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Isthmocele. Hysteroscopic & Laparoscopic surgery
Wed - January 8, 2020 12:04 pm  |  Article Hits:1248  |  A+ | a-
isthmoceles
isthmoceles
This “gap” in the anterior lower uterine segment receives different names, being the terms “niche” or isthmocele the most commonly used. This defect and its relation with some clinical symptoms such as menorrhagia, abdominal pain, dyspareunia and dysmenorrhea was first described by Morris using the term “cesarean scar syndrome”. The estimated incidence of cesarean scar defect (CSD) ranges from 24% to 56% [10]. This incidence varies considerably depending on the reports. This is due to variation on definitions and the differences in the methods used for the diagnosis of the defect. There is a clear relationship between the anatomic defect and the presence of different degrees of postmenstrual bleeding and other gynecological symptoms such as dysmenorrhea, chronic pelvic pain and infertility. The diagnosis of this condition is mainly based in the clinical symptoms, ultrasound evaluation, and hysteroscopy. There is a high correlation between transvaginal ultrasound and hysteroscopy in the diagnosis of cesarean scar defects as have been observed in different papers.



Different treatments have been proposed to corret this defect. Medical therapy with the use of oral contraceptives to reduce menstrual blood, hysteroscopy surgery to facilitate the drainage of blood and to reduce the local production and laparoscopic or vaginal surgery to correct the defect, trying to restore the normal anatomy of the istmical area. When performing Isthmocele repair surgery, regardless of the selected approach, the aim should be at treating the factors responsible for postmenstrual bleeding. Acting in this way will improve the patient's symptoms, solve the problem of infertility associated with impaired sperm transport and reduce chronic inflammation, which will improve the associated painful symptoms.

The hysteroscopic surgical isthmocele correction technique consists of four steps following Gubbini's recommendation. As previously mentioned, the difference with the technique proposed by Fabres lies in the resection of both the lower and upper fibrous arch.

The surgical technique is usually performed with resectoscopes of 26-27 fr after dilation of the cervical canal. Many authors prefer the use of smaller resectors or even mini-resectors that do not require prior cervical dilation. By not performing a previous cervical dilation, the normal anatomy of the isthmocele is not altered, better identifying the defect in its natural state without creating any artifact in the anatomical structures.

The steps to follow to perform an Ithmocele repair are the following:

1- Resection of the lower fibrous arch. The resection of this fibrous tissue that is responsible for the natural exit of the menstrual flow is performed. This anterior arc must be resected until the continuity of the anterior face is restored, making the defect flat, allowing visualization the isthmocele dome. By resecting this fibrous tissue, we prevent the isthmocele from acting as a reservoir of postmenstrual blood.

2- Resection of the posterior arch. Resecting the posterior arch reduces fibrous retraction and improves uterine contractility, a very important factor in cleaning the uterus after menstruation.

3- Superficial coagulation of the vessels at the bottom of the isthmocele. The objective is to reduce the production of menstrual blood and debris in situ derived from the inflammation and vascular fragility found at the bottom of the isthmocele. We must remember that deep 4- Closing the opening. Most authors use resorbable suture material in double layer for the closure of the myometrium. We have observed that it is easier if it is done first at the corners and then at the level of the center of the defect. These two layers are intended to achieve a greater thickness of residual myometrium thus eliminating the previous defect. Subsequently, the peritoneal closure is performed.

The laparoscopic correction technique requires a high skill level of laparoscopic surgery and a good laparoscopic suture technique, the most difficult step of the procedure is the dissection of the vesicouterine space. There is currently a consensus on choosing the laparoscopic repair technique when the thickness of the residual myometrium is less than 3 mm given that there is little safety margin of the residual myometrium increasing the chance of bladder injury if performed with a hysteroscopic approach.

CHOICE OF ROUTE FOR REPAIR

Surgical techniques for treating isthmocele can be divided into defect reparative with symptoms relief or symptomatic relief only.
Symptomatic surgery aims to improve the symptoms associated with isthmocele such as postmentrual bleeding, infertility and pain. This type of surgery is performed with an hysteroscopic approach which is not intended to repair the healing defect but simply to improve the associated symptoms. 

Corrective or reparative surgery pursues the goal to repair the defect and restore the normal anatomy at the isthmic level. This type of surgery can be performed laparoscopically, robotically, combined or vaginally. The opening of the defect, the excision of the fibrous scar tissue from the edges and the closure of the defect by planes are the common points to these techniques.
It should be noted that not all isthmoceles are symptomatic, that not all are associated with postmenstrual bleeding or infertility and that surgery should be reserved only for symptomatic cases.

Recently an agreement of the scientific committee of the Global Congress on Hysteroscopy was published in which is stated that
the hysteroscopic approach represents a comfortable and safe option to treat this pathology when the residual endometrial thickness is at least in 3 mm. On the other hand, when the thickness of the residual myometrium is less than 3 mm, the
preferred route should be laparoscopic, robotic, vaginal or combined, due to the risk of uterine perforation and bladder injury if the hysteroscopic route is chosen .
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