Tips and Tricks for Successful Resection of Cesarean Scar Ectopic With an Obliterated Anterior Cul De Sac

Study Objective

To describe the classification of cesarean scar pregnancies (CSP). To demonstrate tips and tricks for resection of exogenous CSP with an obliterated anterior cul de sac.

Design

Surgical educational video.

Setting

Procedure performed under general anesthesia with robotic assistance. Patient in dorsal lithotomy position.

Patients or Participants

35 years old gravida 4 para 3 women at 9 weeks and 6 days gestation who presented to the emergency room with vaginal bleeding. Her BHCG was 9,506mIU/mL, she had a history of 3 prior cesarean sections, and a BMI 41.

Interventions

Robotic assisted resection of type IIIA cesarean scar ectopic pregnancy with dissection of obliterated anterior cul de sac and temporary uterine artery occlusion.

Measurements and Main Results

This video demonstrates various strategies to safely navigate these complex cases. Retroperitoneal dissection with a lateral and a medial approach are demonstrated in order to access the uterine artery at its origin for temporary occlusion. A lateral to medial approach to the obliterated cul de sac by starting the dissection in the avascular space anterior to the round ligament is discussed. Lysing filmy adhesions prior to dense scar may assist in safe dissection. Placing a uterine manipulator under laparoscopic guidance may prevent disruption and acute bleeding of the ectopic pregnancy. Identifying the cervical cup anterior to the uterine vessels allows for better dissection around the ectopic pregnancy and decreases the chance of bladder, ectopic, or uterine vessel injury. Most adhesions from prior cesarean sections happen at the lower uterine segment and a tunnel is developed under the dense lower uterine segment adhesions to separate the bladder from the ectopic pregnancy. An angled 30-degree scope may help with adequate visualization for the anterior dissection. Back-filling the bladder is useful to determine the boarders of a safe dissection.

Conclusion

This video demonstrates tips and tricks for successful resection of type IIIA exogenous cesarean scar ectopic pregnancy.