Laparoscopic Excision of Cesarean Scar Pregnancy with Scar Revision

Objective To demonstrate our technique for robotic assisted laparoscopic ectopic pregnancy excision and concomitant scar revision. Design We present a stepwise narrated demonstration of our primary laparoscopic technique. Setting Although cesarean scar pregnancy is rare, it leads to life-threatening complications and often emergent hysterectomy. Because of its rarity there is a scarcity of centers with high volume experience with its treatment, and no standardized diagnostic or management guidelines are yet available. Recent evidence suggests that primary surgical management may be superior to medical or radiologic management as the latter methods carry a high reintervention rate. An additional consideration while selecting a treatment method is a patient's plans for future fertility, as cesarean scar defects are associated with secondary infertility. Evidence shows that repair of cesarean scar defects decreases the likelihood of future recurrence and secondary infertility, thus it may be pertinent to select a management strategy that allows accomplishment of both ectopic pregnancy removal and defect revision. We present our primary laparoscopic approach to ectopic pregnancy excision and revision of the cesarean scar defect utilizing techniques rooted in evidence and robust experience. Interventions Robotic assisted laparoscopic excision of a cesarean scar ectopic pregnancy with concomitant scar revision demonstrating key strategies to minimize blood loss and preserve future fertility. 1. A laparoscopic approach allows for concomitant ectopic pregnancy removal followed by cesarean scar revision. 2. Generous use of dilute vasopressin and purposeful application of electrosurgical energy provides hemostasis without the use of more invasive measures such as vascular clips or uterine artery balloons. 3. A multilayer closure is associated with a lower risk of wedge defect formation and uterine rupture. 4. Diagnostic hysteroscopy is a useful tool for identifying the location of the scar defect, assessing for an adequate repair, and identifying potential additional uterine pathology. Conclusion Primary laparoscopic management is not only the most effective method with lowest complication rates but is an approach that allows for simultaneous repair and revision of the cesarean scar defect. We demonstrate easily adaptable techniques for maintaining hemostasis, minimizing injury to normal myometrium, and creating multilayer closures which lead to successful revisions with minimal impact to subsequent fertility.