PMC6367910_01
Magnetic resonance imaging before surgical treatment. (a) T2-weighted image sagittal image. (b) Gd-T1-weighted image sagittal image in the early phase (the scar was slightly enhanced.) The cesarean scar is marked with a triangle
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F1
We found only the cesarean section scar as was shown in a vaginal echo test, but the scar was slightly enhanced in the early phase and was suspected to be the bleeding site [Figure 1]. T2-weighted image sagittal MRI. The ratio of thickness of uterine muscle in the most thinned lesion to full thickness of lower uterine segment was changed from 0.14 [1.3/9.1 mm; Figure 1a] to 0.72 [9.2/12.7 mm; Figure 4] after surgery.
Findings in hysteroscopic examination for the cesarean scar. (a) Remaining suturing of the cesarean scar (white triangle) and entry of the diverticulum (black triangle). (b) Dendritic vessels on the surface of the cesarean scar (white triangle)
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F2
We also found atypical dendritic vessels on the surface of the scar [Figure 2].
Procedure and findings in laparoscopic surgery (a) Visualized thinned lesion with light source of hysteroscope (Triangle: Lighted lesion) (b) Resection of scar lesion by ultrasonic scalpel (c) Closed myometrium by Albert-Lembert suturing (Triangle: Closed uterine myometrium) (d) Shortening of round ligaments by suturing (Triangle: Sutured round ligaments)
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F3
We first confirmed the thinned lesion of the cesarean scar guided by the light source of hysteroscope [Figure 3a]. After peeling off the vesicouterine adhesion, we resected the thinned layer using an ultrasonic scalpel [Figure 3b]. Interrupted suturing was performed for the entire thickness of the myometrium, and continuous Lembert suture was added to the uterine surface [Figure 3c]. We added suture on the bilateral round ligament to fix the uterus in an antenatal position and reduce tension of the sutured lesion [Figure 3d].
MRI at 6 months after surgery. Repaired cesarean scar was marked with triangle
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F4
The cesarean scar slightly remained but was well adapted [Figure 4]. T2-weighted image sagittal MRI. The ratio of thickness of uterine muscle in the most thinned lesion to full thickness of lower uterine segment was changed from 0.14 [1.3/9.1 mm; Figure 1a] to 0.72 [9.2/12.7 mm; Figure 4] after surgery.