Department of Public Health, University of Naples Federico II, Naples, Italy.
Department of Neuroscience, Reproductive Sciences and Dentistry, Naples, Italy.
J Minim Invasive Gynecol. 2018 Feb;25(2):338-339. doi: 10.1016/j.jmig.2017.09.002. Epub 2017 Sep 8.
To demonstrate our technique for surgical hysteroscopy performed with a standard-size resectoscope or miniresectoscope in 3 cases of isthmocele.
Step-by-step demonstration of the technique using slides, pictures, and video (educative video) (Canadian Task Force classification III).
Isthmocele is a characteristic semidiverticular anomaly of the anterior isthmic wall of the uterus, located at the site of a previous cesarean delivery scar. The etiopathogenesis of isthmocele remains poorly understood, although several hypotheses have been proposed. Factors that may possibly play a role in niche development include a very low incision through cervical tissue, inadequate suturing technique during closure of the uterine scar, surgical interventions that increase adhesion formation, and patient-related factors that impair wound healing or increase inflammation or adhesion formation. The treatment of isthmocele focuses on relieving symptoms (i.e., postmenstrual spotting, suprapubic pelvic pain, dysmenorrhea, dyspareunia, and infertility), and, consequently, asymptomatic cases should not be treated. Various surgical approaches have been described to treat isthmocele-related symptoms, including hysteroscopy, laparoscopy, vaginal, robotic, and combined techniques.
Our local Institutional Review Board approved the study protocol. The procedures were performed in operative room using a 26 Fr and 16 Fr continuous-flow resectoscope under general anesthesia. The surgical technique involves resection of the fibrotic tissue of the lower margin and then the upper margin of the pouch using a cutting loop, until the underlying muscular tissue is reached, followed by resection of the inflamed and necrotic tissue of the base of the pouch. Similar surgical maneuvers are performed on the contralateral side (right anterolateral wall) for complete ablation of the isthmic region (inverted ablation).
According to the most recent literature, hysteroscopic hystmoplasty appears to be a safe and effective treatment option in cases of isthmocele with a niche at least 2 mm deep and a residual myometrial thickness of at least 3 mm to improve postmenstrual bleeding. When residual myometrial thickness is <3 mm, the hysteroscopic approach is not recommended, mainly because of the risk of bladder injury. In these symptomatic cases, laparoscopic or vaginal repair may be considered.
展示我们在 3 例峡部憩室中使用标准大小的电切镜或迷你电切镜进行手术宫腔镜检查的技术。
使用幻灯片、图片和视频（教育视频）逐步演示技术（加拿大工作队分类 III）。
峡部憩室是子宫前峡部壁的一种特征性半憩室异常，位于先前剖宫产瘢痕的部位。峡部憩室的病因学仍知之甚少，尽管已经提出了几种假说。可能在龛形成中起作用的因素包括宫颈组织的极低切口、子宫瘢痕闭合时的缝合技术不足、增加粘连形成的手术干预以及影响伤口愈合或增加炎症或粘连形成的患者相关因素。峡部憩室的治疗侧重于缓解症状（即月经后点滴出血、耻骨上盆腔疼痛、痛经、性交困难和不孕），因此无症状病例不应治疗。已经描述了各种手术方法来治疗与峡部憩室相关的症状，包括宫腔镜检查、腹腔镜检查、阴道、机器人和联合技术。
我们的机构审查委员会批准了该研究方案。在全身麻醉下，在手术室中使用 26Fr 和 16Fr 连续流电切镜进行手术。手术技术包括使用切割环切除下边缘和憩室上边缘的纤维组织，直到到达下方的肌肉组织，然后切除憩室底部的炎症和坏死组织。在对侧（右侧前外侧壁）进行类似的手术操作，以完全消融峡部区域（反向消融）。
根据最新文献，对于峡部憩室伴至少 2mm 深的龛和至少 3mm 残留子宫肌层厚度的患者，宫腔镜下憩室成形术似乎是一种安全有效的治疗选择，可改善月经后出血。当残留子宫肌层厚度<3mm 时，不建议采用宫腔镜方法，主要是因为膀胱损伤的风险。在这些有症状的病例中，可能会考虑腹腔镜或阴道修复。
