Isthmocele Repair: Robotic-Assisted Laparoscopy with Simultaneous Hysteroscopy

Video Objective To illustrate the use of robotic-assisted laparoscopy with simultaneous hysteroscopy for the repair of an isthmocele. Setting An isthmocele is a pouch-like anterior uterine wall defect at the site of a previous cesarean scar. The incidence is not well known but is estimated in the literature is between 19 and 88%. Complications arising from an isthmocele may include abnormal uterine bleeding (especially postmenstrual bleeding), abdominal pain, diminished fertility, ectopic pregnancy, or obstetric complications such as uterine rupture. Repair of isthmocele may be indicated for symptomatic relief and preservation of fertility. Multiple surgical approaches have been described in the literature including laparoscopic, hysteroscopic, and vaginal approaches. Interventions In this video, we illustrate the key surgical steps of robotic-assisted laparoscopy with simultaneous hysteroscopic guidance for the repair of an isthmocele. Key surgical steps include: 1. Pre-surgical planning with MRI 2. Diagnostic hysteroscopy for confirmation of isthmocele 3. Simultaneous laparoscopy for identification of borders 4. Strategic hysterotomy 5. Excision of scar tissue 6. Tension-free closure Conclusion Robotic-assisted laparoscopy with simultaneous hysteroscopy is a feasible and safe approach for the repair of an isthmocele.