
Careful localization of the pregnancy, bladder mobilization, controlled removal of pregnancy tissue, and meticulous reconstruction of the myometrium help minimize these risks while restoring the integrity of the cesarean scar.