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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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Chapter 3.2
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Repair of Cesarean Section Scar
Pete r S. Uzelac, Steven T. Nakajim a
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GENERAL PRINCIPLES
Definition
A cesarean section scar defect is characterized by incomplete healing of the anterior uterine wall at the site of a previous
cesarean section incision. The classic imaging appearance is that of a thin residual myometrium and a tent-like indentation
of the lower uterine segment which peaks toward the serosal border. An array of nomenclature to describe the defect
appears in the literature and includes uterine scar isthmocele, niche, diverticula, and postcesarean scar defect (PCSD) (Fig.
3.2.1A).
Symptoms associated with a previous cesarean section scar defect include abnormal uterine bleeding, pelvic pain, and a
reduction in fertility potential (attributed to persistent fluid or blood collection at the site of the defect which can impact the
cavity in a similar fashion as the presence of a hydrosalpinx).
1
A thin anterior uterine wall also increases the risk for obstetrical complications in subsequent pregnancies including scar
dehiscence, placenta accreta, and a cesarean section scar ectopic pregnancy.
2
Although there is no established criteria for the diagnosis, some authors have suggested that repair is indicated if the residual
myometrial thickness is <3.5 mm or there is a defect present that accounts for >50% of the thickness of wall.
3
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Risk Factors
Several modifiable and nonmodifiable risk factors for the development of cesarean section scar defect have been
proposed.
4
Modifiable techniques during the cesarean section procedure include the location of incision, closure technique
(single versus double layer, locked versus unlocked, suture material), and factors involved with adhesion formation
(nonclosure of peritoneum, inadequate hemostasis, tissue manipulation). Nonmodifiable risk factors include poor inherent
tissue healing and an increasing number of prior cesarean sections.
5
An association with retroflexion of the uterus has also
been observed.
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Differential Diagnosis
A cesarean section scar defect is often symptomatic and can present with abnormal uterine bleeding (postmenstrual spotting
or blood-tainted discharge), dysmenorrhea, dyspareunia, or abdominal pain.
The suspected defect should not be confused with a nabothian cyst (circular anechoic area(s) in cervix) and can easily be
differentiated from a vascular malformation with the use of color flow Doppler (Fig. 3.2.2A,B).
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IMAGING AND OTHER DIAGNOSTICS
A cesarean section scar defect can be detected as an incidental or diagnostic finding on B-mode ultrasound or after the
instillation of saline contrast during hysterosonography. A high index of suspicion is sometimes necessary in the latter as air
bubbles can enter the scar pouch during saline infusion, generating ultrasound echoes and masking the defect (Figs.
3.2.3A,B).
The defect can also be observed at the time of hysteroscopy and is characterized by an indentation in the anterior uterine
wall cephalad to the internal cervical os.
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PREOPERATIVE PLANNING
Preparation for the repair of a previous cesarean section scar defect should take into account the patient’s future
reproductive goals. Successful amelioration of irregular bleeding symptoms have been reported with the use of electrical
energy (resection and/or roller ball).
6
However, many practitioners employ a technique that reinforces and thickens the
anterior wall in the event of a future pregnancy. Although long-term and randomized data is lacking, it is generally accepted
that the thicker the residual anterior uterine wall, the less likely a subsequent adverse obstetrical event. Preoperative
quantification of the thickness of the anterior wall at the sight of the defect (in millimeters) can help as a comparison to
postoperative assessment.
Figu re 3 .2.1. A: P ost cesarean scar defect (P CSD) prior t o repair. The scar was 1.5 to 2.5 mm in t hickness. B : After t he repair, the P CSD was 5.5 mm in t he
thinnest section.
Figu re 3 .2.2. A: Retroflexed ut erus wit h scar defect anteriorly. The cervical canal is delineated wit h yellow dashed line. B: Same defect with color flow
confirming the anechoic area is not vascular in origin.
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Figu re 3 .2.3. A: Scar defect during hysterosonography. B: Air bubbles obscuring same defect as in Figure 3.2.3A.
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SURGICAL MANAGEMENT
Surgical reconstruction of a cesarean section scar defect has been described by both vaginal and abdominal (laparoscopic,
robotic, open) techniques. One advantage of an open mini-laparotomy approach (through the site of the previous
Pfannenstiel incision) may be the ease in identification of the extent of defect and evaluating the completeness of the repair.
The advantage of a laparoscopic (with or without robotic assistance) or hysteroscopic approach would be a shorter
recovery time from these minimally invasive approaches.
Indication for surgical repair of a cesarean section scar defect is for cessation of abnormal uterine bleeding, amelioration of
pelvic pain, promotion of fertility, and decreasing obstetrical risks in subsequent pregnancies. The procedure involves
identification of the scar defect, characterizing the extent of the defect, separation, and reapproximation of the superior and
inferior edges. After repair, the defect can be tested for completeness.
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Positioning
The patient should be placed in the normal standard dorsal lithotomy position as for other laparoscopic gynecologic
procedures. The partial introduction of an intrauterine system to the level of the lower uterine segment for the installation of
dye (Kronner Manipujector
®
[Cooper Surgical, Trumbull, CT]) can be helpful in identification of the defect as it is
approached abdominally and as a test of water-tightness after the repair.
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