Management of Cesarean scar ectopic pregnancies (CSP) is individualized and often requires a multi-modal approach. This case demonstrates a fertility-sparing approach to CSP through restoration of normal anatomy, provision of a systematic approach to finding avascular planes for lysis of adhesions, and the use of intra-myometrial vasopressin and pre-emptive skeletonization of the uterine vessels for vascular control.
University of Saskatchewan
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Video Transcript: Laparoscopic Wedge Resection of a Cesarean Scar Ectopic Pregnancy at 9 Weeks Gestation
This video demonstrates a laparoscopic resection of a cesarean scar ectopic pregnancy. The authors have no conflicts of interest.
Cesarean scar ectopics occur in one in 500 pregnancies with a prior cesarean delivery. They account for 4% of all ectopic pregnancies.
Management varies on a case-by-case basis but can include a combination of medical and surgical management. Uterine artery embolization can be used as an adjunct to reduce surgical morbidity.
Our case is a 40 year old, healthy G6P3 who presented with fatigue, abdominal cramping, and irregular menstrual cycles. Her past obstetrical history is significant for two spontaneous abortions and three cesarean sections.
Ultrasound revealed a possible ectopic pregnancy measuring eight plus three weeks gestation. The patient was promptly admitted to the hospital for further assessment and management.
A transvaginal ultrasound revealed a viable intrauterine pregnancy extending through the cesarean scar and bulging toward the bladder. There were multiple vessels crossing the endometrium, which was suspicious for a type one placenta percreta with no bladder involvement.
The patient opted for termination of pregnancy but wished to preserve fertility. Therefore, she received a dose of systemic Methotrexate and Mifepristone on post-admission days two and three, respectively
and MIS consultation was obtained to discuss surgical options. Intragestational Methotrexate injection and Uterine Artery Embolization were discussed, agreed upon, and planned prior to laparoscopic wedge resection of the ectopic to reduce the risk of interoperative hemorrhage, which would likely result in hysterectomy.
On post-admission day four, the patient experienced acute vaginal bleeding of at least 800 millilitres. Although she was hemodynamically stable, her hemoglobin was 89 milligrams per millilitre. Surgical intervention was recommended at this time, and she was counselled on a higher risk of interoperative hemorrhage and hysterectomy.
Written informed consent was obtained for the procedure, and she was transferred urgently to the operating room.
In this video, we will demonstrate the importance of restoring normal anatomy, a systematic approach to extensive lysis of adhesions. And two methods of interoperative vascular control with the use of Vasopressin and pre-emptive skeletonization of the uterine vessels.
Laparoscopic entry was made at Palmer’s Point with the ports placed in the following pattern.
The ectopic pregnancy can be visualized with a bulge in the anterior aspect of the uterus with bladder adhesions high over the lower uterine segment. This is in keeping with the ultrasound findings to the right.
The uterine fundus is infiltrated with dilute Vasopressin.
The round ligament on the left is sealed and transected using bipolar cutting forceps to separate the leaflets of the broad ligament and facilitate the lysis of adhesions.
The anterior leaf of the broad ligament is dissected from lateral to medial.
The vesicouterine peritoneal fold is carefully dissected off the ectopic from lateral to medial with a combination of blunt and sharp dissection. The plane is found by taking thin adhesions down first with a push and spread technique.
The right round ligament is then sealed and transected.
The anterior leaf of the broad is taken down to meet the previously dissected vesicouterine peritoneum.
The medial paravesical space is developed to skeletonize the uterine vessels in case hemorrhage is encountered, and quick vascular ligation is necessary.
Note the proximity of the uterine vessels to the ureter.
The ureter is lateralized by further developing the paravesical space.
The ureter is visualized transperitoneally to confirm its course. Skeletonization is repeated on the left-hand side.
Dissection of the extensive bladder adhesions is then continued. These are taken down systematically, again from lateral to medial.
Then adhesions are taken down bluntly, followed by the dense adhesions with the forceps.
Normal anatomy has been restored, and the bladder adhesions have been completely dissected off the ectopic pregnancy.
The Foley Balloon can now be seen well below the lower uterine segment. As the effect of the initial Vasopressin injections had worn off, dilute Vasopressin was again injected into the uterine fundus. Vasopressin is also injected into the proximal aspect of the lower uterine segment in preparation for wedge resection.
Using the cut setting with the monopolar L-hook, the serosa and myometrium are incised just proximal to the ectopic pregnancy.
Note the effect of Vasopressin on the blanched appearance of the uterus and the minimal blood loss with an incision.
The cut edges are retracted to better visualize the dissection plane into the myometrium.
The uterine cavity is entered, and the placenta is visible. The pregnancy can be seen more clearly by invading the anterior myometrium.
The serosa at the left lateral aspect of the gestational sac is carefully divided using monopolar energy.
The incision is continued inferiorly to complete the wedge resection.
The section of the anterior myometrium with the attached products of conception is placed in a laparoscopic bag and removed through the left upper quadrant port.
To ensure there are no retained products, the lower uterine segment, cervix, and upper vagina are clearly visualized and inspected.
The myometrial defect is then closed with an absorbable barbed suture in a continuous non-locking fashion.
The defect is closed in two layers.
The total estimated blood loss from the procedure was 100 millilitres. There were no surgical or postoperative complications. The patient was discharged home postoperative day one, and her beta HCG levels returned to normal within one month.
This video showed a laparoscopic resection of a cesarean scar ectopic through the restoration of normal anatomy, development of avascular planes, and judicious use of Vasopressin for vascular control.