Isthmocele: One Problem, Many Faces.

Objective: To review the clinical presentation, diagnosis, and management of uterine isthmoceles, as well as to highlight potential variations and complications.

Design: Narrated video of surgical technique with descriptions of key steps. This video article was deemed by the Mayo Clinic Institutional Review Board (IRB) to not require IRB review. The authors report no conflicts of interest.

Subjects: Patients with isthmoceles desiring future fertility. The patients included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites.

Exposure: Robot assisted laparoscopy or hysteroscopy.

Main Outcome Measures: Complete surgical repair of isthmoceles via robot assisted laparoscopy or hysteroscopy as well as management of isthmocele variations and complications.

Results: The presentation and imaging findings of isthmoceles are reviewed. Surgical videos are then used to demonstrate the principles of surgical management of isthmoceles, both laparoscopically and hysteroscopically. Variations and complications of isthmoceles, and their associated surgical management, are also reviewed. Key surgical techniques include: Careful identification of isthmocele and surrounding anatomy Adequate dissection of vital structures is key for visualization and hemostasis Injection of dilute vasopressin to minimize bleeding Placement of a uterine manipulator or sound to delineate the endometrial cavity prior to repair Pre and post hysteroscopy to visualize defect and subsequent repair CONCLUSION: Key surgical techniques can be applied to the repair of isthmoceles in typical locations. However, there are unique anatomic and surgical considerations when approaching variations and complications of isthmoceles.