{Reference Type}: Case Reports
{Title}: Surgical Management of Cesarean Scar Defect: The Hysteroscopic-Assisted Robotic Single-Site Technique.
{Author}: Guan Z;Liu J;Bardawil E;Guan X;
{Journal}: J Minim Invasive Gynecol
{Volume}: 27
{Issue}: 1
{Year}: 01 2020
{Factor}: 4.314
{DOI}: 10.1016/j.jmig.2019.06.007
{Abstract}: To educate surgeons on the advantages of robotic techniques in hysteroscopic-assisted single-site resection of cesarean scar defect.<BR>A step-by-step video presentation detailing the complete surgical procedure.<BR>University Hospital, Baylor College of Medicine, Houston, Texas.<BR>The first patient was a 34-year-old G2P2002 who complained of dysmenorrhea and menorrhagia, with an expressed desire for a single-site cesarean scar defect correction. Her surgical history included 2 cesarean deliveries, in 2012 and 2014. The second patient was a 34-year-old G4P3013 who complained of dysmenorrhea and a persistent mucus vaginal discharge, with an expressed desire for a cesarean scar defect correction in anticipation of conception. Her surgical history was notable for 3 previous cesarean deliveries. Neither patient's ultrasound report showed adenomyosis or any other pathologies.<BR>In both patients, hysteroscopic-assisted robotic single-site resection of the cesarean scar defect was performed, using a monopolar hook, wristed needle drivers, cold scissors, and a diagnostic vs operative hysteroscope. Entry was made through the umbilicus with a 15-mm incision and carried down through the subcutaneous tissue until the fascia was grasped and entered using Mayo scissors. The abdomen was inspected. The bladder was carefully disected off of the lower uterine segment and then backfilled to aid identification of the correct plane for dissection. Once the bladder was adequatetly dissected off of the uterus, the suspected defect could be identified. The monopolar hook was used to incise the defect, and the tip of the hysteroscope was placed through the defect to fully delineate it. The edges were trimed with cold scissors (Endoshears) in the first surgery and the monopolar hook in the second surgery. The uterine defect was closed with 2 layers of countinuous running V-Loc suture. The peritonium was closed with an additional V-Loc suture in a running fashion. Finally, hysteroscopy was performed. The closure was noted to be watertight, verifying successful repair of the defect. In the second case, an intercede was placed over the defect to help prevent future adhesive disease. In addition, after consulting with experts in cesarean scar repair, an energy device was recommended, and thus the monopolar hook over cold scissors was used for the second case due to its superior cutting effect. In both cases, the pelvis was inspected, and hemostasis was observed throughout.<BR>The 2 cases had similar outcomes, with successful repair of the cesarean scar defect and resolution of the patient's symptoms. The thickness of the residual myometrium in cesarean scar defect was 2.8 mm in the first case and 2.3 mm in the second case. This video is exempt from Institutional Review Board review. In the first case, the surgery was completed in 90 minutes with only 15 mL of blood loss. The patient was discharged home on the day of surgery and denied any postoperative complications at her follow-up appointment. In the second case, the surgery was completed in 85 minutes with only 10 mL of blood loss. The patient was discharged home on the day of surgery. At her follow-up appointment, she had a positive pregnacy test and denied any postoperative complications. When contacted at a later date, she revealed that she was 15 weeks pregant.<BR>Hysteroscopic-assisted single site resection of a cesarean scar defect is a feasible method for the resection of cesarean scar defect. Use of the robot makes the difficult surgical techniques required for this operation easier and more accessible.