LAUSR

STUDY OBJECTIVE To educate surgeons on the advantages of robotic techniques in hysteroscopic-assisted single-site resection of cesarean scar defect. DESIGN A step-by-step presentation detailing the complete surgical procedure. SETTING University Hospital, Baylor College of Medicine, Houston, Texas PATIENTS: 1. A 34-year-old G2P2002 who complained of dysmenorrhea and menorrhagia with an expressed desire for a single-site cesarean scar defect correction. Her surgical history included two cesarean deliveries in 2012 and 2014 respectively. 2. A 34-year-old G4P3013 who complained of dysmenorrhea and a persistent mucus vaginal discharge with an expressed desire for a cesarean scar defect correction in anticipation of conception. Her surgical history was notable for three prior cesarean deliveries. Our two patients' ultrasound reports did not show adenomyosis or any other pathologies. INTERVENTIONS A hysteroscopic-assisted robotic single-site resection of a cesarean scar defect was performed on the patient. The instruments that we used during the procedure were the monopolar hook, wristed needle drivers, cold scissors, and a diagnostic vs operative hysteroscope. Entry was made through the umbilicus with a 15mm incision and carried down through the subcutaneous tissue until the fascia was grasped and entered using Mayo scissors. The abdomen was inspected. The bladder was carefully disected off of the lower uterine segment. The bladder was backfilled to aid in the identification of the correct plane for dissection. Once the bladder had been adequatetly dissected off of the uterus, the suspected defect could be identified. The monopolar hook was utilized to incise the defect and the tip of the hysteroscope was placed through the defect in order to fully delineate it. The edges were trimed with cold scissors (Endoshears) in the first surgery and the monopolar hook in the second. The uterine defect was closed with two layers of countinuous running v-loc. The peritonium was closed with an additional v-loc suture in a running fashion. Finally, a hysteroscopy was performed and the closure was noted to be watertight and thus the defect was successfully repaired. In the second surgery, an intercede was placed over the defect to help prevent future adhesive disease. Additionally, after consulting with experts in CS scar repair, an energy device was recommended and thus the monopolar hook over cold scissors was used for the second case due to its superior cutting effect. In both cases, the pelvis was inspected and hemostasis was observed throughout. MEASUREMENTS AND MAIN RESULTS The two cases had similar outcomes, the cesarean scar defect was repaired with resolution of the patient's symptoms. The thickness of the residual myometrium in CS scar defect was 2.8mm and 2.3mm in the first and second case respectively. This video is exempt from IRB review at our institution. 1. The surgery was completed in 90 mins with only 15 mL of blood loss. The patient was discharged home on the day of surgery and denied any post operative complications at her follow-up appointment. 2. The surgery was completed in 85 mins with only 10 mL of blood loss. The patient was discharged home on the day of surgery. At her follow up appointment she had a positive pregnacy test and denied any post-operative complications. She was contacted at a later date and reveiled that she was 15 weeks pregant. CONCLUSION The hysteroscopic-assisted single site resection of a cesarean scar defect is a feasible method for the resection of CSD. The use of the robot makes the difficult surgical techniques required for this surgery easier and more accessible.