This article presents the methods and surgical tips for hysteroscopy and robotic-assisted laparoscopic repair of the isthmocele.

Step-by-step explanation of the technique by using videos and pictures.

The isthmocele is a pouch-shaped defect, which is filled with fluid, and forms on the anterior uterine wall, where it has been previously incised during a cesarean section. Although some patients may be asymptomatic, others may complain of the following symptoms: abnormal uterine bleeding, pelvic pain, cesarean scar pregnancy, or infertility. Transvaginal sonography (TVS) and saline infusion sonohysterography are used for the diagnosis of isthmoceles. Symptomatic isthmocele is surgically treated through laparoscopy, hysteroscopy, and endometrial ablation. Here, we conducted a robotic-assisted surgery to repair an isthmocele.

A 38-year-old female patient who delivered her child through a cesarean section 6 years ago presented with secondary infertility as the chief complaint. Although in vitro fertilization (IVF) was attempted, the IVF treatment failed, and TVS revealed endometrial fluid collection and an isthmocele. Therefore, we decided to conduct IVF after performing surgical repair of the isthmocele. First, we confirmed the location of the isthmocele through hysteroscopy, and performed the isthmocele repair by robotic-assisted surgery. After detaching the bladder flap, we identified the location of the isthmocele intraperitoneally, and subsequently made an incision. Surrounding tissues were debrided, and the surgical site was sutured in a layer-by-layer manner.

The total operation time was 60 minutes. There were no side effects before and after the surgery. We confirmed that the isthmocele was not visible on ultrasonography conducted immediately after the surgery. Because endometriosis was identified, the patient was administered dienogest 2 mg/day for 3 months. After 3 months, another ultrasonography was conducted, during which neither isthmocele nor endometrial fluid was observed. Therefore, the patient was referred for infertility treatment.

When compared to laparoscopic or hysteroscopic surgeries, repair of isthmoceles through robotic-assisted surgery can allow a surgeon to more elaborately perform the surgery in a layer-by-layer manner.