Transluminal endoscopic metroplasty for uterine scar failure after cesarean section
The transluminal endoscopic method combines hysteroscopy and laparoscopy for precise uterine scar excision and suturing, using an ultrasonic scalpel and barbed sutures, addressing the limitations of existing methods by reducing trauma and blood loss, and enabling concurrent pelvic pathology treatment.
Patent Information
- Authority / Receiving Office
- RU · RU
- Patent Type
- Patents
- Current Assignee / Owner
- МАЛУШКО АНТОН ВИКТОРОВИЧ
- Filing Date
- 2025-12-17
- Publication Date
- 2026-06-30
AI Technical Summary
Existing methods for treating uterine scar failure after cesarean section, such as laparotomy, endoscopic, and vaginal metroplasty, are traumatic, require specialized skills, cause significant blood loss, have a high risk of adhesions, and are inefficient in the presence of concomitant pathologies like endometriosis, leading to prolonged recovery and cosmetic issues.
A transluminal endoscopic method using combined hysteroscopy and laparoscopy for precise scar excision and suturing, employing an ultrasonic scalpel for bloodless tissue removal and self-fixing barbed sutures, accessed through a vaginal incision with CO2 insufflation, providing panoramic visualization and minimizing trauma.
The method achieves precise scar excision and suturing with reduced blood loss, trauma, and risk of adhesions, while allowing for concurrent treatment of pelvic pathologies, offering a less invasive and more effective surgical approach.
Abstract
Description
[0001] The invention relates to the field of medicine, namely obstetrics and gynecology, and can be used in the surgical treatment of patients of reproductive age with an incompetent scar on the uterus after a cesarean section.
[0002] Also known is a method of metroplasty in case of repeated caesarean section using an absorbable anchor thread and sealing the sutures with amniotic membranes (Method of metroplasty in case of repeated caesarean section using an absorbable anchor thread and sealing the sutures with amniotic membranes: patent RU 2801415, Russian Federation, application RU 2023115921, filed 06 / 18 / 2023, published 08 / 08 / 2023), which includes opening the uterus at the border with the thinned part of the scar, suturing the corners of the uterine incision, followed by suturing the uterine defect with a continuous suture.Moreover, the thinned scar tissue is excised, after the sutures at the corners of the uterine incision are pulled, the center of the incision on the uterus is determined, at this point the tissues of the upper and lower edges of the uterine wall are stitched with an anchor absorbable thread with two needles at the ends, the distance to the needles is aligned so that it is the same, and a simple double knot is tied, then from the center a continuous suture is applied sequentially to each corner of the wound, suturing the wound on the uterus with an anchor thread, upon reaching the corners of the wound, the anchor thread is tied with the thread of the corner suture, forming a knot; then, retreating from the center of the wound by 1 cm and by 3 cm, two supporting U-shaped absorbable sutures are applied on each side; A flap is cut out from the placental part of the amniotic membrane and placed on the suture with the fetal surface, fixed with absorbable thread at the corners and in the center of the sutured wound, and peritonization is performed with the vesicouterine fold.
[0003] The disadvantages of this method include the need for a laparotomy approach, which is traumatic and results in significant postoperative pain. This leads to a prolonged postoperative hospital stay. Other disadvantages of this technique include significant blood loss, an increased incidence of abdominal adhesions, and a lack of cosmetic effect (a 6-7 cm scar) on the anterior abdominal wall.
[0004] Also known is a method of treating women of reproductive age with an insolvent scar on the uterus by using a laparoscopic approach when performing metroplasty and consisting in performing an operation through small punctures of the anterior abdominal wall, first, pneumoperitoneum is imposed, then trocars are inserted into the abdominal cavity: at the lower umbilical or at the upper umbilical point - d 10 mm for a laparoscope, above the pubis, in the right and / or left iliac regions d 5 mm for surgical instruments, then the insolvent scar on the uterus is isolated, dissected and excised, the defect of the myometrium and peritoneum over the newly formed scar is sutured, then the instruments are removed from the abdominal cavity and the wounds on the anterior abdominal wall are sutured (V.I. Eremkina, Yu.V. Garifullova. Reconstructive and restorative plastic surgery of an insolvent scar on the uterus with vaginal Access outside of pregnancy. URL: https: / / cyberleninka.ru / article / n / rekonstruktivno-vosstanovitelnaya-plastika-nesostoyatelnogo-rubtsa-na-matke-vlagalischnym-dostupom-vne-beremennosti / viewer).
[0005] The disadvantages of this method include its duration, complexity, and the risk of tissue injury. This is due to the lengthy and difficult endoscopic suture procedure required, which also requires specialized surgical skills. Endotracheal anesthesia administered with this method can also have a negative impact on the patient's health. Other disadvantages include the need for complex and expensive equipment.
[0006] The closest to the claimed method is the method of vaginal metroplasty of an incompetent uterine scar after a cesarean section (Method of vaginal metroplasty of an incompetent uterine scar after a cesarean section: patent RU 2840188, Russian Federation, RU 2024132338, filed 10 / 29 / 2024, published 05 / 19 / 2025). During the method, the patient is placed on a table with her legs spread apart as in a gynecological chair under spinal anesthesia. After surgical treatment, a self-fixing speculum and a lift are inserted into the vagina, the cervix is grasped with bullet forceps, and the uterine cavity is probed. Then, the cervical canal is expanded using Hegar dilators up to 9, then a hysteroscope is inserted into the uterine cavity, the uterine cavity, the area of the scar on the anterior wall, the area of its defect and incompetence are examined.An anterior colpotomy is then performed with a scalpel, 1 cm above the external os of the cervix, using a transverse arcuate incision in the vaginal mucosa, corresponding to the size of the postoperative incompetent uterine scar. The bladder is retracted using a blunt and sharp blade. Vicryl ligatures, 70 cm long and 0 mm thick, with a 30 mm diameter piercing-cutting needle, are applied to the anterior lip of the cervix. These ligatures are used as reins to pull the cervix up, and the uterine scar is removed by passing them one after the other. The area of the defect and thinning is visualized. Two ligatures are applied in front of the scar and behind it above, and the scar itself is removed by pulling the threads. The scar and defect are excised transversely with a scalpel. While pulling the applied ligatures, the scar area is sutured vertically with separate Vicryl sutures. The scar's integrity is then checked under hysteroscopy, and the vaginal mucosa is closed with individual Vicryl sutures. Hemostasis is monitored, and vaginal packing is performed.
[0007] The disadvantages of the closest analogue include relatively low efficiency in the presence of concomitant pathology, such as endometriosis, adhesive disease of the abdominal organs, ovarian formations, requiring one-stage correction, due to limited visualization and the inability to conduct a revision of the abdominal organs.
[0008] The technical problem is the need to develop an effective method of transluminal endoscopic metroplasty for uterine scar failure after cesarean section, devoid of the above-mentioned disadvantages.
[0009] The technical result consists in increasing the effectiveness of transluminal endoscopic metroplasty in case of uterine scar failure after cesarean section.
[0010] The technical result is achieved in that in the method of transluminal endoscopic metroplasty in case of uterine scar failure after cesarean section, including anterior colpotomy, lowering of the bladder, visualization of the scar, its excision and layer-by-layer suturing of the defect, according to the invention, access to the abdominal cavity is carried out through a monoport for transluminal endoscopy installed in an incision in the anterior wall of the vagina, with subsequent insufflation of carbon dioxide to a pressure of 6 mm Hg., by introducing optics and working instruments, while the identification of the thinnest section of the scar is carried out under combined control: by preliminary hysteroscopy from the inside of the uterine cavity and subsequent laparoscopic revision from the outside (using the vNOTES system), and perforation of this area to begin excision is performed with a pipel probe under endoscopic visual control, after which excision of the scar tissue is performed bloodlessly using an ultrasonic scalpel, and suturing of the defect is carried out in two continuous rows, namely muscular-muscular and seromuscular, with a self-fixing thread with notches through transluminal access.
[0011] The advantages of the proposed technique include combined control: hysteroscopy (from within the uterus) and laparoscopy (from outside the uterus) simultaneously, as well as the ability to examine the abdominal cavity and, if necessary, remove foci of endometriosis, ovarian cysts, and dissect adhesions. This allows for precise identification of the thinnest area of the scar and control of the entire excision and suturing process on both sides, minimizing the risk of damage to surrounding organs. The proposed method also offers an increased field of view: laparoscopic optics with a 30° viewing angle provide the surgeon with a panoramic view of the pelvis, which is impossible with the old technique, where the view is limited by the wound. Furthermore, the use of an ultrasonic scalpel (harmonic scalpel) allows for tissue excision with simultaneous coagulation of small vessels without unnecessary coagulation. This dramatically reduces intraoperative blood loss compared to excision with a conventional scalpel in the old method.Another major advantage is the absence of large incisions: the vNOTES method does not require a laparotomy (abdominal incision). All procedures are performed through a natural opening (the vagina) using thin instruments, minimizing trauma to the abdominal wall, pain, and the risk of postoperative hernias.
[0012] The claimed method is carried out as follows.
[0013] The patient is positioned on the operating table with pneumatic legs, hips abducted at 90 degrees, and knees rotated at 45 degrees, resembling the position in a gynecological chair. The surgery is performed under endotracheal anesthesia in the Trendelenburg position at a 15-degree angle. After preparing the surgical field, a self-fixing speculum and elevator are inserted into the vagina. The cervix is grasped with bullet forceps. An arcuate incision of the vaginal mucosa along the anterior semicircle is made 2 cm above the external os of the cervix along the transitional fold. The bladder is sharply lowered, and an anterior colpotomy is performed. A monoport is inserted for transluminal endoscopic intervention (vNOTES) with a valve for carbon dioxide delivery and three ports: one for a video camera and two for working instruments. Next, CO2 insufflation is performed to a pressure of 6 mm Hg.A 30-degree viewing scope and working instruments (bipolar clamp, ultrasonic hook) are inserted into the abdominal cavity. The abdominal cavity is inspected. The cervical canal is then dilated to size #7 with Hegar dilators, and hysteroscopy is performed. The scar area and the thinnest point are visualized, after which the hysteroscope is removed. Under video camera control, the thinnest point is perforated with a Pipelle probe. The scar tissue is then excised without coagulation using an ultrasonic scalpel. The scar area is then sutured continuously in two rows with 1 / 0 self-locking barbed thread on a ½" 37 mm needle. First, a myomuscular suture is placed through all layers, followed by a seromuscular suture. The abdominal cavity is then debrided and inspected, and hemostasis is monitored. The instruments are removed from the abdominal cavity. Anterior colporrhaphy is performed using 2 / 0 Vicryl suture on a 36 mm needle using interrupted sutures. The vagina is packed.
[0014] The claimed method is explained by an example.
[0015] The patient was positioned on the operating table with her legs in pneumatic slings, her hips abducted at 90 degrees, and her knees rotated at 45 degrees, resembling a gynecological examination chair. The surgery was performed under endotracheal anesthesia in a 15-degree Trendelenburg position.
[0016] After preparing the surgical field, a self-fixing speculum and elevator were inserted into the vagina. The cervix was grasped with bullet forceps. An arcuate incision was made in the vaginal mucosa along the anterior semicircle 2 cm above the external os of the cervix along the mucosal fold. The bladder was sharply lowered, and an anterior colpotomy was performed.
[0017] A monoport was installed for transluminal endoscopic intervention (vNOTES) with a valve for supplying carbon dioxide and with 3 ports: one for a video camera and two for working instruments.
[0018] Next, CO2 insufflation was performed to a pressure of 6 mmHg. A 30-degree viewing scope and working instruments (bipolar clamp, ultrasonic hook) were inserted into the abdominal cavity. An abdominal examination was performed.
[0019] Then, the cervical canal was dilated with Hegar dilators to size #7 and a hysteroscopy was performed. The scar area and the thinning area were visualized, after which the hysteroscope was removed.
[0020] Under video camera control, the thinnest point was perforated with a Pipelle probe. The scar tissue was then excised without coagulation using an ultrasonic scalpel.
[0021] Next, the scar area was sutured with 1 / 0 self-fixing barbed suture on a ½" 37 mm needle in two continuous rows. First, a myomuscular suture was placed through all layers, followed by a seromuscular suture.
[0022] After this, the abdominal cavity was debridemented and inspected, hemostasis was monitored, and the instruments were removed from the abdominal cavity.
[0023] Anterior colporrhaphy was performed using 2 / 0 Vicryl suture on a 36 mm needle with individual interrupted sutures. The vagina was packed.
[0024] The operation and postoperative period were successful.
Claims
A method of transluminal endoscopic metroplasty for uterine scar failure after cesarean section, including anterior colpotomy, bladder lowering, scar visualization, its excision, and layer-by-layer suturing of the defect, characterized in that access to the abdominal cavity is achieved through a monoport for transluminal endoscopy installed in an incision in the anterior vaginal wall, followed by insufflation of carbon dioxide to a pressure of 6 mm Hg., by introducing optics and working instruments, while the identification of the thinnest section of the scar is carried out under combined control: by preliminary hysteroscopy from the inside of the uterine cavity and subsequent laparoscopic revision from the outside, and perforation of this area to begin excision is performed with a pipel probe under endoscopic visual control, after which excision of scar tissue is performed bloodlessly with an ultrasonic scalpel, and suturing of the defect is carried out in two continuous rows, namely muscular-muscular and seromuscular, with a self-fixing thread with notches through a complete transmural approach.