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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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Laparotomy
Abdominal inci sion
The first step is re-entry of the abdomen at the site of the previous Pfannenstiel incision. Taking into account patient habitus
and extent of the uterine defect it may be possible to begin with a mini-laparotomy. A preoperative diagnosis of a
retroverted uterus should be appreciated. Special attention should be made to minimizing tissue trauma with gentle
manipulation. Blunt dissection should be avoided. This area can be vascular and timely hemostasis without the excessive
use of electrocautery should be the goal. Lysis of any adhesions should be performed. Anatomy can be distorted especially
with multiple prior cesarean sections. It is important to verify that you are in the correct plane of the defect to ensure equal
cut edges.
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Creation of the bladder flap
We recommend the creation of a bladder flap to avoid entry into the bladder.
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Determine location of defect
From the abdominal approach, the exact location of the scar defect may not be readily apparent. Instillation of uterine dye
may provide localization. We have also employed a blunt tip probe for localization of the scar defect (Tech Fig. 3.2.1).
Te ch Fig ure 3.2.1. A blunt tip probe is used to aid in localization of scar dehiscence.
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Incise and open defect
Once the area of the defect is identified, we prefer a sharp incision to open. This provides the cleanest edges for
reapproximation.
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Reclosure of scar
A two-layered, running, nonlocking suture is performed with 2–0 and 3–0 Vicryl
®
suture (Ethicon, Inc., Somerville, NJ)
(Te ch Fig. 3.2.2). Careful attention should be made to reapproximate the endometrial edges.
Te ch Fig ure 3.2.2. Sut ure material in place after reclosure of cesarean section scar.
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Reapproximation of bladder flap
The bladder flap should be reapproximated, but not advanced upward onto the lower uterine segment of the uterus.
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Laparoscopy and/or Hysteroscopy
Initial choice of either procedure
The use of either a laparoscopic versus a hysteroscopic approach is primarily influenced by the patient’s desire for future
fertility. If symptoms of pelvic pain or dysmenorrhea are attributed to residual menstrual blood sequestered behind a fibrous
band of adhesions in the niche, then resection of fibrous tissue with the hysteroscope may be the only treatment required to
resolve these symptoms. If the patient is interested in future fertility, a laparoscopy to incise the defect and reapproximate
the cut edges is the treatment of choice. Hysteroscopy may also be utilized during the laparoscopy to identify the extent of
the niche defect.
The initial description of the laparoscopic repair of an uteroperitoneal fistula was described by Nezhat and colleagues in
2003.
7
A recent review of this topic by the same group highlighted the increased incidence of this defect due to the rise in
cesarean delivery.
8
https://t.me/med1917
Creation of the bladder flap
A bladder flap is created to move the bladder off the lower uterine segment and avoid entry into the bladder.
https://t.me/med1917
Determine location of defect
The light from a hysteroscope can illuminate the niche defect. The brightness of the hysteroscopic light source can be seen
through the thinned myometrium. The extent of the defect can also be identified with the use of cervical dilator.
https://t.me/med1917
Incise and open defect
Once the area of the defect is identified, a sharp incision through and around the defect is made. This provides the cleanest
edges for reapproximation.
https://t.me/med1917
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