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- The management of USD in pregnancy remains a matter
edly in the last decade, exposing women to a greater risk of debate, however. In particular, there is a lack of studies
of complications in future pregnancies, such as placenta ac- evaluating the risks and benefits of a surgical repair
creta, uterine rupture, and ectopic caesarean scar pregnancy. compared with conservative treatment in subsequent preg-
An important role in this pathological process seems to be nancies. We present a surgical technique for laparoscopic
played by an inappropriately healed caesarean scar [1–3]. ultrasound-guided repair of a large uterine scar isthmocele
After a CS, the presence of a uterine caesarean scar defect connected with the extra-amniotic space in the first trimester
(USD) is frequent, with incidence ranging from 24% to of pregnancy.
70% [3–5]. This defect, also called isthmocele, is
diagnosed on transvaginal ultrasound (TVUS) and is
Case Report
characterized by a myometrium gap in the site of the
caesarean scar [3–5]. A 29-year-old woman, gravida 3 para 1, was referred to
Isthmocele-associated symptoms are abnormal uterine our hospital at 8 weeks of gestation for management of an
bleeding, including postmenstrual spotting and prolonged incidental finding on TVUS of a wide USD connected
menstruation and infertility [6]. In these cases, the recom- with the extra-amniotic space. She had undergone CS 2 years
mended treatment is the surgical repair of the caesarean earlier owing to breech presentation and an early miscar-
scar. Various techniques for isthmocele repair with excellent riage. At admission, ultrasound confirmed a very thin uterine
outcomes have been described [7–10]. scar with a wide interruption of the myometrium and a
25 ! 25-mm herniating isthmocele connected to the
Disclosures: None declared. extra-amniotic space of the early pregnancy (Fig. 1).
Corresponding author: Daniele Bolla, MD, Department of OBGYN, Univer- Given the entity of the defect and the early gestational age
sity of Bern, Inselspital, Effingerstrasse 102, CH-3010 Bern, Switzerland. of the patient, decision was taken to attempt a surgical repair
E-mail: [email protected] of the uterine defect to reduce the risk of perinatal complica-
Submitted August 16, 2015. Accepted for publication September 6, 2015. tions. Laparoscopic ultrasound-guided repair of USD was
Available at www.sciencedirect.com and www.jmig.org performed under general anesthesia at 13 weeks gestation.
1553-4650/$ - see front matter Published by Elsevier Inc. on behalf of AAGL.
http://dx.doi.org/10.1016/j.jmig.2015.09.010
2 Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2015

Fig. 1 Fig. 2
Transvaginal ultrasound (Voluson 730; GE Ultrasound, Glattbrugg, The bladder was separated from the anterior wall of the uterus until a
Switzerland) of a uterine scar dehiscence at 13 0/7 weeks gestation con- dehiscence of 25 ! 25 mm with herniation of the amniotic sac was
nected with the extra-amniotic space. A, cervix; B, scar dehiscence with identified. A, cervix; B, scar dehiscence with herniation of the isthmo-
herniation of the isthmocele; C, bladder; D, gestational sac. 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
Antibiotic prophylaxis with Augmentin (amoxicillin and the obstetric importance of an isthmocele when detected
clavulanic acid) was given. A uterine manipulator was not early in pregnancy. Only a few studies have evaluated the
used. Pneumoperitoneum (CO2) using the Veres technique, relationship between the presence of USD and the risk of
with an intraabdominal pressure of 10 mmHg, was per- uterine rupture in subsequent pregnancies. Vikhareva
formed to reduce the risk of possible hemodynamic or respi- Osser et al [13] found that patients with a larger USD were
ratory adverse effects. A 10-mm optical trocar was placed in at increased risk for uterine dehiscence and rupture in subse-
the umbilicus, and a 30 scope was used. Three 5-mm ancil- quent pregnancies compared with patients with smaller
lary trocars were placed in each lower abdominal quadrant defects, suggesting a direct relationship between USD size
laterally and suprapubically in the midline. and risk of pregnancy complications. Similar results have
The intra-abdominal procedure started with opening of the been reported by Warnick et al [14]. Unfortunately, owing
bladder peritoneum with a bipolar hook. The bladder was to the small number of studies, the retrospective study
carefully separated from the anterior wall of the uterus to leave design, and small sample size, predicting which type of
sufficient myometrial tissue around the protruding isthmocele USDs are more likely to lead to obstetrical complications
in which to place the sutures (Fig. 2). To minimize the risk of and which are not is not possible. Some previous studies
rupturing the membranes of the amniotic sac, the procedure have demonstrated that near-term sonographic measurement
was performed under continuous TVUS. The edges of the of the lower uterine segment thickness is predictive of uter-
myometrial defect were reapproximated with 3 interrupted ine rupture [11–17]. Moreover, Bujold et al [18] reported
sutures. To avoid confusion, the threads were kept in that patients between 35 and 38 weeks gestation with a
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- Fig. 3
cedure ended with the peritonealization of the bladder perito- Three sutures were placed using a synthetic polyfilament.
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
Bolla et al. Laparoscopic Ultrasound-Guided Repair of Uterine Scar Isthmocele 3

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 Supplementary Data

of 2.3 mm have a 40% risk of complete uterine rupture.
Supplementary data related to this article can be found at
In the present case, the patient presented at 8 weeks gesta-
http://dx.doi.org/10.1016/j.jmig.2015.09.010.
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, References
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