Page 2 - World Journal of Laparoscopic Surgery

ABSTRACT
Minimal Access Surgery in Cesarean Scar Pregnancy:

Challenges, Outcome and Road Ahead

1
Sandip Sudhakar Sonawane , Manasi Kathaley 2
Received on: 20 March 2023; Accepted on: 04 June 2023; Published on: 05 September 2023

AbstrAct
Introduction: The incidence of cesarean scar pregnancies (CSPs) has increased worldwide due to increase in cesarean deliveries. Laparoscopic
management is an effective strategy to deal with CSP resulting in immediate recovery, remediation, and repair of the cesarean scar defect. The
diagnosis and management of CSP are challenging, and awareness of this condition is needed among the patients and obstetricians.
Aims and objectives: To study preventable factors, role of minimal access surgery, and outcome in CSPs over a period of 2 years.
Materials and methods: It is a retrospective cohort study in which patient’s demographic characteristics, previous obstetric and surgical record,
β-hCG, USG parameters, clinical presentation, contraception, etc., were studied.
Results: Eleven cases of CSPs were admitted in a tertiary care hospital from 2019 to 2021. Median maternal age was 28 years with a median parity
of two. The most common presenting symptom was vaginal bleeding. Nine out of eleven cases were successfully managed by laparoscopy.
Hysteroscopy and ultrasonography were found very useful intraoperatively. Two patients required exploratory laparotomy. One patient had
an intrauterine pregnancy following the CSP.
Conclusion: Minimal access surgery remains the mainstay for the treatment of CSP in stable patients. Hysteroscopy and ultrasonography could
be very useful during laparoscopic management of CSP. Cesarean scar pregnancy preventable factors are to be taken into consideration while
performing cesarean section as the CSP incidence is increasing.
Clinical significance: This study will help in finding out risk factors to CSP. Preventive factors of CSP, if studied further in detail, can help in
reducing the incidence of this dreadful pathology. Early diagnosis and timely intervention with the help of minimal access surgery can save
young women from losing their fertility.
Keywords: Cesarean scar pregnancy, Hysteroscopy, Laparoscopy minimal access surgery.
World Journal of Laparoscopic Surgery (2023): 10.5005/jp-journals-10033-1557

IntroductIon 1,2 Department of Obstetrics and Gynecology, Dr Vasantrao Pawar
Cesarean scar pregnancy (CSP) is a rare type of ectopic pregnancy Medical College, Nashik, Maharashtra, India
where the embryo implants at the site of previous cesarean scar. Corresponding Author: Sandip Sudhakar Sonawane, Department
1,2
The reported incidence of CSP is ~1:1800–1:2216. It is of two types of Obstetrics and Gynecology, Dr Vasantrao Pawar Medical College,
endogenous and exogenous. When pregnancy grows toward the Nashik, Maharashtra, India, Phone: +91 9561999758, e-mail: drsss101@
uterine cavity, it is called as endogenous CSP, and when pregnancy gmail.com
grows toward the bladder, it is known as exogenous CSP. The risks How to cite this article: Sonawane SS, Kathaley M. Minimal Access
and complications associated with this condition are severe in Surgery in Cesarean Scar Pregnancy: Challenges, Outcome and Road
nature, those are ruptured uterus, massive hemorrhage, bladder Ahead. World J Lap Surg 2023;16(1):1–3.
involvement, etc. Continuation of pregnancy further may lead to Source of support: Nil
morbidly adherent placenta and life-threatening complications. 3 Conflict of interest: None
The incidence of cesarean section has increased worldwide
due to various reasons, and so the incidence of CSP has increased
significantly in the past decade. This is just a tip of an iceberg raising etc., causes cesarean scar defect in the anterior wall of the lower
alarm worldwide. Various conservative and surgical methods have uterine segment. 5–7
been tried till date, but the standard protocol for management of Insufficient decidualization enhances the process of
CSP is yet to be formed. 4 implantation through defective scar site causing invasion through
Advanced minimal access surgery inclusive of laparoscopy myometrium. Quality of suture material, techniques of suturing, and
and hysteroscopy has provided a ray of hope in the successful surgical sterility play an important role in repair at scar site. Various
management of CSP with less morbidity and quick recovery. other factors like total number of cesarean sections, dilatation and
Preventable factors, early diagnosis, skills of minimal invasive curettage procedures, short intervals between the present and
surgery, and guidelines need to be formed to counter this dreadful last pregnancy, cesarean section during labor, planned elective
condition on priority basis. cesarean sections, etc., have been correlated with a higher risk
8
Currently, knowledge on the exact etiological factors for CSP of CSP by different authors. Various conservative and surgical
is limited though multiple theories have been put forth. Wound modalities have been tried while managing CSP with limited
healing due to multiple factors like infection, anemia, misalignment, success. Since the management part has not been clear among the

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