Video Description
This video demonstrates laparoscopic resection and repair of a cesarean section niche defect for the treatment of abnormal uterine bleeding.
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Affiliations
University of Saskatchewan
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Video Transcript: Laparoscopic Resection of a Caesarean Section Niche Defect for Treatment of Abnormal Uterine Bleeding
The objective of this video abstract is to demonstrate laparoscopic resection of a niche defect for the treatment of abnormal uterine bleeding. A 39-year-old gravida 2, para 2 with two previous cesarean sections presented with worsening menorrhagia, dysmenorrhea, intermenstrual bleeding, occasional post-coital bleeding and a sense of heaviness throughout her cycle.
Ultrasound imaging was unremarkable, with a note made of the previous lower segment cesarean section scar. As seen here, a hysterosonogram noted a niche anteriorly in the lower uterine segment within the previous cesarean scar, measuring 6.9 mm in size.
Based on history, symptoms and imaging, a diagnosis of the cervical niche was made. Options for medical and surgical management were discussed. The patient elected to undergo surgical resection. The risks of the procedure were discussed, and informed consent was obtained for diagnostic laparoscopy, hysteroscopy and resection of the uterine niche.
cesarean section rates have increased worldwide over the last 30 years, nearing 30%. Increasing cesarean rates have been associated with many well-known obstetrical and gynecological complications, including the development of abnormal uterine bleeding and pain postpartum.
A niche is a discontinuity of the myometrium within the cesarean section scar, seen on sonography, contrast sonography, hysteroscopy and/or hysterosalpingogram. The niche is known by many names and is alternatively labelled in the literature as a cesarean scar defect, a deficient cesarean scar, a diverticulum, a pouch and/or an isthmocele.
Niche prevalence is widely estimated to be between 24% and 84%, depending on the diagnostic tools used. Prevalence is difficult to determine because of no standardization as to shape, size or other characteristics, as well as no gold standard for detection or measurement within the literature.
A niche most commonly presents postpartum as dysmenorrhea, chronic pelvic pain or postmenstrual spotting, and occasionally as dyspareunia. Abnormal uterine bleeding associated with the presence of the niche can be improved drastically with the use of either surgical or medical management. Surgical interventions have shown complete resolution of pain associated with the niche.
To date, only 14 cases of laparoscopic niche excision have been published. To the best of our knowledge, this is the first surgical video of a cesarean section niche defect to be excised and repaired laparoscopically with hysteroscopic assistance.
The surgery took place at the Regina General Hospital in a minimally invasive surgical suite. The abdomen was entered and inflated at the umbilicus using a Veress needle. As you can see in the diagram, a 12 mm port was placed there.
The diagram also depicts the placement of all other ports, with two 5 mm ports in the left lower quadrant and a third 5 mm port in the right lower quadrant. All ports were placed under direct visualization, using a 10 mm zero-degree video laparoscope at the umbilicus. A Rumi uterine manipulator was also incision into the uterus through the vagina.
Upon entering the abdomen, it was noted that there were adhesions between the bladder and the cesarean scar. Monopolar laparoscopic scissors were used to create a vesicouterine peritoneal reflection, pulling the bladder down easily away from the isthmic portion of the uterus. 10 ml of dilute vasopressin, 20 units in 40 ml of normal saline were infiltrated into the isthmic portion of the uterus, using a spinal needle to aid with hemostasis.
The Rumi uterine manipulator was removed from the uterus, and a 70-degree hysteroscopic camera was introduced. The niche area was identified, and the hysteroscope was then used to transilluminate the niche as a landmark. A monopolar hook was used to outline a 1-cm-square area to be resected.
The hysteroscopic camera was again removed and the Rumi manipulator was reintroduced to aid as a landmark for the endometrial cavity. Using the monopolar hook, the outlined niche area was then resected down through the myometrium and the endometrium towards the manipulator.
Using a Covidien V-Loc suture in a running fashion, the resected area was then closed in two layers, first, the endometrium, followed by the myometrium and serosa together. The suture was cut and excellent hemostasis of the area was then confirmed.
The resected niche specimen was removed from the abdomen via the 12 mm port. A Gynecare Interceed Adhesion Barrier was placed over the resection site to help prevent adhesions. The vaginal manipulator was removed, and hysteroscopy was again performed to confirm appropriate closure of the resected area, with no suture trapped in the endometrium.
The patient tolerated the procedure very well. The estimated blood loss for the surgery was minimal. She had an uncomplicated postoperative course and was prepared for discharge the same day.
Pathology report. Microscopic examination of the resected specimen showed smooth muscle proliferation with a focus of benign endometrial glands and stroma consistent with adenomyosis. There was no evidence of hyperplasia or malignancy.
At a six-week postoperative follow-up visit, the patient reported that she was doing well. She had completed two menstrual cycles since the procedure. During the first cycle, she had experienced similar symptoms prior to her surgery. During the second cycle, she said that her menses were much improved, with lighter bleeding and less pain. She had no further complaints of intermenstrual bleeding or pain.
In summary, uterine niche defects in cesarean section scars can cause many negative gynaecological symptoms. Laparoscopic resection, with the assistance of intraoperative hysteroscopy for surgical landmarking, is an effective surgical intervention for abnormal uterine bleeding associated with niche defects.