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Hysteroscopic/Laparoscopic Isthmocele Repair

Arzu Arınkan and Nurettin Aka*
Department of Gynecology and Obstetrics, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey


*Corresponding author: Nurettin Aka, Department of Gynecology and Obstetrics, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey


Published: 09 Mar 2018
Cite this article as: Arınkan A, Aka N. Hysteroscopic/ Laparoscopic Isthmocele Repair. Clin Surg. 2018; 3: 1928.

Clinical Image

Isthmocele is pocket like cesarean scar defect. This defect contains debris, mucus and blood which is responsible from symptoms like postmenstrual bleeding, dysmenorrhea, dyspareunia, infertility. It is often associated with postmenstrual abnormal uterine bleeding which is characterized by spotting after menstruation. Isthmocele slows evacuation of blood from the uterus. Persistence of menstrual blood in the cervix may negatively influence mucus quality which obstruct sperm transport and affect sperm quality even the embryo implantation [1,2]. Here in we reported a case presented to clinic via postmenstrual bleeding (Figure 1). This paper presented isthomocele case that treated with both laparoscopy and hysteroscopy and two year follow up after surgery. A 30-year-oldwoman (gravida 1 parite 1) presented to clinic with postmenstrual spotting since delivery of her child seven years ago. There was no response to priororal contraceptive treatment (Figure 2). Transvaginal ultrasonoghraphy showed ishtmocele with 2 mm myometrial thickness. She underwent hysteroscopy and laparoscopy. There was a pouch with 1 cm diameter. On the cesarean scar line, a defect was observed laparoscopically via hysteroscopic transillumination. Visceral peritoneum covering the isthmus was incised transversally by using bipolar esiccation and scissors, and the bladder was mobilized by blunt and sharp dissections. Caesarean scar was removed, the resulting cervical defect was repaired with a continuous polyglact in 2/0 suture (Figure 3). Her complaints subside after surgery and no problem was seen at two year follow up. After two year, myometrium thickness was measured 12 mm at transvaginal ultrasound examination. If the scar defect is diagnosed by chance and the patient does not have any symptom, surgery is not necessary. Hysteroscopic isthmoplasty is safe and efficient therapy method when myometrial thickness is more than 3 mm. When the thickness of the residual myometrium is measured to be less than 3 mm, then it is recommended to perform a planned laparoscopy during which the scar tissue is resected and the edges of the scar are renewed (Figure 4). If the symptoms only postmenstrual bleeding both laparoscopy and hysteroscopy is suitable for treatment. If the chronic pain is the symptom,patient should be evaluated extensively before deciding laparoscopy or hysteroscopy [3,4].

Figure 1

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Figure 1
Niche view at ultra sound examination.

Figure 2

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Figure 2
Niche/scar - hysteronscopic view.

Figure 3

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Figure 3
Laparoscopic bladder dissection.

Figure 4

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Figure 4
Hysteroscopic translumination.

Figure 5

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Figure 5
Niche view at ultra sound examination after two years.

References

  1. Nazik H, Nazik E. A new problem arising after the cesarean, cesarean scar defect (Isthmocele) a case report. Obstet Gynecol Int J. 2017;7(5):1-3.
  2. Urman B, Arslan T, Aksu S, Taskiran C. Laparoscopic repair of cesarean scar defect “Isthmocele”. J Minim Invasive Gynecol. 2016;23(6):857-8.
  3. Setubal A, Alves J, Osório F, Guerra A, Fernandes R, Albornoz J, et al. Treatment for uterine isthmocele, a pouchlike defect at the site of a cesarean section scar. J Minim Invasive Gynecol. 2018;25(1):38-46.
  4. Nezhat C, Falik R, Lie A. Surgical management of niche, isthmocele, uteroperitoneal fistula, or cesarean scar defect: a critical rebirth in the medical literature. Fertil Steril. 2017;107(1):69-71.