Robotic-Assisted Isthmocele Repair: A Review of Surgical Principles in a Patient Desiring Future Fertility

Study Objective

To assess the safety and effectiveness of minimally invasive approaches for isthmocele repair in a patient desiring future fertility.

Design

Video case presentation of a single patient undergoing robotic-assisted isthmocele excision and repair, performed outpatient with postoperative follow-up.

Setting

The patient was placed in dorsal lithotomy position with arms tucked. She was prepped and draped in standard sterile fashion per robotic surgery protocol. A Foley catheter and OG tube were inserted using sterile technique.

Patients or Participants

A 31-year-old G1P1001 woman presented with persistent pelvic pain 19 months after a low transverse cesarean complicated by chorioamnionitis and hysterotomy extension. Imaging confirmed a 5.4mm x 1.7mm isthmocele. Desiring future fertility, she provided informed consent for robotic-assisted excision and repair.

Interventions

Robotic-assisted excision and repair of the isthmocele was performed using minimally invasive techniques. Retrograde bladder filling aided anatomical orientation. The right broad ligament was opened to allow a lateral-to-medial dissection for vascular preservation. Hysteroscopy with transillumination guided identification of the isthmocele. Fluorescence imaging enhanced localization of the defect. After excision, the uterine wall was closed in two layers using barbed suture. Post-repair hysteroscopy confirmed decreased transillumination and water-seal, confirming closure of the defect.

Measurements and Primary Results

The surgery was complication-free. The patient was discharged the same day without adverse events. She is doing well on Nuvaring contraception; however, follow-up imaging has not been performed due to financial constraints.

Conclusion

Robotic-assisted isthmocele excision and repair provides a safe, minimally invasive option for patients seeking future fertility. Continued follow-up and further studies are needed to assess long-term outcomes.