Yusuke Sako and team carried out Technical video introducing
laparoscopic scar repair using nonperfusion hysteroscopy for patients with a
CSD at a Tertiary referral facility for gynecology to demonstrate a 5-step
approach to accurately identify the extent of resection of a cesarean scar
defect (CSD) and perform excision and repair of the lesion.
A 33-year-old woman who underwent intrauterine insemination
for secondary infertility 3 times but did not conceive complained of repeated
irregular bleeding caused by a CSD during infertility treatment was taken as
subject.
The video presents a systematic 5-step approach to
laparoscopic repair of a CSD.
Step 1: the lesion was coagulated and marked using a
hysteroscope.
Step 2: the lesion was thinned by cutting it using the
hysteroscope.
Step 3: after laparoscopic dissection of the bladder from
the lower uterine segment and turning off the laparoscope’s light source, the
thinned lesion could be identified using light from the hysteroscope.
Step 4: an incision was made at the lit-up point from the
abdominal cavity side using an ultrasonic coagulation incision device to access
the uterus.
Step 5: once the uterine lumen was reached, reflux from the
hysteroscope was stopped.
Intraperitoneal insufflation gas then flowed into the uterus
through the uterine wall perforation, and the lesion could be observed without
the use of a reflux fluid. This technique is called nonperfusion hysteroscopy.
By observing the marked lesion using nonperfusion hysteroscopy, it could be
resected laparoscopically along the appropriate incision line.
Advantage of performing 5 successive surgical steps to completely
resect a CSD using laparoscopic repair and resolve the patient’s symptoms was
the main objective. Laparoscopic repair using nonperfusion hysteroscopy allowed
recognition of the upper and lower edges of the lesion from the abdominal
cavity side.
The combined use of nonperfusion hysteroscopy allows
observation of the uterine lumen without the use of a reflux fluid because
pneumoperitoneum gas fills the uterine lumen. Intraoperative monitoring using a
hysteroscope and laparoscope allows visualization of the lesion site from both
sides while resection is being performed. This 5-step procedure permited
precise identification of the lesion area, complete removal of lesions, and
prevention of excessive resection that may reduce uterine function and increase
perinatal risk.
Source: Yusuke Sako, Tetsuya Hirata and Mikio Momoeda; Fertility
Sterility 2022