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WJOLS

Laparoscopy in Cesarean Scar Pregnancy

A B
Figs 3A and B: Incision on the bulge

Table 1: Treatment modalities in Cesarean scar pregnancy segment, which is very important for future pregnancy
Severe outcomes.
Cases Success complication Medical management leaves the scar behind which
Method of treatment (n) rate (%) rate (%) can predispose to recurrence and also requires strict
Expectant management 41 41.5 53.7 adherence to monitoring by ultrasound and hormone
Systemic MTX 339 75.2 13 12
Needle aspiration + MTX/KCl 148 84.5 13.5 profile.
Hysteroscopy 95 83.2 3.2 Laparoscopy helps to confirm the diagnosis, removal
Selective UAE without MTX 295 93.6 3.4 of scar ectopic under better visualization, repair of defect,
13
UAE + D&C + hysteroscopy 85 95.4 1.2 as well as preservation of reproductive capacity. Use of
UAE + MTX 427 68.6 2.8 vasopressin intraoperatively and suturing can minimize
Local + systemic MTX 34 76.5 2.3 chances of hemorrhage and allow safe removal of ectopic
Local MTX 74 64.9 4.1 with multilayer closure of uterine defect. 14
Transvaginal resection 118 99.2 0.9 Based on a review of literature by Api et al, they
15
D&C 243 48.1 21 concluded that laparoscopy has an edge over hysteros-
Laparoscopy 69 97.1 0
Repeated HIFU ablation 16 100 0 copy with respect to repair of cesarean scar defect as it
HIFU + hysteroscopic suction 53 100 0 increases uterine wall thickness when compared with
curettage repair by hysteroscopic approach which does not help in
reducing the potential risk of scar dehiscence or rupture
in subsequent pregnancies.
16
In a case report published by Mahgoub et al from
a study conducted in Starsbourg, France, enucleation of
ectopic mass was done with isthmocoele treatment with
no complications, intraoperative blood loss of less than
100 mL, and discharge of patient on day 3.

DISCUSSION
From the studies reviewed, treatment of CSP should be
individualized with choice of management based on pre-
venting severe complications and conservation of fertility.
With facilities for laparoscopy readily available, it should
be considered as a good option for management of CSP.
Fig. 4: Uterine scar repair by endo-suturing after enucleation of sac In centers where facilities and skills are there, HIFU is
also an effective alternative but limited by availability.
Limitation in this area is that many of the reviewed
11
According to a literature review by Fuchs et al, the articles are case reports. Well-designed multicentric ran-
laparoscopic approach in management of CSP is safe domized controlled trials are required before any conclu-
and effective with minimal blood loss. It also gives an sion is made regarding best method of management. Until
excellent visualization of the pathology at hand and then, evidence-based treatment is followed with individu-
permits a good reconstruction of the lower uterine alization of cases also taking into account surgeon’s skills
World Journal of Laparoscopic Surgery, September-December 2017;10(3):135-138 137