NEAR-INFRARED AND HYSTEROSCOPY-GUIDED ROBOTIC EXCISION OF UTERINE ISTHMOCELE WITH LASER FIBER: A NOVEL HIGH-PRECISION TECHNIQUE.

OBJECTIVE: To describe a novel high-precision technique for robotic excision of uterine isthmocele, employing a carbon dioxide laser fiber, under hysteroscopic guidance, and near-infrared guidance.

DESIGN: Video article.

SUBJECT(S): A 36-year-old multipara with three prior cesarean sections presented to our infertility clinic with secondary infertility. The patient had been trying to conceive for 6 months without success. The patient underwent a hystero-salpingo contrast sonography which identified a large cesarean scar defect with a 1.4 mm residual myometrial thickness (RMT). The patient was counseled on surgical management with robotic approach due to RMT < 3 mm precluding her from hysteroscopic resection and the potential risk for a cesarean scar ectopic or abnormal placentation if she were to become pregnant in the future. She elected to undergo excision and repair and informed consent was obtained from the patient.

INTERVENTION(S): The robot was docked for traditional gynecologic robotic surgery. The uterus was injected with 5 units of vasopressin. We used a carbon dioxide laser fiber (Lumenis® FIberLase) at a power of 5 watts as the sole energy source for dissection. The bladder was dissected off the uterus to identify the general area of the isthmocele. At that point, diagnostic hysteroscopy was performed using a 30-degree 5 mm hysteroscope (Karl Storz®) to identify and enter the isthmocele. Near-infrared vision (da Vinci Firefly®, Intuitive USA) was activated to precisely outline the extent of the isthmocele, which was not visible with simple transillumination from the hysteroscope. We proceeded with laser excision in infrared/grey scale using the laser at a power of 20 watts removing the entire area that was highlighted by the Firefly®. After full excision of the isthmocele, the hysteroscope was removed and was eventually replaced by a uterine manipulator (ConMed VCare DX®). The hysterotomy was closed with a two layer closure: 4 mattress sutures of 2-0 Vicryl (Ethicon®) followed by a running 2-0 PDS Stratafix (Ethicon®). The peritoneal layer was closed over these two layers with 2-0 PDS Stratafix (Ethicon®) in a running fashion. The uterine manipulator was removed and a 14 French Malecot catheter (Bard®) was placed in the uterine cavity to allow the healing to proceed with minimal risk of cervical stenosis. The bladder was backfilled to ensure integrity of the bladder wall. Interceed adhesion barrier (Gynecare®) was then placed over the area of the repair and the procedure was concluded. The patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites.

MAIN OUTCOME MEASURES: Completion of excision and repair of cesarean scar defect without surgical complications.

RESULTS: Robotic excision and repair of a sizable uterine isthmocele with carbon dioxide laser fiber and da Vinci Firefly® was completed successfully without any surgical complications. Diagnostic hysteroscopy was used to positively identify the isthmocele and provide transillumination. However, the thickness of the cervical myometrium only allows the hysteroscopic light to shine through the thinnest portion of myometrium at the apex of the isthmocele, while the near-infrared vision allowed by the da Vinci Firefly® technology was used to precisely identify the borders of the defect. The carbon dioxide laser was used to completely remove the defect while avoiding damage to delicate reproductive tissue and over-excision. No complications were identified during the postoperative visit. MRI three months after the surgery revealed a RMT of 10 mm at the location of excision compared to the initial RMT of 1.4 mm.

CONCLUSION: Currently, there is no gold-standard technique for surgical management of isthmocele. This is the first description of the combined use of hysteroscopy, near-infrared vision and laser fiber for the robotic excision of isthmocele. This specific setup proves to be a useful technical improvement. The use of near-infrared vision combined with precise hysteroscopic targeting allows much clearer definition of the isthmocele borders, and the flexible laser fiber allows millimetric excision in the absence of appreciable lateral thermal spread. Further investigation is warranted to identify a gold standard surgical technique for patients with CSD.