Page 15 - World Journal of Laparoscopic Surgery

WJOLS

Should Laparoscopy be the Gold Standard for Isthmocele?
On this basis, treatment should be aimed to relieve the
symptoms and strengthen the wall of the myometrium
again to prevent potential complications, that is, surgical
reconstruction of the uterotomy scar. 17
Medical and hormonal (combined contraceptive
pills and intra uterine device (IUD)) have not shown
any improvement in quality of life. Hysteroscopy and
treatment appear to remove the symptoms. Also some
studies have suggested hysterectomies for postmenstrual
bleeding. Laparoscopy has been used on its own or in
conjunction with hysteroscopy in surgically correcting
this defect. Very few cases of vaginal revision and endo-
metrial ablations have also been mentioned.
Saline infusion sonohysterosonography (SIS lavage)
Fig. 1: Cesarean scar defect was described by Ida et al in successfully healing the
25
defect spontaneously in a single case report.
cally found on the anterior surface of the uterus on the
hysterotomy scar. Thinning of the myometrium creates dISCuSSIon
a pouch (Fig. 1). 7 The niche is still an unknown or a new entity for many.
There is no clear definition for a CSD; neither is it a
Patient Related Factors common terminology. Hence, the prevalence of the

• Multiple Cesarean deliveries condition has huge variations. Some have a vague
• Factors impacting wound healing definition ie a U-, V-, or triangular-shaped anechoic or
17
21
• Factors that possibly hamper normal wound healing hypoechoic fluid collection seen on scan or SIS is
8
18
and related angiogenesis, retroflexed uterus, simply considered as a niche. No standardized defini-
• Labour before CS. 21,22 tion is found in the literature. Hence, comparing studies
is challenging.
Surgery Related
Possible Mechanism
• Single-layer uterine wall closure (incomplete/dis-
rupted closure of myometrium), The collected blood from the niche present as postmen-
• Use of locking sutures, closure of hysterotomy with strual bleeding problems. The flow of menstrual blood
7
endometrial-sparing technique. through the cervix may be slowed by the presence of
• Low location (cervix) of uterine scar at the time of CS, isthmocele, as the blood may accumulate in the niche
• Surgical activities that may induce adhesion formation because of the presence of fibrotic tissue, causing pelvic
(i.e., non closure of peritoneum, inadequate hemosta- pain in the suprapubic area. Moreover, persistence of
sis, applied sutures, use of adhesion barriers). 8 the menstrual blood after menstruation in the cervix
This abnormality can be visualized on transvaginal may negatively influence the mucus quality and sperm
ultrasound, saline-infused sonohysterography (SIS), and quality, obstruct sperm transport through the cervical
9
hysterosalpingography (HSG). It is seen as a hypoechoic canal, and interfere with embryo implantation, leading
9
area as a discontinuation of the myometrium. An mag- to secondary infertility.
netic resonance imaging (MRI) should be used to confirm Hysteroscopy is the most commonly reported
the position and defect size prior to attempting to repair approach in the literature. Other methods include mostly
23
the defect. Hysteroscopy is also a useful modality to laparoscopy in combination with hysteroscopy or on its
26,27
assess the defect. 24 own. Few suggest vaginal, medical (hormonal, IUD),
and SIS lavage). In spite of hysteroscopy being the famous
method, it has its own pitfalls. Resectoscope is less
Treatment options
9
invasive and can be used to correct the defect, but the
All theories point to a thin disrupted layer of myome- hysteroscopic approach is not possible in all cases, and
trium surrounding the niche. Possibilities of the niche also it is good only in correcting the defect, not strength-
been covered by polypoidal endometrium, congested ening the myometrium or correcting the disruption and
endometrium/new blood vessels, 8,16 and hyalinized myo- reinforcing the endurance. Potential scar rupture or
6
metrium are being described in histological specimens. dehiscence is not corrected in hysteroscopic approach. 28,29
World Journal of Laparoscopic Surgery, September-December 2016;9(3):118-121 119