Fertility and sterilityVideo-Audio Media
06 May 2025
To provide an overview of cesarean scar pregnancy (CSP) including its risk factors and diagnosis; describe a case of CSP managed via robotic-assisted laparoscopic resection; and provide eight tips for minimally invasive surgical management of such cases. Currently, there is no gold standard treatment for CSP. Therefore, treatment options include a wide array of surgical and nonsurgical therapies. The technique described here may be useful to increase the success of minimally invasive surgical management of such cases where future pregnancy is desired, and to avoid complications associated with more invasive surgical management.
Description of the technique with narrated video footage. 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.
Academic tertiary hospital.
A 27-year-old G2P0101 patient with a history of one prior low-transverse cesarean section presented to clinic with vaginal bleeding after a positive home urine pregnancy test. Transvaginal ultrasound demonstrated an embryo with cardiac activity located in the anterior isthmic region of the uterus, consistent with CSP at 6 weeks gestation. The patient received appropriate counseling regarding her treatment options; she elected to undergo robot-assisted laparoscopic en bloc resection of the ectopic pregnancy. Informed consent was obtained from the patient.
Robot-assisted laparoscopy was performed under general anesthesia in an outpatient setting using the Da Vinci robotic platform (Intuitive, Sunnyvale, CA). The patient's abdomen was entered laparoscopically, pneumoperitoneum was attained, and the Da Vinci robot was docked. Using sharp dissection, the vesicovaginal space was entered, revealing the CSP inferiorly. The surrounding retroperitoneal spaces were further developed to define the borders of the pregnancy. Next, the bilateral ureters were identified within the pararectal spaces, allowing safe skeletonization of the uterine arteries. To optimize hemostasis, laparoscopic bulldog clamps (Aesculap, Center Valley, Pennsylvania) were placed on the bilateral uterine arteries at the level of the cardinal ligaments, as well as the utero-ovarian vessels, and 12 milliliters of dilute vasopressin (20 units vasopressin in 100 milliliters normal saline) were injected into the tissue surrounding the CSP. Next, an EEA sizer was inserted into the patient's vagina to delineate the cervicovaginal junction. The CSP was then resected en bloc with wide margins to minimize bleeding, and the specimen was placed within a laparoscopic specimen bag. To identify the cervical canal in aiding repair of the affected myometrium, a uterine sound was inserted through the cervix. The cervix was then reapproximated, starting with modified mattress stitches at the bilateral apices using two separate 2-0 V-loc sutures (Medtronic, Minneapolis, MN), then two layers of running 2-0 V-loc on the anterior and posterior cervix.
Complete minimally invasive treatment of CSP with the absence of surgical complication.
Treatment of CSP was performed successfully with robotic-assisted laparoscopic resection. The procedure was performed in an outpatient setting, and no complications were detected during or after the surgery. The patient was seen in clinic at two weeks postoperative and had a negative urine pregnancy test. Additionally, she had a saline-infused sonogram performed at eight weeks postoperative which demonstrated normal filling of the endometrial cavity and no uterine niche noted.
Minimally invasive laparoscopic resection of CSP may be a valuable treatment, especially for patients desiring future pregnancy. Surgical treatment of CSP is advantageous in that it allows for definitive treatment of the ectopic pregnancy in addition to revision of the cesarean scar, compared with medical management which would just treat the ectopic. Surgical treatment for CSP can have high morbidity, thus should be performed by an experienced minimally invasive gynecologic surgeon using a thoughtful, systematic approach as described in this video. While the specific techniques described here may not be novel, the combination of these techniques - as well as the pre- and post-operative workup - can be used as a road map for similar future cases.
Article info
Journal issue:
Doi:
10.1016/j.fertnstert.2025.04.042
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