Stepwise Approach to Laparoscopic Removal of Type 2 Cesarean Scar Ectopic Pregnancy скачать в хорошем качестве

Stepwise Approach to Laparoscopic Removal of Type 2 Cesarean Scar Ectopic Pregnancy

This case details the surgical management of a Type 2 cesarean scar ectopic pregnancy (CSEP), a rare but dangerous condition where a pregnancy implants in the uterine wall at the site of a prior cesarean scar. CSEP occurs when the gestational sac grows into a myometrial defect created by a previous cesarean incision. It is estimated to occur in roughly 1 in 1,800 to 1 in 2,500 pregnancies, and incidence is rising as cesarean delivery rates increase. Unrecognized CSEP can result in catastrophic bleeding, massive transfusion, uterine rupture, or emergency hysterectomy. The patient was a 39-year-old woman, gravida 4 para 3, with three prior cesarean deliveries and a desired ongoing pregnancy. Imaging revealed a gestational sac implanted in the lower uterine segment with an anterior myometrial thickness of only 1 mm, indicating a high risk of rupture and severe hemorrhage. Several classification systems exist for CSEP. The traditional system defines type 1 as superficial implantation that grows inward toward the uterine cavity, while type 2 involves deep implantation growing outward toward the abdominal cavity. Newer research incorporates gestational sac size and anterior myometrial thickness as independent hemorrhage risk factors. In this patient, the sac measured approximately 30–50 mm and the myometrium was less than 1 mm thick, placing the pregnancy in a type 2 to 3 category and making laparoscopic resection the preferred management strategy. Physiologically, wall stress on the thin myometrium increases as the gestational sac enlarges. A mathematical formula illustrates the risk: wall stress equals internal pressure multiplied by the sac radius, divided by twice the wall thickness. With increasing radius and pressure and an extremely thin wall, the risk of rupture escalates as pregnancy progresses. The team employed a four-step laparoscopic approach. First came inspection and visualization to confirm the location and extent of the ectopic pregnancy. Second was incision and dissection of the vesicouterine peritoneum to develop the bladder flap and expose the lower uterine segment. To limit bleeding, mechanical hemostasis was achieved by temporary bilateral internal iliac artery clamping, and chemical hemostasis was provided by vasopressin injection. A uterine manipulator was introduced only after the arteries were secured. The third step involved careful dissection and removal of the gestational sac and the associated isthmocele (the scar defect), and the fourth step was meticulous repair of the uterine wall. During the operation, the pregnancy appeared as a bulge just above the bladder peritoneum. Initial dissection through an anterior retroperitoneal approach was attempted to identify the ureter and uterine artery, but the patient’s body habitus (BMI 35) and the nine-week gravid uterus with significant vascularity made this challenging. The team switched to a lateral approach to isolate the ureters and internal iliac arteries. Each artery was carefully dissected, and bulldog vascular clamps were placed to achieve temporary occlusion. The right ureter was reflected medially as the right clamp was introduced, and the process was repeated on the left despite the extensive vascularity. Securing both internal iliac arteries provided a stable field with minimal bleeding before the uterine manipulator was inserted. With vascular control established, the vesicouterine peritoneum was dissected and the bladder flap completed, revealing the prominent bulge of the pregnancy. The boundaries of the gestational sac were demarcated with an ultrasonic device to avoid distortion of anatomy. Vasopressin was injected into the outer edges of the pregnancy to further reduce blood flow. Dissection proceeded along the contour of the sac to preserve healthy myometrium. The gestational sac was entered, fluid was aspirated, and placental tissue was removed. The fetus was encountered and removed, though that portion of the procedure was not shown. A specimen retrieval bag was placed in advance to capture excised tissue. The isthmocele was then carefully excised from surrounding myometrium, following the natural direction of the defect rather than cutting a perpendicular wedge to minimize removal of healthy tissue. Bleeding was minimal—estimated at only 30 cc—due to the combined effect of mechanical and chemical hemostasis, though minor venous bleeding required suturing. Inspection confirmed complete excision of the scar tissue. Closure of the uterine defect was performed with a barbed suture in a double-layer fashion to ensure a strong repair and preserve future fertility. The specimen retrieval bag containing the pregnancy and scar tissue was removed through a 10 mm umbilical port. The bulldog clamps were then carefully released from both internal iliac arteries, and hemostasis was confirmed both abdominally and vaginally at low pressure.