Instruments and Techniques

Laparoscopic Ultrasound-Guided Repair of Uterine Scar Isthmocele

Connected With the Extra-Amniotic Space in Early Pregnancy
Daniele Bolla, MD*, Luigi Raio, MD, Denis Favre, MD, Andrea Papadia, MD,
Sarah In-Albon, MD, and Michael D. Mueller, MD
From the Department of Obstetrics and Gynecology, University Hospital and University of Bern, Bern, Switzerland (all authors).

ABSTRACT We present a video of an ultrasound-guided laparoscopic surgical management of a large uterine scar isthmocele connected
with the extra-amniotic space in early pregnancy. A case of a pregnant patient who was diagnosed with a large isthmocele
connected with the extra-amniotic space on routine ultrasound at 8 weeks of gestational age is presented. The uterine
defect was successfully sutured laparoscopically under ultrasound guidance. The pregnancy continued uneventfully, and a
healthy baby was delivered via cesarean section at 38 weeks gestational age. Journal of Minimally Invasive Gynecology
(2015) -, -–- Published by Elsevier Inc. on behalf of AAGL.
Keywords: Isthmocele; Laparoscopic repair; Uterine scar dehiscence
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The rate of caesarean section (CS) has increased mark-
edly in the last decade, exposing women to a greater risk
of complications in future pregnancies, such as placenta ac-
creta, uterine rupture, and ectopic caesarean scar pregnancy.
An important role in this pathological process seems to be
played by an inappropriately healed caesarean scar [1–3].
After a CS, the presence of a uterine caesarean scar defect
(USD) is frequent, with incidence ranging from 24% to
70% [3–5]. This defect, also called isthmocele, is
diagnosed on transvaginal ultrasound (TVUS) and is
characterized by a myometrium gap in the site of the
caesarean scar [3–5].
Isthmocele-associated symptoms are abnormal uterine
bleeding, including postmenstrual spotting and prolonged
menstruation and infertility [6]. In these cases, the recom-
mended treatment is the surgical repair of the caesarean
scar. Various techniques for isthmocele repair with excellent
outcomes have been described [7–10].
Disclosures: None declared.
Corresponding author: Daniele Bolla, MD, Department of OBGYN, Univer-
sity of Bern, Inselspital, Effingerstrasse 102, CH-3010 Bern, Switzerland.
E-mail: daniele.bolla@insel.ch
Submitted August 16, 2015. Accepted for publication September 6, 2015.
Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ - see front matter Published by Elsevier Inc. on behalf of AAGL.
http://dx.doi.org/10.1016/j.jmig.2015.09.010
The management of USD in pregnancy remains a matter
of debate, however. In particular, there is a lack of studies
evaluating the risks and benefits of a surgical repair
compared with conservative treatment in subsequent preg-
nancies. We present a surgical technique for laparoscopic
ultrasound-guided repair of a large uterine scar isthmocele
connected with the extra-amniotic space in the first trimester
of pregnancy.
Case Report
A 29-year-old woman, gravida 3 para 1, was referred to
our hospital at 8 weeks of gestation for management of an
incidental finding on TVUS of a wide USD connected
with the extra-amniotic space. She had undergone CS 2 years
earlier owing to breech presentation and an early miscar-
riage. At admission, ultrasound confirmed a very thin uterine
scar with a wide interruption of the myometrium and a
25 ! 25-mm herniating isthmocele connected to the
extra-amniotic space of the early pregnancy (Fig. 1).
Given the entity of the defect and the early gestational age
of the patient, decision was taken to attempt a surgical repair
of the uterine defect to reduce the risk of perinatal complica-
tions. Laparoscopic ultrasound-guided repair of USD was
performed under general anesthesia at 13 weeks gestation.
2 Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2015
Fig. 1
Transvaginal ultrasound (Voluson 730; GE Ultrasound, Glattbrugg,
Switzerland) of a uterine scar dehiscence at 13 0/7 weeks gestation con-
nected with the extra-amniotic space. A, cervix; B, scar dehiscence with
herniation of the isthmocele; C, bladder; D, gestational sac.
Antibiotic prophylaxis with Augmentin (amoxicillin and
clavulanic acid) was given. A uterine manipulator was not
used. Pneumoperitoneum (CO2) using the Veres technique,
with an intraabdominal pressure of 10 mmHg, was per-
formed to reduce the risk of possible hemodynamic or respi-
ratory adverse effects. A 10-mm optical trocar was placed in
the umbilicus, and a 30 scope was used. Three 5-mm ancil-
lary trocars were placed in each lower abdominal quadrant
laterally and suprapubically in the midline.
The intra-abdominal procedure started with opening of the
bladder peritoneum with a bipolar hook. The bladder was
carefully separated from the anterior wall of the uterus to leave
sufficient myometrial tissue around the protruding isthmocele
in which to place the sutures (Fig. 2). To minimize the risk of
rupturing the membranes of the amniotic sac, the procedure
was performed under continuous TVUS. The edges of the
myometrial defect were reapproximated with 3 interrupted
sutures. To avoid confusion, the threads were kept in
tension extracorporeally. A synthetic polyfilament 2-0 (Premi-
Cron; B. Braun Surgical S.A., Barcelona, Spain) was used
(Fig. 3). The isthmocele was gently pushed under the
cervico-isthmic segment, and the sutures were tied. The pro-
cedure ended with the peritonealization of the bladder perito-
neum using a continuous absorbable suture (V LOC). The
patient was discharged on postoperative day 2 in good clinical
conditions. The pregnancy continued uneventfully, and no
signs of USD were identified on routine sonographic controls
(Fig. 4). A healthy newborn was delivered by an uncompli-
cated elective caesarean delivery at 38 weeks gestation.
Discussion
Herniating isthmocele due to USD is a newly recognized
entity, which will be diagnosed more often in the future
Fig. 2
The bladder was separated from the anterior wall of the uterus until a
dehiscence of 25 ! 25 mm with herniation of the amniotic sac was
identified. A, cervix; B, scar dehiscence with herniation of the isthmo-
cele; C, bladder.
owing to the increasing rate of CSs. Several studies have
observed that patients with a previous CS are at increased
risk for uterine rupture or dehiscence in subsequent pregnan-
cies [11,12]. Notwithstanding, controversy remains about
the obstetric importance of an isthmocele when detected
early in pregnancy. Only a few studies have evaluated the
relationship between the presence of USD and the risk of
uterine rupture in subsequent pregnancies. Vikhareva
Osser et al [13] found that patients with a larger USD were
at increased risk for uterine dehiscence and rupture in subse-
quent pregnancies compared with patients with smaller
defects, suggesting a direct relationship between USD size
and risk of pregnancy complications. Similar results have
been reported by Warnick et al [14]. Unfortunately, owing
to the small number of studies, the retrospective study
design, and small sample size, predicting which type of
USDs are more likely to lead to obstetrical complications
and which are not is not possible. Some previous studies
have demonstrated that near-term sonographic measurement
of the lower uterine segment thickness is predictive of uter-
ine rupture [11–17]. Moreover, Bujold et al [18] reported
that patients between 35 and 38 weeks gestation with a
Fig. 3
Three sutures were placed using a synthetic polyfilament.
Bolla et al. Laparoscopic Ultrasound-Guided Repair of Uterine Scar Isthmocele
Fig. 4
Postoperative transvaginal ultrasound at 13 weeks gestation (left) and at 26 weeks gestation (right). All ultrasounds were performed with a Voluson 730 unit.
A, cervix; B, repaired caesarean scar defect.
sonographically measured lower uterine segment thickness
of 2.3 mm have a 40% risk of complete uterine rupture.
In the present case, the patient presented at 8 weeks gesta-
tional age with a large, full-thickness defect of the lower
uterine segment. In addition, the isthmocele had a connec-
tion to the extra-amniotic space. Given these characteristics,
the patient was considered at elevated risk for miscarriage
and uterine rupture. After extensive counseling, the patient
opted for surgical repair of the USD. The goal of the inter-
vention was to repair the myometrial defect, thereby
increasing the strength of the uterine wall [19].
The procedure was performed laparoscopically in accor-
dance with current guidelines [20]. The surgery was per-
formed at 13 weeks gestational age, when the risk of a
spontaneous abortion (not related to the isthmocele) drops
and before the uterus is too large to allow further stretching
of the defect and to interfere with good visualization of the
lower uterine segment.
To minimize the risk of rupture of the amniotic sac and
increase the precision of the surgery, the procedure was per-
formed under continuous TVUS monitoring, facilitating pre-
cise placement of stiches. Interventional and intraoperative
TVUS are now increasingly used in minimally invasive
surgery, providing real-time anatomic and pathological in-
formation for intraoperative surgical planning [10,21–23].
Controversy remains as to whether or not vaginal delivery
is safe after such a procedure, and whether or not the risk of
uterine rupture is increased [10,24]. In this case, the patient
opted for a CS, deciding not to incur further risks. We believe
that the proposed laparoscopic ultrasound-guided repair of
USD is a safe approach to handling similar clinical situa-
tions.
3
Supplementary Data
Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.jmig.2015.09.010.
References
1. Caughey BA, Cahill AG, Guise J, et al. Safe prevention of the primary
caesarean delivery. Am J Obstet Gynecol. 2014;210:179–193.
2. Melo-Cerda I. Caesarean scar defect. Ginecol Obstet Mex. 2014;82:
530–534.
3. Vikhareva Osser O, Jokubkiene L, Valentin L. High prevalence of de-
fects in Caesarean section scars at transvaginal ultrasound examination.
Ultrasound Obstet Gynecol. 2009;34:90–97.
4. Stirnemann JJ, Chalouhi GE, Forner S, et al. First-trimester uterine scar
assessment by transvaginal ultrasound. Am J Obstet Gynecol. 2011;205:
551.e1–551.e6.
5. Bij de Vaate AJ, van der Voet LF, Naji O, et al. Prevalence, potential risk
factors for development and symptoms related to the presence of uterine
niches following Cesarean section: systematic review. Ultrasound
Obstet Gynecol. 2014;43:372–382.
6. Tower AM, Frishman GN. Cesarean scar defects: an underrecognized
cause of abnormal uterine bleeding and other gynecologic complica-
tions. J Minim Invasive Gynecol. 2013;20:562–572.
7. Fabres C, Aviles G, de La Jara C, et al. The cesarean delivery scar
pouch: clinical implications and diagnostic correlation between trans-
vaginal sonography and hysteroscopy. J Ultrasound Med. 2003;22:
695–700.
8. Raimondo G, Grifone G, Raimondo D, et al. Hysteroscopic treatment of
symptomatic cesarean-induced isthmocele: a prospective study.
J Minim Invasive Gynecol. 2015;22:297–301.
9. Xie HZ, Wu YX, Yu F, et al. A comparison of vaginal surgery and oper-
ative hysteroscopy for the treatment of cesarean-induced isthmocele: a
retrospective review. Gynecol Obstet Invest. 2014;77:78–83.
10. Marotta ML, Donnez J, Squifflet J, et al. Laparoscopic repair of post-
caesarean section uterine scar defects diagnosed in non-pregnant
women. J Minim Invasive Gynecol. 2013;20:386–391.
4 Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2015
11. Rozenberg P, Goffinet F, Phillippe HJ, et al. Ultrasonographic measure-
ment of lower uterine segment to assess risk of defects of scarred uterus.
Lancet. 1996;347:281–284.
12. Asakura H, Nakai A, Ishikawa G, et al. Prediction of uterine dehiscence
by measuring lower uterine segment thickness prior to the onset of
labor: evaluation by transvaginal ultrasonography. J Nippon Med Sch.
2000;67:352–356.
13. Vikhareva Osser O, Valentin L. Clinical importance of appearance of
cesarean hysterotomy scar at transvaginal ultrasonography in nonpreg-
nant women. Obstet Gynecol. 2011;117:525–532.
14. Waniorek A. Hysterography after cesarean section, with special refer-
ence to the effect of subsequent delivery on the hysterographic findings.
Am J Obstet Gynecol. 1966;94:42–49.
15. Cheung VY, Constantinescu OC, Ahluwalia BS. Sonographic evalua-
tion of the lower uterine segment in patients with previous cesarean
delivery. J Ultrasound Med. 2004;23:1441–1447.
16. Sen S, Malik S, Salhan S. Ultrasonographic evaluation of lower uterine
segment thickness in patients of previous cesarean section. Int J Gynae-
col Obstet. 2004;87:215–219.
17. Gotoh H, Masuzaki H, Yoshida A, et al. Predicting incomplete uterine
rupture with vaginal sonography during the late second trimester in
women with prior cesarean. Obstet Gynecol. 2000;95:596–600.
18. Bujold E, Jastrow N, Simoneau J, et al. Prediction of complete uterine
rupture by sonographic evaluation of the lower uterine segment. Am J
Obstet Gynecol. 2009;201:320.e1–320.e6.
19. Api M, Boza A, Gorgen H, et al. Should cesarean scar defect be treated
laparoscopically? A case report and review of literature. J Minim Inva-
sive Gynecol. 2015 Jun 26. [Epub ahead of print].
20. Guidelines Committee of the Society of American Gastrointestinal and
Endoscopic Surgeons, Yumi H. Guidelines for diagnosis, treatment, and
use of laparoscopy for surgical problems during pregnancy. Surg
Endosc. 2008;22:849–861.
21. Ukimura O, Okihara K, Kamoi K, et al. Intraoperative ultrasonogra-
phy in an era of minimally invasive urology. Int J Urol. 2008;15:
673–680.
22. Acker D, Frigoletto FD, Birnholz JC, et al. Ultrasound-facilitated
intrauterine transfusions. Am J Obstet Gynecol. 1980;138:1200–
1204.
23. Bolla D, Kettenbach J, Vial Y, et al. Percutaneous embolization of a
giant placental chorioangioma with histacryl gel: a case report and
review of the literature. Am J Ultrasound. 2014;1:25–31.
24. Jeremy B, Bonneau C, Guillo E, et al. Uterine ishtmique transmural
hernia: results of its repair on symptoms and fertility. Gynecol Obstet
Fertil. 2013;41:588–596.