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Uterine and Pelvic Conditions · Acquired Uterine Conditions

Combined hysteroscopic and laparoscopic management of an isthmocele: about a case report

Slaoui A, Ghazalah A, Lamrani M, Harmouchi OE, Mouiman S, Baidada A

Published July 2025 International Journal of Surgery Case Reports, 132, 111436
DOI 10.1016/j.ijscr.2025.111436 PMC PMC12148717

RRM Academy Synopsis

Isthmocele repair with two scopes resolved one cesarean scar defect

A cesarean scar defect resolved completely at 8 weeks after surgery with two scopes. This Moroccan case report followed one 29-year-old woman who had pelvic pain, irregular bleeding and secondary infertility.

Key Findings

  • The woman was 29 and had a cesarean section three years earlier. She reported six months of diffuse pelvic pain, intermittent metrorrhagia (irregular uterine bleeding) and secondary infertility.
  • Ultrasound showed a triangular defect in the anterior uterine wall at the cesarean scar, with a residual myometrial thickness of 2.2 mm. Diagnostic hysteroscopy confirmed the isthmocele.
  • With the laparoscopic light dimmed, hysteroscopic light shone through the thin uterine wall and marked the defect margins. The surgeons excised the defect and closed it in two layers.
  • The operation took 45 minutes with minimal blood loss (<100 mL). The woman went home on postoperative day two.
  • At the 8-week follow-up, hysteroscopy showed the defect had resolved completely.

Interpretation

The report follows one woman, treated at one university hospital in Rabat, for 8 weeks. Follow-up assessed how the defect looked on hysteroscopy. The surgeons chose laparoscopy because the muscle layer left over the defect measured 2.2 mm. They cite 3 mm as the thickness below which laparoscopy is typically needed. They added hysteroscopy because laparoscopy had not clearly identified the defect in an earlier patient. The authors call for long-term follow-up and multicenter studies to find the best management.

RRM Context

Restorative reproductive medicine looks for a structural cause and repairs it. Here the cause was a scar defect that can collect menstrual blood. The operation excised the defect and rebuilt the uterine wall in two layers. Excision with reconstruction follows the logic of excision surgery for endometriosis: remove abnormal tissue and restore the anatomy. The authors name fertility preservation as a reason to rebuild the wall.

Our editorial summary of this paper, not the article's abstract.

Abstract

Background

Isthmocele, a cesarean scar defect, is a common complication of cesarean delivery that can cause postmenstrual spotting, pelvic pain, and infertility. Its management requires accurate diagnosis and tailored surgical approaches, especially in women desiring future fertility.

Case Presentation

A 29-year-old woman with a history of cesarean section presented with pelvic pain, metrorrhagia, and secondary infertility. Ultrasound and hysteroscopy confirmed an isthmocele with a residual myometrial thickness of 2.2 mm. She underwent a combined laparoscopic and hysteroscopic repair. The defect was excised and reconstructed using two layers of size 0 absorbable sutures. Postoperative recovery was uneventful, and follow-up hysteroscopy at 8 weeks showed complete resolution of the defect.

Discussion

Isthmocele symptoms arise from menstrual blood retention in the defect. Deeper defects benefit from laparoscopic repair, which restores uterine wall integrity, particularly for fertility preservation. The combined approach enhances defect localization and repair precision, as demonstrated in this case.

Conclusion

This case underscores the effectiveness of a combined laparoscopic and hysteroscopic approach in managing isthmocele, achieving symptom resolution and uterine integrity restoration. Individualized management and long-term follow-up are essential for optimizing outcomes.

Topics

Related research

Uterine and Pelvic Conditions › Acquired Uterine Conditions › Cesarean Scar Defect · Reproductive Surgery › Uterine Surgery › Cesarean Scar Repair
Aziz Slaoui, Amani Ghazalah, Meryem Lamrani, Othmane E. L. Harmouchi, Soukaina Mouiman, Aziz Baidada
A Slaoui, A Ghazalah, M Lamrani, O Harmouchi, S Mouiman, A Baidada
DOI 10.1016/j.ijscr.2025.111436 10.1016/j.ijscr.2025.111436 Slaoui et al. 2025, Slaoui 2025

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