A novel approach using vaginal natural orifice transluminal endoscopic surgery to repair a symptomatic uterine isthmocele

Abstract

Objective: To describe the first case of using a vaginal natural orifice transluminal endoscopic surgery approach to repair a uterine isthmocele.

Design: Stepwise explanation of the surgical technique using original video footage. This study was exempted from requiring hospital Institutional Review Board approval.

Setting: Hospital.

Patient(s): A 30-year-old (gravida 2, para 2) patient presented with symptoms of intermenstrual bleeding and secondary subfertility following 2 uncomplicated cesarean section deliveries (elective for breech and repeat). The patient had a transvaginal ultrasound (US) demonstrating an isthmocele with a defect of 8.1 × 7.0 mm with a myometrial thickness of 2 mm over the defect and proceeded to undergo surgery because of persistent symptoms.

Intervention(s): An anterior vaginal incision is made on the cervix from the 3 o'clock to 9 o'clock position after local anesthetic and adrenaline infiltration of the tissue. The vaginal epithelium was carefully dissected cephalad, although an attempt was made to maintain the uterovesical space and fold. A small (7 cm) V-path gel port was inserted into this uterovesical space and the gel port was affixed with a port connected to an insufflation stabilization bag to minimize the pressure fluctuations within the confines of a small operative space and help maintain visualization throughout. Under endoscopic view, the site of the isthmocele was identified using an endoscopic US probe and confirmed on 2 dimensional imaging. A monopolar hook with an inbuilt aspirator and suction function was used to incise over the isthmocele with a grasper used to dissect into this space. A Hegar dilator was used to delineate the cervical canal. Once the isthmocele was excised, the defect was reinforced and obliterated with a barbed suture whereas the Hegar dilator was in place to prevent inadvertent canal occlusion during suturing. Continuous suturing took place from the cephalad to the caudal directions in 2 layers. Once hemostasis was confirmed, the gel port was removed, and the vaginal epithelium was closed with interrupted sutures using a braided absorbable suture. The perioperative course and care were uneventful with the Foley catheter being removed 3 hours after surgery. The patient was discharged within 24 hours. A follow-up organized 6 weeks after surgery demonstrated obliteration and repair of the previously detected uterine isthmocele on the pelvic US scan. The patient also reported a resolution of symptoms at this postoperative visit.

Main outcome measure(s): N/A.

Result(s): N/A.

Conclusion(s): Uterine-conserving surgical approaches to an isthmocele have been described, including vaginal, hysteroscopic, and laparoscopic (with and without robotic assistance) approches and laparotomy, with no single approach deemed to be superior to the others. The existing evidence is limited by the lack of uniformity in the definition and diagnosis of uterine isthmocele, consistency in indication for surgery, and small case numbers in published surgical series. Vaginal natural orifice transluminal endoscopic surgery provides a novel approach to this type of surgery, which may be potentially less invasive as the procedure is conducted outside the peritoneal cavity and combines the best vaginal approach to the surgical site with endoscopic magnification and capacity for microscopic dissection. This approach should be considered new and only in a clinically appropriate and carefully counseled patient.

Keywords: Cesarean scar defect; gynecology; isthmocele; natural orifice transluminal endoscopic surgery; niche; vNOTES.