Uterine dehiscence: a laparoscopic uterine repair in early pregnancy

Objective: To review the existing literature on uterine cesarean scar defect repair in pregnancy and describe an approach to minimally invasive surgical repair in early pregnancy to facilitate a term live birth. Design: A case study and literature review, followed by a demonstration of the procedure with surgical video and concurrent ultrasound footage. Setting: Academic medical center. Patient(s): This video is a case presentation of a 35-year-old, gravida 2, para 1 woman with a previous cesarean section. She presented at 10 weeks and 3 days gestational age with complete uterine dehiscence at the site of her previous cesarean section scar, which was diagnosed by ultrasound. Surgical video and medical images have been extracted from this patient's chart after consent was obtained. Intervention(s): Ultrasound-guided laparoscopic repair of cesarean scar defect at 11 weeks and 3 days of gestation. Main Outcome Measure(s): The video showed a large 2.6-cm uterine scar defect in early pregnancy confirmed using ultrasound and magnetic resonance imaging. This diagnosis was confirmed by direct visualization at the time of surgery. This video demonstrates our surgical approach as follows: careful uterine manipulation and identification of the defect with laparoscopy and concurrent transvaginal ultrasound; reflection of the bladder using an ultrasound-guided approach to confirm the borders of the defect; and repair with a running 2-layer closure under transvaginal ultrasound guidance. Result(s): Through ultrasound-guided laparoscopic repair, we were able to demonstrate a restoration of approximately 8 mm of myometrial thickness across the cesarean scar defect on antenatal follow-up. The patient had a term live birth via cesarean section. Conclusion(s): With an increased number of cesarean sections and improved quality of ultrasound imaging, an increase in the incidental findings of cesarean scar defects has been observed. The risk of spontaneous prelabor uterine rupture remains unknown. There is a literature gap in this area regarding the appropriate standard of care. This video demonstrates that ultrasound-guided laparoscopic repair was possible, safe, and effective in our patient. However, further studies are required to establish the safety and efficacy of this approach. (C) 2022 by American Society for Reproductive Medicine.