Impact of Vertical vs. Transverse Closure on Outcomes of Laparoscopic Correction of Isthmocele

Isthmocele, also known as a cesarean scar defect (CSD), is a common complication following cesarean section, characterized by a myometrial defect at the site of the hysterotomy scar. It can lead to various symptoms including abnormal uterine bleeding, dysmenorrhea, pelvic pain, and infertility.

Laparoscopic repair aims to restore the anatomical integrity and physiological function of the lower uterine segment.

• Vertical Closure: This technique involves closing the defect along the longitudinal axis of the uterus. Proponents suggest it may be more anatomically aligned with the muscle fibers of the lower uterine segment, potentially leading to stronger scar formation and reduced tension.
• Transverse Closure: This technique involves closing the defect perpendicular to the long axis of the uterus. This approach is more commonly used during primary cesarean sections.

Arguments for transverse closure in isthmocele repair include familiarity for surgeons and potentially less shortening of the lower uterine segment.

However, the actual impact of these different closure methods on long-term outcomes such as defect recurrence, scar integrity, and fertility, remains largely unexplored in a randomized controlled trial setting.

Inclusion criteria

• Women aged 18-45 years.
• Diagnosis of symptomatic isthmocele confirmed by transvaginal ultrasound (myometrial thickness at the defect < 2.5 mm).
• History of at least one prior cesarean section.
• Symptoms attributable to isthmocele (e.g., abnormal uterine bleeding, pelvic pain, dysmenorrhea, secondary infertility).
• Desire for surgical correction of isthmocele.
• Ability to understand and provide informed consent

Exclusion criteria

• Asymptomatic isthmocele.
• Active pelvic infection or malignancy.
• Significant medical comorbidities contraindicating laparoscopic surgery.
• Coagulopathy.
• Known uterine anomalies (e.g., bicornuate uterus).
• Pregnancy at the time of recruitment.
• Inability to comply with follow-up protocol.