{"paper_id":"364282c8-7e91-453a-8e33-97b17071b475","body_text":"CLINICAL PRACTICE\nLaparoscopic Strassman ’s metroplasty for bicornuate uterus\nSanket Pisat & Benedikt Tas & Bruno van Herendael\nReceived: 3 December 2008 / Accepted: 29 December 2008 / Published online: 30 January 2009\n# Springer-V erlag 2009\nAbstract The authors report the case of a 28-year-old\nnulliparous woman with a bic ornuate uterus and one\nprevious second trimester pregnancy loss, in whom inves-\ntigations for other probable causes of abortion like genetic,\ninfective, hormonal, and immunological were negative. A\nlaparoscopic metroplasty was performed by Strassman ’s\nmethod. Second-look hysteroscopy and laparoscopy, which\nwas performed 7 months later, revealed a single uniform\ncavity with a median muscular ridge, which resembled an\narcuate uterus. Pelvic adhesions were noted between the\nsmall bowel, omentum, and posterior wall of the uterus,\nalong with pelvic endometriosis and a chocolate cyst of the\nleft ovary. Adhesiolysis, cyst excision, and fulgration of\nendometriotic deposits were carried out, which were\nfollowed by the application of an adhesion barrier.\nKeywords Laparoscopic metroplasty . Bicornuate uterus .\nStrassman’s metroplasty . Mullerian abnormalities\nIntroduction\nThe incidence of uterine malformations in the general\npopulation is about 4.3%, and in patients with recurrent\npregnancy loss, it is about 13% [ 1]. Bicornuate uteri\nconstitute around 25% of Mullerian anomalies [ 2]. The\npregnancy outcome of patients with untreated bicornuate\nuterus is poor, with reported term delivery rates of up to\n62.5%, with early miscarriages and preterm deliveries being\nquite common [ 3]. Conventional transabdominal metro-\nplasty has been shown to significantly improve the\npregnancy outcome in patients with bicornuate uterus [ 4].\nLaparoscopic metroplasty, though technically difficult,\noffers the distinct advantages of the laparoscopic approach\nover laparotomy. There are, till date, very few published\nreports of laparoscopic metroplasties, the first one being\nreported in January 2006 [ 5]. In this case report, the authors\ndescribe a laparoscopic metroplasty for a bicornuate uterus,\nwith good postoperative results confirmed by second-look\nhysterolaparoscopy.\nCase report\nA 28-year-old woman with a history of one previous\nsecond trimester pregnancy loss at 17 weeks of gestation\nwas referred for management. On physical examination, she\nhad normal physical and secondary sexual characteristics.\nExternal genital organs were normal. An ultrasound\nexamination revealed a bicornuate uterus with two sym-\nmetrical uterine horns and a single cervix. Both ovaries\nwere normal. On inquiry, the patient gave a history of\nsimilar malformations in other members of her family. A\nrenal ultrasound was done to rule out associated anomalies\nof the urinary system. Investigations for other probable\nGynecol Surg (2009) 6:153 –158\nDOI 10.1007/s10397-008-0463-1\nS. Pisat : B. Tas : B. van Herendael ( *)\nEndoscopic Training Centre Antwerp (ETCA),\nZiekenhuis Netwerk Antwerpen [ZNA] Stuivenberg,\nLange Beeldekensstraat 267,\n2060 Antwerp, Belgium\ne-mail: bruno.vanherendael@beline.be\nURL: www.etca.be\nS. Pisat\ne-mail: sanket.pisat@gmail.com\nURL: www.etca.be\nB. Tas\ne-mail: benedictus.tas@zna.be\nURL: www.etca.be\nB. van Herendael\nObstetrics and Gynecology Department, Università dell ’Insurbia,\nV arese, Italy\n\ncauses of abortion like genetic, infective, hormonal, and\nimmunological were negative.\nMaterials and methods\nOperative procedure\nDiagnostic hysterolaparoscopy with laparoscopic metro-\nplasty was performed in the early proliferative phase. A\nsingle dose of antibiotic (third generation cephalosporins)\nwas given intravenously at the start of the surgery.\nAntiembolic stockings were used for thromboembolism\nprophylaxis. A written informed consent of the patient and\nher husband was taken after explaining the procedure, its\npossible complications, and impact on her reproductive\noutcome.\nAfter placing the patient in lithotomy position, diagnos-\ntic hysteroscopy and laparoscopy was done to confirm the\ndiagnosis of bicornuate uterus (Fig. 1). Both horns of the\nuterus were found to be of approximately the same size and\nshape. Both horns were functional and communicating at\nthe isthmus. Both tubal ostia, one in each horn, appeared\nnormal. Bilateral tubal patency was confirmed by methy-\nlene blue test.\nThe surgical procedure of laparoscopic Strassman ’s\nmetroplasty\nA 2.5-cm-long intraumbilical incision was taken, and a\n20 cm V eress needle was inserted through it. Pneumo-\nperitoneum was created using prewarmed and humidified\nCO\n2 at a rate of 4.5 L/min. The temperature of the CO 2 gas\nat abdominal entry was 35°C at a preset pressure of 20 mm\nHg using a special CO 2 insufflator (Thermoflator, Karl\nStorz Gmbh & Co. KG, Tuttlingen, Germany). An 11 mm\ntrocar with reduction to 10 HiCap (Karl Storz Gmbh & Co.\nKG) was inserted through this incision, and the abdominal\ncavity was inspected using a zero degree telescope. Two\n5 mm trocars were placed in the right and left lower\nquadrants of the abdomen, medial to the inferior epigastric\nvessels, and a third 10 mm trocar was placed in the midline\n15 cm above the pubic symphysis. An adhesion band was\nseen extending from the bladder to the rectum, between the\ntwo uterine horns. The fallopian tubes and ovaries were\nnormal. There were no adhesions in the ovarian fossa.\nSuperficial endometriotic deposits were seen in the pouch\nof Douglas, which were fulgrated with bipolar cautery.\nUsing bipolar current, the adhesion band was cauterized\nand then cut with scissors.\nEpinephrine solution (30 mL) in a dilution of 1 mg\nepinephrine in 100 mL saline was infiltrated subserosally\nalong the medial aspect of both uterine horns. Using a\nmonopolar cautery at 120 W pure cutting current, an\nincision deep enough to cut the myometrium was taken.\nThis incision started from the supero-medial aspect of each\nuterine horn, about 2 cm medial and caudal to the origin of\nthe fallopian tube and extended along the medial aspect of\nthe horn up to its base. For controlling myometrial\nbleeding, bipolar cautery at 80 W coagulating current was\nused. The endometrial cavity was then opened along the\nsame line using scissors (Fig. 2). The uterus was manipu-\nlated using a blunt-tipped metallic uterine sound. Initially,\nthe sound was inserted into the cervix up to the base of the\nuterine horns to push up the base while taking myometrial\nincision with monopolar cautery. Then, the sound was\ninserted into one uterine horn at a time to stabilize it before\ncutting the endometrium with scissors over the instrument.\nCO\n2 inflow was increased to 20 L/min to prevent loss of\npneumoperitoneum. Although there was a loss of pneumo-\nFig. 1 Bicornuate uterus with adhesion band between bladder and\nrectum\nFig. 2 Opening endometrial cavity with scissors after myometrial\nincision with unipolar cautery\n154 Gynecol Surg (2009) 6:153 –158\n\nperitoneum after opening the endometrium, the loss was\nslow and gradual due to presence of the cervix. Increasing\nCO2 inflow was enough to nullify this gradual loss and\nmaintain good abdominal distension for surgery. Hence,\nvaginal packing was not necessary.\nThe opposing myometrial edges were sutured using\ninterrupted sutures of 0 polyglactin 910 (Vicryl; Ethicon,\nSomerville, NJ, USA), taking successive sutures on the\nanterior and posterior walls. Vicryl no. 0, 90 cm in length,\non a 26 mm half circle round body needle was used. Care\nwas taken to exclude the endometrium. One layer of\ninverting sutures was used, thereby burying the knots in\nthe myometrium to minimize postoperative adhesion\nformation. After placing two sutures each on the anterior\nand posterior wall at the base, two square sutures of Vicryl\nno. 1 (second layer) were placed at the fundus, anteriorly\nand posteriorly. The purpose of these sutures was to achieve\ngood approximation of the opposing walls, achieve hemo-\nstasis, and to enable manipulation of the uterus, thereby\nmaking it easier to take the rest of the sutures. The\nperitoneal cavity was irrigated with saline solution and\nhemostasis was confirmed (Fig. 3). The uterus and\nperitoneal cavity were then irrigated with 1 L of Icodextrin\n4% solution (Adept; Baxter Healthcare S.A., Belgium),\nwhich was left inside the peritoneal cavity to minimize\npostoperative adhesion formation. The infraumbilical port\nwas closed with a delayed absorbable monofilament suture\nin two layers. Skin closure of all ports was done using\ncyanoacrylate skin adhesive (Dermabond; Ethicon). The\nintraoperative blood loss was 100 cm\n3, and the duration of\nsurgery was 3 h.\nPostoperative course and second-look hysterolaparoscopy\nThe patient had an uneventful recovery and was discharged\non the third postoperative day. Antibiotics were continued\nfor 5 days. Barrier contraceptives were prescribed. She was\nadvised to follow up after 4 months for repeat hysterola-\nparoscopy, but it was postponed by the patient for family\ncauses.\nA repeat hysteroscopic and laparoscopic examination\nwas performed 7 months later. Hysteroscopy using the\nBettochi vaginoscopy technique and a 3.5 mm rigid\nthrough flow hysteroscope (Karl Storz Gmbh & Co. KG)\nshowed a uniform, spacious uterine cavity with a median\nmuscular ridge less than 1 cm in size, resembling an arcuate\nuterus, for which no treatment was felt necessary (Fig. 4).\nEndometrium and tubal ostia were normal. No synechiae\nwere seen. On laparoscopy, a normal uterus with a uniform\nexternal contour and perfect bilateral symmetry was seen.\nThere were filmy adhesions between both the omentum,\nsmall bowel, and the posterior uterine wall (Fig. 5). A\nchocolate cyst was seen in the left ovary. The adhesions\nwere coagulated and cut, and the chocolate cyst was\ndrained and then excised. The raw areas were covered with\nan adhesion barrier substan ce (SprayShield; Covidien,\nMansfield, MA, USA) to prevent recurrence of adhesions\n(Fig. 6).\nDiscussion\nTransabdominal metroplasty by laparotomy and its impact\non reproductive capability have been extensively studied by\nvarious authors [ 4, 6]. This procedure has been shown to\nsignificantly improve the obstetric outcome in women with\nrecurrent abortions or premature delivery before surgery\n[4]. The term pregnancy rates after unification procedure\nhave approached 80% to 85% [ 6]. Although there are as yet\nFig. 3 Reconstructed uterus after completion of suturing\nFig. 4 Second-look hysteroscopy showing spacious cavity with\nmedian muscular ridge\nGynecol Surg (2009) 6:153 –158 155\n\nfew reports of laparoscopic metroplasty, initial results are\nencouraging. Authors have reported minimal peritoneal\nadhesions, good restoration of uterine anatomy, and a\nspacious, uniform cavity [ 5, 7].\nAlthough there is limited experience with the laparo-\nscopic correction of Mullerian anomalies, the laparoscopic\napproach could be a viable alternative to abdominal\nStrassman ’s metroplasty. Reduced tissue handling and\ndrying, which are inherent in laparoscopy, may contribute\nto reduced adhesion formation after laparoscopic surgery\n[8]. Also, early ambulation, reduced hospital stay, quicker\nwound healing, and a more cosmetic scar are some of the\nobvious advantages of the laparoscopic approach over\nlaparotomy.\nHowever, some issues are of concern. Strassman ’s\nmetroplasty is technically quite challenging when per-\nformed through the laparoscopic route [ 5]. Precise suturing\nto achieve good approximation of the anterior and posterior\nwalls is difficult and tiresome. Manipulation of the needle\nholders while suturing the base of the posterior uterine wall\ncan be extremely difficult [ 5]. Bleeding through the cut\nedges of the uterine wall can interfere with the suturing\nprocess. The laparoscopic metroplasty procedure differs\nsomewhat from conventional abdominal metroplasty. Fewer\nsutures were used to approximate the uterine walls than are\nneeded in conventional metroplasty. The authors used no. 0\nVicryl, which is thicker and stronger than finer sutures that\nare otherwise used, as these sutures tend to break easily\nduring intracorporeal knot tying. While suturing the uterine\nwalls, interrupted inverting sutures were used. The needle\nwas first passed into the myometrium adjacent to the\nendometrial lining, to exit just below the serosa, on the left\nhorn. The needle then passed through the myometrium of\nthe right horn, first subserosally and exited adjacent to\nendometrium. On tying this suture intracorporeally, the\nendometrial edges were apposed perfectly, and the knot was\nburied in the myometrium. Inverting the myometrium in\nthis way prevents growth of endometrial glands in the\nuterine scar [ 5, 9]. Placing all knots within the cavity or on\nthe serosa of the uterus would aggravate formation of\nintrauterine synechiae and external adhesions, respectively.\nThe second issue is that of achieving meticulous\nhemostasis, vis-à-vis with the excessive use of current,\nwhich may cause weakening of the scar. Most authors have\ndescribed opening the myometrium using a monopolar\nneedle. The myometrium is damaged to a certain extent\nusing this technique, which causes weakening of the scar,\nbut it gives good hemostasis [ 5, 7]. The myometrial edges\nmust not be sutured under tension, and hematoma forma-\ntion in the wall should be avoided. Suturing myometrial\nedges under tension increases the chances of necrosis of the\nuterine musculature. Good approximation without tension\nwill prevent hematoma formation in the uterine muscula-\nture. It will also reduce the likelihood of healing by\nsecondary intent, which could make the uterine wall fragile\nduring pregnancy [ 5, 7, 9].\nThe third issue is the integrity of the scar and its\nperformance in labor. Reports show a good scar integrity in\nmyomectomy cases wherein the capsule of the fibroid is\nopened with a monopolar needle [ 9]. During the second\nstage of labor, uterine contractions reach 80 –100 mmHg.\nTo evaluate uterine compliance in labor, authors have\nelevated intrauterine pressure up to 150 mm Hg with a\ncontinuous positive pressure flow of 5% dextrose solution\nand confirmed that the uterine wall tolerated it [ 7]. Recent\nstudies have shown that uterine rupture during pregnancy\nafter laparoscopic myomectomy is rare, and vaginal birth\nafter laparoscopic myomectomy appears to be safe in\nselected patients who meet certain criteria [ 10]. However,\nit must be remembered that in Strassman ’s metroplasty, the\nuterine cavity is opened over its entire length and the\nFig. 5 Second-look laparoscopy showing filmy adhesions between\nomentum, small bowel, and uterus\nFig. 6 After adhesiolysis and spraying of adhesion barrier\n156 Gynecol Surg (2009) 6:153 –158\n\nmyometrium is incised longitudinally. These patients will\ndefinitely have an increased risk of scar rupture in late\npregnancy, as compared to myomectomy, where only a\npartial incision of the myometrium overlying the myoma is\ntaken, without opening the cavity in most cases. It is\nworthwhile to note that studies have shown term delivery\nrates in bicornuate uteri to be up to 62.5% [ 3]. Because a\nlaparoscopic metroplasty is an invasive procedure and\nposes an increased obstetric risk in late pregnancy, it is\nonly indicated in case of proven poor obstetric outcome and\nin absence of other reasons for recurrent miscarriage.\nThe fourth issue is that of postoperative adhesion\nformation. Although the minimally invasive endoscopic\napproach has been shown to be less adhesiogenic than\ntraditional surgery, at least with regard to selected proce-\ndures, it does not totally eliminate the problem [ 11].\nMinimal adhesion formation after laparoscopic metroplasty\nfor bicornuate and didelphic uteri has been reported in\nprevious studies [ 5, 7]. In our case, the co-existent\nendometriosis could have been an important factor in the\ndevelopment of postoperative adhesions. A higher inci-\ndence of endometriosis has been reported in patients with a\nseptate uterus [ 12], and this may also be true for other\nMullerian anomalies.\nThe temperature and dryness of the gas used during\nlaparoscopy cause physical and chemical alterations in the\nperitoneum, leading to postoperative adhesion formation.\nDamage to the peritoneal surfaces during laparoscopy can\nbe minimized when the gas stream is kept warm and moist\n[13]. Liquid agents, which can be instilled in the abdominal\ncavity, prevent adhesions by a combination of hydro-\nflotation and barrier principles [ 14]. A study using\nIcodextrin 4% solution conducted in 150 centers across\nsix European countries concluded that the solution was well\ntolerated and easy to use for the reduction of adhesion\nformation following gynecological surgery [ 15].\nThe use of certain sprayable hydrogel adhesion barriers\nhas also been shown to be effective in reducing postoper-\native adhesion severity [ 16]. The authors are of the opinion\nthat in cases where sutures have been taken on the surface\nof the uterus, using a sprayable hydrogel adhesion barrier\nresults in lesser postoperative adhesions between the uterus\nand other organs, like the bowel and omentum. This is\nbecause the gel solidifies after spraying, has excellent tissue\nadherence, remains strong ly adherent to the site of\napplication for 5 to 7 days, and hence is ideal for the\nprevention of site-specific adhesions [ 16]. Hence, the effect\nof the cut ends of sutures, which would otherwise stimulate\nadhesion formation due to a foreign body reaction, is\nminimized. The hope is that an improved formula, which is\nhighly effective, will be developed soon. At their institute,\nthe authors now have a routine policy of using prewarmed,\nhumidified CO\n2 for every laparoscopic procedure. Adhe-\nsion barrier spray (SprayShield; Covidien) is routinely used\nafter every myomectomy and adhesiolysis.\nIt is worthwhile to note that the new uterine cavity after a\nconventional transabdominal metroplasty appears smaller\nthan that of a normal uterus [ 6]. However, this does not\nseem to be applicable for the present case. The final size of\nthe uterine cavity seems to be relatively unimportant to\nreproductive capability; uterine symmetry appears to be a\nmore important factor [ 6].\nConclusion\nIn conclusion, laparoscopic Strassman ’s metroplasty seems\nto be a viable alternative to the traditional transabdominal\napproach by laparotomy. This procedure can be kept as a\nsurgical option in symptomatic cases that require uterine\nunification for bicornuate uteri. More long-term studies, as\nregards scar integrity and reproductive outcome, are needed\nto establish a comparison over the laparotomy approach.\nDeclaration The authors Dr Sanket Pisat, Dr Benedikt Tas, and Prof\nDr Bruno van Herendael hereby declare that the surgery described in\nthis manuscript complies with the current laws of Belgium.\nConflict of interest The corresponding author certifies that there is\nno actual or potential conflict of interest in relation to this article.\nReferences\n1. 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