The objective of this approach, either by traditional laparoscopy or by robotic assisted technology, is the correction of the healing defect. It is therefore a corrective or restorative surgery unlike the hysteroscopic approach that is aimed only at treating the symptoms associated with isthmocele
This reparative treatment is based on the opening of the defect, resection of the fibrotic tissue located at the edges and closing the defect with suture, with the aim of achieving a complete closure of the defect. Fig 5
The steps to follow in this technique are:
1- Identification of isthmocele and dissection of vesicouterine plica to create a bladder flap. This maneuver separates the bladder from the anterior uterine wall, exposing the area of greatest weakness of the isthmocele. This area with less residual myometrium corresponds to the dome of the healing defect. Generally, it is a difficult dissection since there is usually a certain degree of fibrosis and adhesions. The risk of this initial maneuver is the accidental opening of the bladder wall and is therefore the most delicate maneuver of this type of approach. It is important to have an intravesical catheter that serves as a reference or work with the bladder partially filled.
2- Opening of the isthmocele. Once the isthmocele is located, it is opened from side to side throughout its length. There are several methods used to locate exactly the opening area. Perhaps the most common maneuver consists in the simple introduction of a hysterometer at the bottom of the scar of the anterior caesarean section, since it is a very thin area of myometrial tissue, the simple pressure with the tip of the hysterometer will bulge the incision area.
Another proposed technique consists in the use of a hysteroscope that is introduced into the isthmocele, the transillumination that occurs when observed by laparoscopy helps to locate the exact point of ideal opening, this method of locating the defect has been called the “sign of Halloween”
3- Excision of the fibrous edges. This maneuver aims to eliminate scarred fibrous tissue from the edges of the isthmocele, allowing better healing of the closure. We use bipolar in pure cutting mode to carry out this maneuver.
4- Closing the opening. Most authors use resorbable suture material in double layer for the closure of the myometrium. We have observed that it is easier if it is done first at the corners and then at the level of the center of the defect. These two layers are intended to achieve a greater thickness of residual myometrium thus eliminating the previous defect. Subsequently, the peritoneal closure is performed.
The laparoscopic correction technique requires a high skill level of laparoscopic surgery and a good laparoscopic suture technique, the most difficult step of the procedure is the dissection of the vesicouterine space.
There is currently a consensus on choosing the laparoscopic repair technique when the thickness of the residual myometrium is less than 3 mm given that there is little safety margin of the residual myometrium increasing the chance of bladder injury if performed with a hysteroscopic approach.