Prof. Aboubakr Elnashar

1. CAESAREAN
SCAR
DEFECT
Prof.
Aboubakr
Elnashar
Benha
university
hospital,
Egypt
ABOUBAKR
ELNASHAR
CONTENTS
1.
INTRODUCTION
2.
PREVALENCE
3.
RISK
FACTORS
4.
CLINICAL
PRESENTATION
5.
DIAGNOSIS
6.
MANAGEMENT
7.
PREVENTION
7
ABOUBAKR
ELNASHAR

2. INTRODUCTION
▪
Terms
▪
Uterine
niche,
uterine
isthmocele,
caesarean
scar
defect,
uterine
dehiscence
and
diverticulum,
caesarean
niche,
and
caesarean
delivery
scar
pouch.
▪
Define
▪
An
iatrogenic
pouch-like
defect
at
the
site
of
previous
caesarean
scar
due
to
defective
tissue
healing.
▪
Radiologically
▪
A
triangular,
hypoechoic
or
anechoic
area
at
scar
site.
▪
An
indentation
at
the
site
of
CS
with
a
depth
of
at
least
2
mm
(European
Niche
Taskforce,
2019),
ABOUBAKR
ELNASHAR
PREVALENCE
▪
Up
to
70%
women
with
previous
CS
▪
With
TVS:
24–70%
▪
With
gel/saline
instillation
sonohysterography
(SHG):
56–
84%
▪
With
sonohysterography
done
6
months
post-CS:
45.6%
▪
An
underestimation
because
▪
Many
asymptomatic
▪
Clinicians
may
not
recognize
niche
as
a
cause
of
symptoms
due
to
unawareness.
▪
Increases
with
increasing
number
of
previous
CS.
ABOUBAKR
ELNASHAR

3. RISK
FACTORS
▪
Niche
forms
due
to
poor
healing
of
caesarean
scar.
I.
Surgery
factors:
1.
Timing
of
CS:
▪
Cervical
dilatation
of
>5
cm,
>5
h
duration
of
labour&
advanced
foetal
station:
large
niche
{thinner
or
lesser
vascularized
myometrium:
inadequate
healing}
▪
Longer
active
labour
prior
to
emergency
CS:
increases
risk
(OR,
1.06).
▪
However,
there
is
no
difference
between
elective
and
emergency
CS.
ABOUBAKR
ELNASHAR
2.
Level
Of
Uterine
Incision
▪
Lower
uterine
incision
towards
the
cervix:
poor
healing
{
▪
mucus
secreted
by
cervical
glands
interferes
with
myometrial
approximation.
▪
Mucus
gradually
increases
the
niche
size}
▪
CS
done
in
advanced
labour
after
cervical
effacement
and
also
creation
of
uterovesical
fold
of
peritoneum
influence
the
level
of
uterine
incision.
ABOUBAKR
ELNASHAR

4. 3.
Uterine
Closure
Techniques
a.
Single-layer,
decidua
sparing
closure
technique:
incomplete
closure,
compared
to
single
full
thickness
closure.
▪
95%
patients
with
niches
had
single-layer
closure
without
closing
peritoneum.
❖
To
minimize
risk:
1.
Proper
anatomical
approximation
without
tissue
strangulation
2.
If
muscular
edges
are
thick,
they
are
best
approximated
by
including
deeper
part
in
the
first
layer
and
the
remaining
superficial
cut
edges
in
the
second
layer.
ABOUBAKR
ELNASHAR
Single-layer
closure
of
the
uterus
may
increase
niche
formation
due
to
greater
risk
of
incomplete
closure.
ABOUBAKR
ELNASHAR

5. b.
Non-perpendicular
sutures:
1.
An
irregular
myometrium
closure
2.
Locking
sutures
or
very
tight
second
layer:
ischemic
necrosis:
poorly
healed
scar:
niche
formation.
▪
Ischaemia
by
locking
sutures
is
the
single
greatest
risk
factor
for
niche
development.
❖
To
minimize
risk:
Double-layer
uterine
closure
using
non-
locking
sutures
is
the
optimal
closure
technique
that
results
in
thicker
residual
myometrium
(Stegwee
et
al,
2018).
ABOUBAKR
ELNASHAR
c.
Suboptimal
surgical
techniques:
▪
Inadequate
haemostasis
▪
Tissue
ischemia,
devascularization
▪
Excessive
tissue
manipulation
contribute
to
poor
scar
healing
and
adhesions:
niche.
ABOUBAKR
ELNASHAR

6. 4.
Adhesions
▪
Adhesion
formation
with
abdominal
wall
pulls
the
uterine
scar
towards
abdominal
wall,
exerting
counteracting
force
opposite
to
the
direction
of
retracting
uterine
scar
tissue:
impaired
wound
healing
5.
Retroflexed
Uterus
▪
Effect
of
gravity
on
uterine
corpus
also
increases
counteracting
forces.
▪
Large
niches
are
mostly
found
with
retroflexed
uterus
ABOUBAKR
ELNASHAR
Counteracting
forces
on
CS
uterine
scar,
due
to
retraction
of
adhesions
between
the
uterine
scar
and
the
abdominal
wall
in
a
retroflected
uterus:
impair
wound
healing
and
increase
the
formation
of
niches.
ABOUBAKR
ELNASHAR

7. ▪
Laparoscopic
image
of
a
uterus
with
a
large
niche,
illumination
of
the
hysteroscopic
light
in
the
niche
can
be
seen
directly
under
the
adhesions
attached
to
the
niche.
Adhesions
between
the
niche
and
the
abdominal
wall
seen
during
laparoscopy
(a),
owing
to
the
diaphany
of
the
combined
hysteroscopy
it
can
be
seen
that
the
adhesions
are
located
at
the
deepest
point
of
the
niche.
▪
Hysteroscopic
image
of
the
combined
of
a
part
of
the
large
niche
surface
be
seen
in
(b).
▪
Laparoscopic
view
on
adhesions
between
the
lower
uterine
segment
and
the
bladder
at
the
site
of
a
niche.
ABOUBAKR
ELNASHAR
II.
Patient
Factors
1.
Genetic
predisposition
contributes
to
impaired
healing,
poor
haemostasis,
inflammation,
or
adhesion
formation,
post-
operative
infection
2.
Gestational
diabetes
(odds
ratio,
1.73),
previous
CS
(OR,
3.14)
are
independent
risk
factors.
3.
Advanced
BMI
(OR,1.06)
•
Risk
increases
by
6%
for
every
additional
unit
increase
in
BMI.
ABOUBAKR
ELNASHAR

8. CLINICAL
PRESENTATION
▪
Most
asymptomatic
▪
30%
are
symptomatic.
=
gynecologic
complications
1.
Bleeding:
▪
Post-menstrual
Spotting
▪
≥
2
d
of
intermenstrual
spotting,
or
≥2
d
of
brownish
discharge
after
the
end
of
menstruation
if
bleeding
duration
≥7
d
(discharge
is
normal
if
bleeding
duration
is
<7
d)
▪
Most
predominant
symptom
seen
in
30–55%
women
at
6–12
months
post
CS
▪
{1.
collected
menstrual
blood.
The
anterior
edge
of
niche
obstructs
flow
of
menstrual
blood
2.
Poor
contractility
of
surrounding
fibrosed
muscle
retains
it
which
is
then
discharged
gradually}.
ABOUBAKR
ELNASHAR
▪
Prolonged
Bleeding
▪
Impaired
menstrual
drainage:
prolonged
flow.
▪
Since
not
yet
specified,
it
may
be
described
as
AUB-N
as
per
FIGO-PALMCOEIN
nomenclature
of
AUB
▪
Intermittent
Spotting
▪
In
situ
blood
formation
in
the
niche,
evidenced
by
free
erythrocytes
in
scar:
intermenstrual
spotting.
▪
Midcycle
Intrauterine
Fluid
Accumulation
▪
{excess
mucus
formation
by
retained
blood}
▪
approximately
45%
women.
ABOUBAKR
ELNASHAR

9. 2.
Pain
▪
Dysmenorrhea
(40–50%)
▪
Chronic
pelvic
pain
(35%),
▪
Dyspareunia
(18%)
or
suprapubic
pain.
▪
{abnormal
myocontraction
to
empty
niche
contents}
▪
Size
of
the
niche
is
important,
with
larger
niches
being
more
likely
to
present
with
pain
3.
Secondary
Infertility
▪
{chronic
inflammation
by
residual
blood
or
peri-ovulatory
fluid
accumulation
interfering
with
sperm
penetration,
fertilization
and
implantation}.
▪
large
niche
interfere
with
conception
similar
to
hydrosalpinx.
ABOUBAKR
ELNASHAR
4.
Problems
in
IVF
▪
Difficult
ET
in
20%
women
with
niche
undergoing
IVF,
due
to
a
distorted
anatomy,
specially
in
a
retroflexed
uterus
▪
Chances
of
unsuccessful
IVF
are
higher
5.
Bladder
Dysfunction
▪
Local
accumulation
of
fluid
and
scarring:
dysfunction
due
to
proximity
of
niche
to
the
bladder
▪
Prospective
studies
did
not
support
this.
6.
Scar
Abscess
▪
rare,
it
has
been
reported
even
up
to
6
years
after
CS
▪
{residual
blood
and
mucus
that
gets
infected}.
ABOUBAKR
ELNASHAR

10. ▪
Obstetric
Complications
in
Future
Pregnancy
1.
Caesarean
Scar
Ectopic
Pregnancy:
Pregnancy
may
implant
in
the
niche
2.
Placenta
accrete
3.
Scar
dehiscence
and
uterine
rupture.
ABOUBAKR
ELNASHAR
DIAGNOSIS
▪
Diagnostic
criteria:
No
consensus
▪
An
anechoic
space
at
least
1
mm
deep
(vertical
distance
between
base
and
apex),
▪
with
or
without
fluid,
and
▪
at
least
2
mm
deep
in
the
myometrium
at
caesarean
scar
site
clinches
the
diagnosis.
ABOUBAKR
ELNASHAR

11. 1.
Niche
Size
And
Residual
Myometrium
▪
Residual
myometrial
thickness
(RMT)
is
the
vertical
distance
between
uterine
serosa
and
apex
of
defect
▪
Large
niches
are
defined
when
▪
RMT
is<50%
of
adjacent
myometrium
or
▪
≤2.2
mm
on
TVS
or
▪
≤2.5
mm
with
SHG.
▪
≤
3
mm
(Marotta
et
al,2015)
▪
Total
defect:
Absent
residual
myometrium
ABOUBAKR
ELNASHAR
Anechoic
area
at
the
site
of
a
previous
cesarean
section.
This
niche
is
usually
triangular-shaped
3D
view
of
the
niche
2-D
ultrasound
showing
uterus,
cervix,
niche
(n)
measuring
1
cm,
collection
in
the
niche
(C)
and
bladder
(B)
ABOUBAKR
ELNASHAR

12. SHG
of
the
isthmocele
before
surgery
showing
a
2.3
mm
residual
myometrium.
ABOUBAKR
ELNASHAR
SHG
of
the
isthmocele
23
months
after
surgery
showing
a
2.9
mm
residual
myometrium.
ABOUBAKR
ELNASHAR

13. 2.
Shape
▪
Most
defects
are
triangular
or
semicircular
▪
Round,
oval,
droplet
shape
and
inclusion
cysts
described.
▪
An
inward
protrusion,
i.e.
internal
scar
surface
bulging
toward
uterine
cavity
▪
Outward
protrusion,
i.e.
external
scar
surface
bulging
toward
bladder
or
peritoneal
cavity
or
▪
Inward
retraction,
i.e.
external
scar
surface
dimpled
toward
the
myometrium.
3.
Other
Features
▪
Concavity,
abnormal
vascularity,
visible
serosa,
cyst-
or
polyp-like
structure
should
also
be
mentioned.
ABOUBAKR
ELNASHAR
Main
niche
and
vesicovaginal
fold.
(a)
Red
and
green
areas
represent
main
niche
and
blue
area
represents
branch.
(b)
Green
line
indicates
plica
vesicouterina
or
uterovesical
fold,
while
red
line
indicates
vesicovaginal
fold.
ABOUBAKR
ELNASHAR

14. Position
of
calipers
for
different
sonographic
measurements
of
uterine
niche
in
the
sagittal
plane.
ABOUBAKR
ELNASHAR
Position
of
calipers
for
sonographic
measurement
of
width
of
uterine
niche
in
transverse
plane.
Both
largest
width
and
width
at
niche
base
should
be
measured.
ABOUBAKR
ELNASHAR

15. ▪
European
Niche
Taskforce
consensus,2019
recommended
the
following
measurements:
▪
Depth
and
width
of
the
hypoechoic
defect
in
sagittal
plane
▪
Length
of
the
defect
in
transverse
plane
▪
Residual
myometrial
defect
in
the
sagittal
plane
▪
Did
not
specify
any
assessment
for
morphology
of
a
niche
ABOUBAKR
ELNASHAR
▪
In
the
sagittal
plane
▪
Length
▪
Depth:
starting
from
uterine
cavity
to
the
apex
of
the
niche.
▪
Residual
myometrium
is
measured
from
the
apex
of
the
niche
to
the
serosa:
crucial
in
planning
surgery.
▪
Adjacent
myometrial
thicknesses
▪
In
the
transverse
plane
▪
Width
▪
any
branches.
If
present,
should
be
investigated
▪
distance
of
the
niche
from
uterovesical
fold
▪
distance
of
the
niche
from
external
os
which
is
important
in
planning
appropriate
surgery.
ABOUBAKR
ELNASHAR

16. (a)
In
sagittal
view,
a
sonographic
defect
of
at
least
2
mm
associated
with
a
residual
myometrial
thickness
of
<5
mm
defines
the
presence
of
a
niche
on
TVS.
(b–d)
Essential
sonographic
measurements
including
length
(i.),
depth
(ii.),
RMT
(iii.),
adjacent
myometrial
thickness
(iv.),
niche
to
vesicouterine
fold
(v.)
and
niche
to
level
of
external
cervical
os
(vi.).
If
present,
branches
are
treated
separately
with
regard
to
depth
and
RMT
measurements.
ABOUBAKR
ELNASHAR
▪
Methods
of
visualization
▪
HSG
▪
TVS,
SHG,
GHS
▪
3-D
US
▪
MRI
▪
Hysteroscopy
ABOUBAKR
ELNASHAR

17. 1.
TVS
▪
The
first
diagnostic
tool
available
to
most
clinicians
when
investigating
a
woman
with
abnormal
uterine
bleeding
▪
More
easily
accessible
in
most
clinical
settings
▪
Less-invasive
imaging
modality
▪
The
presence
of
fluid
in
the
niche,
would
obviate
the
need
for
additional
gel
or
saline
instillation.
▪
{fluid
is
commonly
seen
during
the
midfollicular
phase,
niche
evaluation
should
be
done
between
D7
and
14
of
the
cycle.
ABOUBAKR
ELNASHAR
2.
SHG
▪
SHG
is
the
investigation
of
choice.
1.
More
accurate:
Higher
prevalence
(45%
vs.
22%)
2.
Sensitivity
&
specificity
of
TVS
when
compared
to
SHG
are
49%
and
100%,
respectively.
3.
Niches
missed
with
TVS
are
usually
small
though
they
can
be
clinically
relevant.
▪
SHG
at
6–12
w
post-partum
when
scar
is
incompletely
healed
▪
facilitates
recognition
of
scar
and
small
niches
▪
aided
by
the
thin
endometrium
during
breastfeeding.
ABOUBAKR
ELNASHAR

18. 3.
GIS
▪
Gold
standard
for
assessing
a
niche
▪
Higher
detection
rates
compared
with
TVS.
▪
Adjusting
pressure
with
the
transvaginal
probe
to
assess
fluid
shift,
or
using
Doppler.
▪
To
facilitate
and
optimise
imaging
ABOUBAKR
ELNASHAR
4.
Hysteroscopic
appearances
▪
concavities
in
the
isthmus
with
a
prominent
distal
ridge,
breech
of
the
mucosa
to
varying
depths,
lateral
branches,
the
presence
of
abnormal
vascular
patterns,
and
the
presence
of
cyst-like
or
polypoid
structures.
5.
Laparoscopy
▪
ballooning
of
the
lower
segment
often
associated
with
dense
adhesions
to
the
bladder
or
anterior
abdominal
wall.
ABOUBAKR
ELNASHAR

19. (A)
TVS
Sagittal
view:
The
CSD
corresponds
to
an
anechoic
area
(arrow)
measuring
14.41
mm
in
length
and
8.13
mm
in
depth.
RMT
is
1.78
mm.
(B)
MRI:
Sagittal
view
of
a
T2-
weighted
showing
a
large
CSD
covered
with
a
thin
layer
of
myometrium
(arrow).
Dense
adhesions
(ellipse)
can
be
seen
between
the
anterior
uterine
wall
and
abdominal
wall
at
some
distance
from
the
CSD.
(C)
Hysteroscopy:
Dendritic
blood
vessels
(arrows)
on
the
surface
of
the
CSD.
(D)
Hysteroscopy:
Old
blood
retention
on
the
right
lateral
part
of
the
CSD
(arrow).
ABOUBAKR
ELNASHAR
(a)
Mid-sagittal
plane;
(b)
transversal
plane;
(c)
schematic
diagram
of
a
niche;
(d)
niche
seen
by
hysteroscopy,
the
internal
os
is
out
of
the
scope
of
this
picture.
ABOUBAKR
ELNASHAR

20. MANAGEMENT
▪
Indications
of
treatment:
▪
only
in
symptomatic
women
presenting
with
▪
Secondary
infertility
▪
Previous
scar
ectopic
▪
Recurrent
miscarriage
▪
AUB
and
bothersome
post-menstrual
spotting.
▪
However,
efficacy
of
treatment
is
yet
to
be
ascertained.
▪
Routine
repair
of
incidentally
diagnosed
niche
with
no
plans
for
future
childbearing
is
not
recommended.
Treatment
options
for
a
uterine
niche
are
as
follows:
ABOUBAKR
ELNASHAR
Marotta
et
al,
2013
ABOUBAKR
ELNASHAR

21. A.
Medical
Treatment
▪
Hormonal
therapy
symptomatically
relieves
AUB.
▪
Oral
contraceptives
are
suitable
if
pregnancy
is
not
desired.
▪
LNGIUS
was
not
found
to
decrease
menstrual
length
▪
Symptoms
related
to
menstrual
bleeding
should
be
managed
medically
in
the
first
instance
with
usual
hormone
treatment,
unless
contemplating
conception
ABOUBAKR
ELNASHAR
B.
Uterine
Sparing
Surgical
Treatment
▪
Conservative
surgical
interventions
should
be
considered
after
eliminating
other
causes
of
presenting
symptoms.
▪
The
options
include
either
▪
Resection
by
hysteroscopic
route
or
▪
Excision
plus
repair
by
▪
Transabdominal:
▪
Laparotomy
▪
Laparoscopic
▪
Robotic
▪
Vaginal
route
ABOUBAKR
ELNASHAR

22. I.
Hysteroscopic
Niche
Resection
or
Isthmoplasty
1.
Resection
▪
of
only
distal
rim,
or
both
distal
and
proximal
edges
with
resectoscope
using
bipolar
or
unipolar
current
▪
facilitates
drainage
of
menstrual
blood,
though
it
inevitably
increases
niche
size.
2.
Coagulation
▪
of
fragile
vessels
at
the
base
or
even
entire
niche
with
ball
electrode.
▪
Fulgurating
base
prevents
in
situ
fluid/blood
collection.
▪
At
the
end
of
procedure,
flow
and
pressure
of
distending
medium
can
be
reduced
to
ensure
adequate
haemostasis.
ABOUBAKR
ELNASHAR
Hysteroscopy
surgery:
(1)
view
of
the
cesarean
scar
defect
(2)
resection
of
the
fibrotic
tissue
of
the
inferior
part
of
the
scar
(3)
local
fulguration
of
the
dilated
blood
vessels
and
endometrial
glands
(4)
final
view
ABOUBAKR
ELNASHAR

23. Hysteroscopic
excision:
a.
CSD
with
uterine
synechiae
formation
within
the
cavity
b.
CSD
with
a
distal
ridge
c.
after
resection
and
rollerball
coagulation
ABOUBAKR
ELNASHAR
Hysteroscopic
resection
e.
The
superior
and
inferior
edges
of
the
CSD
are
resected
(arrows),
and
the
bottom
of
the
defect
(triangles)
is
fulgurated
or
electrocoagulated.
f.
Final
view
after
hysteroscopic
resection
of
the
CSD.
ABOUBAKR
ELNASHAR

24. Remodeling(hysteroscopic):
Reshaping
the
isthmocele
so
that
it
becomes
asymptomatic
ABOUBAKR
ELNASHAR
▪
Complications
▪
Uterine
perforation
▪
Bladder
injury
especially
if
overlying
RMT<3
mm,
▪
Cervical
incompetence
with
proximal
rim
resection
▪
Uterine
rupture
in
subsequent
pregnancies
▪
Bladder
safety
can
be
ensured
by
▪
intraoperative
ultrasound
guidance
and
▪
filling
bladder
with
methylene
blue
as
shown
in
HysNiche
trial
ABOUBAKR
ELNASHAR

25. II.
Niche
Repair
▪
Repair
is
the
preferred
method
when
RMT
is
<3
mm
▪
involves
1.
Identification
of
defect
by
simultaneous
▪
Hysteroscopy
▪
Hegar’s
dilator,
▪
Intracervical
foley’s
catheter,
▪
Transvaginal
or
transrectal
ultrasound
2.
Excision
of
fibrotic
tissue
from
the
edges
3.
Re-approximation
in
2
Layers
▪
by
▪
Transabdominal:
laparotomy,
laparoscopic,robotic
route
▪
Vaginal
route.
ABOUBAKR
ELNASHAR
Repairing
(laparoscopic,
vaginal
or
laparotomic):
▪
Adhesiolysis
▪
cutting,
debridement
▪
suturing
of
the
isthmocele
ABOUBAKR
ELNASHAR

26. Laparotomy
repair
a
bulge
prior
to
incision
b
after
incision
over
niche
c
after
excision
of
fibrotic
tissue
from
the
niche
edges
ABOUBAKR
ELNASHAR
Laparoscopic
repair:
▪
A
transillumination
view
by
laparoscopy;
the
view
is
from
laparoscopy
without
any
light
enabling
the
visualization
of
the
defect
with
the
help
of
hysteroscopy
light
through
the
defect.
▪
Laparoscopic
tissue
removal,
a
view
of
the
vesicouterine
pouch
with
scar
tissue
being
pulled
and
resected
with
cold
scissors
▪
Laparoscopic
suturing
of
the
defect
after
isthmocele
resection
suturing
the
defect
in
double-layer
suture
enabling
a
thicker
and
stronger
uterine
wall
ABOUBAKR
ELNASHAR

27. Laparoscopic
repair
▪
view
on
a
mucus-containing
large
niche
that
is
located
in
the
lower
cervix.
▪
Mucus
is
expelled
during
a
laparoscopic
niche
resection
after
dissection
of
the
bladder
and
opening
of
the
niche
ABOUBAKR
ELNASHAR
Laparoscopic
repair:
a.
view
of
the
cesarean
scar
with
a
probe
inserted
into
the
endocervix.
The
residual
myometrium
covering
the
scar
is
very
thin
(arrow).
b.
cesarean
section
scar
defect
cavity
(arrows)
c.
first
layer
of
suture
(arrows)
d.
second
layer
of
suture
(arrows).
ABOUBAKR
ELNASHAR

28. Laparoscopic
repair
(1)
identification
of
the
affected
area
(2)
bladder
dissection
(3)
opening
of
the
scar
(4)
first-layer
suture
(5)
second-layer
suture
(6)
final
view
Vaginal
ABOUBAKR
ELNASHAR
▪
Vervoort’s
technique
▪
Laparoscopic
repair
combined
with
hysteroscopy
▪
Round
ligament
plication
in
extremely
retroflexed
uterus
▪
using
hyaluronic
acid
as
adhesion
barrier.
▪
Nirgianakis’
‘Rendezvous
technique
▪
laparoscopy
light
source
is
put
of
with
simultaneous
hysteroscopy
light
eliciting
the
‘Halloween
sign’
or
‘positive
diaphanoscopy’
or
transillumination
where
hysteroscopy
light
shines
through
the
defect
ABOUBAKR
ELNASHAR

29. a.
Dense
adhesions
(arrows)
between
the
anterior
uterine
wall
and
anterior
abdominal
wall
b.
CSD
(between
arrows).
No
adhesions
are
visible
between
the
CSD
and
the
bladder
c.
Complete
resection
of
fibrotic
tissue
(arrows)
is
essential
to
ensure
further
healing
d.
first-layer
suture
before
the
knots
are
tightened
e.
second-layer
suture
before
the
knots
are
tightened
f.
after
covering
the
suture
with
a
bladder
peritoneal
flap.
ABOUBAKR
ELNASHAR
▪
‘slip
and
hook’
technique
▪
Hegar
dilator
is
placed
in
cervical
canal
and
is
blindly
slipped
anteriorly
to
bulge
out
and
perforate
the
defect
under
laparoscopic
vision
▪
Donnez
technique
▪
large
isthmoceles
are
excised
laparoscopically
using
CO2
laser
▪
round
ligaments
shortening
in
retroflexed
uterus.
ABOUBAKR
ELNASHAR

30. ▪
Vaginal
route
▪
Can
be
undertaken
by
experienced
surgeons
when
niche
is
not
at
higher
level.
▪
After
reflecting
bladder
from
cervix,
niche
is
identified,
excised
and
hysterotomy
closed
in
two
layers.
▪
Cost-effective
with
shorter
operation
time.
▪
Simultaneous
hysteroscopy
to
visualize
niche
by
transillumination
and
single-port
laparoscopy-assisted
vaginal
repair
is
also
described.
ABOUBAKR
ELNASHAR
▪
Preference
of
the
Route
▪
All
effective,
and
no
particular
TT
modality
superior
to
the
other
in
a
recent
systematic
review
of
30
studies
▪
Hysteroscopic
resection:
smaller
niches
of
<2.5–3
mm
with
RMT>3
mm
▪
Vaginal
route
is
preferred
when
niche
is
at
the
lower
level.
▪
Transabdominal
approach
preferred
for
▪
large
defects
residual
myometrium
is<3
mm
as
bladder
can
be
mobilized
out
of
surgical
field
offering
better
niche
visualization
with
lesser
bladder
injury.
▪
Women
desiring
future
pregnancy
since
uterine
wall
thickness
and
strength
increase.
ABOUBAKR
ELNASHAR

31. ▪
Among
transabdominal
routes
▪
laparoscopy
and
robotic
surgery
offer
advantages
of
being
minimally
invasive
with
lesser
morbidity.
▪
Incidental
endometriosis
is
reported
in
21%
women;
hence,
consent
for
correction
of
any
associated
pathology
should
also
be
taken
if
transabdominal
route
is
planned.
❑
Hysterectomy
offers
definitive
treatment
for
niche-related
gynecological
symptoms
ABOUBAKR
ELNASHAR
▪
Macroscopic
image
of
a
uterus
with
a
niche,
removed
by
laparoscopy
because
of
AUB
and
dysmenorrhoea.
▪
Note
that
the
adhesions
are
located
at
the
deepest
point
of
(a
relatively
small)
niche.
(A)
Sagittal
view
of
a
frozen
section
from
a
hysterectomy
specimen.
A
shallow
depression
covered
with
a
thick
layer
of
myometrium
(rectangle)
at
the
level
of
the
supposed
site
of
CS
(B)
Sagittal
view
of
a
frozen
section
from
a
hysterectomy
specimen.
A
deep
anterior
defect
covered
with
a
thin
layer
of
myometrium
(rectangle)
can
be
seen
at
the
level
of
the
supposed
site
of
CS
(C)
Enlarged
view
of
the
shallow
depression
from
A
(D)
Enlarged
view
of
the
deep
anterior
defect
from
B
(E)
Actin
immunostaining
in
a
hysterectomy
specimen.
The
muscular
density
of
myometrium
covering
CSD
is
similar
to
adjacent
healthy
myometrium
(F)
Actin
immunostaining
in
an
excised
CSD.
The
muscular
density
of
myometrium
covering
the
CSD
is
significantly
decreased
compared
with
adjacent
healthy
myometrium.
ABOUBAKR
ELNASHAR

32. ▪
Outcomes
of
Surgical
Management
of
Post-caesarean
Niche
▪
Hysteroscopic
niche
resection
▪
Pain
improvement
in
97%
▪
Reduces
post-menstrual
spotting
by
a
median
of
3.8
days
▪
Complete
resolution
of
AUB
in
72.4%
cases
▪
AUB
gets
cured
in
87.5%
patients
within
first
month
and
96.8%
patients
in
the
second
month
after
surgery
▪
5%
patients
may
have
recurrence
ABOUBAKR
ELNASHAR
▪
Laparoscopic
repair:
▪
Vervoort’s
study:101
women
with
large
niche&<3
mm
RMT
▪
79%
had
symptom
relief
▪
83.3%
women
felt
very
satisfied
▪
Post-menstrual
spotting
reduced
by
7
days
at
6
months,
▪
Dysmenorrhea
reduced
▪
Myometrial
thickness
increased
▪
Donnez
study
▪
93%
symptom-free
▪
increase
in
mean
myometrial
thickness
from
1.4
to
9.6
mm
at
3-month
follow-up,
▪
44%
pregnancy
rate
in
infertile
women,
all
delivered
at
ABOUBAKR
ELNASHAR

33. ▪
(A,
C,
E)
Sagittal
view
of
T2-weighted
MRI
showing
a
thin
RMT;
arrows)
covering
a
deep
CSD
▪
(B,
D,
F)
Sagittal
view
of
postoperative
T2-
weighted
MRI
after
laparoscopic
repair.
The
defect
is
corrected
and
RMT
is
significantly
increased
at
the
level
of
the
isthmus
(arrows).
ABOUBAKR
ELNASHAR
▪
Calzolari,
in
a
retrospective
study
(n=35),
noted
▪
Isthmocele
as
the
primary
cause
of
infertility
in
45.7%
▪
all
women
were
relieved
of
AUB
and
pain
▪
56.3%
conceived
after
hysteroscopic
isthmoplasty.
▪
Women
who
failed
to
conceive
had
higher
BMI,
higher
isthmocele
grade,
higher
number
of
prior
CS
and
advanced
age.
▪
Pregnancy
rate
varied
from
22–71%
in
various
studies.
ABOUBAKR
ELNASHAR

34. ▪
Enderle
study:
retrospective
series
of
18
surgically
treated
▪
Poor
obstetric
outcomes
with
55%
miscarriages
▪
Hysteroscopy
had
poorer
results
as
miscarriage
occurred
in
3/4
patients.
▪
One
patient
who
underwent
transvaginal
repair
delivered
vaginally;
others
underwent
CS
▪
Another
study
▪
Pregnancy
rate
of
71%
as
10/14
infertile
women
conceived
including
six
spontaneous
pregnancies
after
laparotomy,
laparoscopy
or
vaginal
approach
▪
Eight
had
CS;
one
had
vaginal
delivery,
and
one
aborted,
with
no
case
of
placenta
accrete
or
rupture.
ABOUBAKR
ELNASHAR
PREVENTION
OF
NICHE
FORMATION
▪
Primary
prevention
by
minimize
CS
rates
▪
Secondary
prevention
by
adopting
correct
surgical
techniques
ensuring
thicker
residual
myometrium
and
strong
scar
ABOUBAKR
ELNASHAR

35. (a)
Recommended
traditional
judicious
double
layer
closure
with
the
first
continuous
non-locking
suture
to
include
minimal
decidua
(<
5
mm)
and
about
two-thirds
of
inner
myometrium;
and
second
nonlocking
suture
taking
upper
half
of
myometrium
would
correct
eversion
of
myometrial
edges.
This
used
to
be
the
long-
standing
practice
in
UK
more
than
a
decade
ago.
Care
should
be
taken
not
to
make
the
edges
of
the
incision
ischemic.
(b)
One-layer
closure
could
interpose
decidua
in
between
inner
myometrium
and
the
superficial
myometrial
edges
can
often
be
seen
to
be
everted
(not
in
good
apposition).
(c)
The
current
popular
technique
in
UK.
The
transverse
myometrial
bites
of
second
layer
are
taken
with
the
needle
travelling
back
and
forth
on
either
side
of
incision
which
seem
partly
akin
to
“figure-of-eight”
haemostatic/devascularizing
sutures.
It
is
easy
to
be
paradoxically
reassured
by
the
apparent
(excessive)
apposition
and
sense
of
security
derived
from
very
tight
sutures.
Ischemic
necrosis
is
likely
to
be
causative
in
CS
defect.
ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR

36. ▪
A
recent
study
in
138
women
demonstrated
that
uterine
closure
using
far-far-near-near
double-layer
unlocked
technique
may
benefit
in
reducing
isthmocele
formation
and
ensuring
sufficient
residual
myometrium
(Kalem
et
al,
2019)
Top
view
of
tissue
sutured
by
far-far,
near-near
suture
technique.
chematic
representation
of
far-
ar,
near-near
uture
technique.
ABOUBAKR
ELNASHAR
CONCLUSION
▪
Risk
factors:
▪
potentially
iatrogenic
▪
With
increasing
caesarean
delivery
rates,
niche-related
problems
are
predicted
to
rise
▪
Diagnosis:
▪
requires
high
index
of
suspicion.
▪
significant
morbidity
in
at
least
one-third
of
women
▪
Prevention:
▪
non-locking
double
layer
closure
of
the
uterus
with
inclusion
of
the
innermost
decidua
▪
careful
surgical
prowess
to
avoid
a
low
incision.
ABOUBAKR
ELNASHAR

37. ▪
Treatment:
▪
For
bleeding
symptoms,
hormonal
treatment
is
preferable,
whereas
subfertility
may
require
surgical
correction
▪
Surgery
not
recommended
as
first-line
option
for
menstrual
symptoms.
▪
Hysteroscopic
resection
is
preferred
for
smaller
niches
with
RMT
>
3
mm,
▪
Niche
located
lower
down
can
be
treated
transvaginally
▪
Transabdominal
approach
is
preferred
for
large
defects
and
in
women
desiring
future
pregnancy.
▪
Surgery
is
very
effective,
not
without
substantial
risk,
and
should
be
performed
only
by
experienced
surgeons.
ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR