Page 14 - World Journal of Laparoscopic Surgery

WJOLS

Roshan Zeirideen Zaid 10.5005/jp-journals-10033-1287
REVIEW ARTICLE

Should Laparoscopy be the Gold

Standard for Isthmocele?

Roshan Zeirideen Zaid

ABSTRACT The ripple effect of the rising CS rates are being seen in
Isthmocele is born due to the overwhelmingly increasing cesar- many ways. Apart from the well-known placental compli-
ean section (CS) rates all over the world. It was an unknown cations and others following CS, the rising concerns have
entity in the last century. Cesarean sections are and can be turned toward the potential long-term morbidity of the
responsible for short- and long-term maternal and fetal mor- scar. Isthmocele is an iatrogenic entity created in the last
bidity, mortality, and financial issues, directly and indirectly
associated to the former. Out of the many problems that are few decades due to the worldwide increase in CS rates.
caused by CS, isthmocele is a growing surgical concern that Isthmocele aka CS scar defect (CSD), CS scar abnormality,
needs attention in identifying, diagnosing, managing, and pouch, niche, atypical cesarean scar syndrome or cesar-
treating this problem. Currently, treatments include medical ean scar syndrome, uterine diverticulum, uteroperitoneal
and surgical approaches. Hysteroscopy as well as laparoscopy fistula is a result of weak or incompletely healed scar. 3-7
are used in the treatment. This review was carried out to show
that laparoscopy is superior in treating an isthmocele than all Isthmocele is believed to cause symptoms like post-
other treatment modalities. menstrual spotting, discharge, smelly postmenstrual
8
Materials and methods: An electronic search was done and bleeding, chronic pelvic pain, and dyspareunia, and
various articles and studies were reviewed to support the lately, there has been evidence that this could be related
hypothesis. to secondary subfertility. Apart from the above, other
9
Keywords: Cesarean section, Hysteroscopy, Isthmocele, problems associated with scar defect are high-risk
Niche, Postmenstrual bleeding, Scar defect. complications with subsequent pregnancies, such as
10
How to cite this article: Zaid RZ. Should Laparoscopy be dehiscence, placenta previa or accrete, and cesarean scar
11
the Gold Standard for Isthmocele? World J Lap Surg 2016; ectopic pregnancy, and difficulty with gynecological
12
9(3):118-121.
procedures like uterine evacuation, hysteroscopy, and
Source of support: Nil
intrauterine-device insertion. 13
Conflict of interest: None Thurmond postulated in 1999 that a niche in the cesar-
ean scar could be the cause of abnormal bleeding due to
14
InTRoduCTIon the collection of menstrual blood in the pouch. . In 1961
it was first described as a wedge in HSG (hysterosalpi-
Cesarean section (CS) was always believed to be a lifesav- gogram) by Poidevin. Also Morris had similar find-
16
15
ing operation for the mother and the unborn. But ironi-
cally, its rates are rising in the midst of highly improving ings while analyzing uterine specimens of women who
underwent hysterectomies. U- or V-shaped hypoechoic
medical advances in maternal and newborn care. Forbes
1
magazine has recently published that in the Organisation or anechoic fluid accumulation in the region of former
17
uterotomy was considered as diagnostic with the above-
for Economic Co-operation and Development (OECD)
countries, the CS rate approximately stands at 28%. This described symptoms.
The incidence of ismocele varies so much from as low
includes 34 countries around the world. Further, the World
health organization (WHO) Global Survey indicates that as 24% to as high as 84%. Prospective cohort studies done
9,18,19
Van der
by Florio state the prevalence as 30 to 52%.
overall CS rates have increased over time in all countries 20
except Japan from 26.4 to 31.2% in a multicountry survey voet et al. found the prevalence to be 64.5% 6 to 12 weeks
after CS in women using transvaginal ultrasound and
(p = 0.003). 2
sonohysterography. All studies agree that all women
who have the scar defect are not symptomatic. Tower and
21
Board-Certified (UK) Resident Consultant Frishman found the prevalence of symptomatic CSD
could be as low as 19.4% to as high as 88%.
Department of Obstetrician and Gynaecologist, Nawaloka
Hospitals PLC, Colombo, Sri Lanka
Theories/Risk Factors Contributing
Corresponding Author: Roshan Zeirideen Zaid, Board Certified to the Formation of the defect
(UK) Resident Consultant, Department of Obstetrician and
Gynaecologist, Nawaloka Hospitals PLC, Colombo, Sri Lanka The exact reason is unknown, but there are many hypoth-
e-mail: roshanzeirideen@yahoo.com
eses regarding the contributing factors. The niche is typi-
118