This document outlines a study protocol to evaluate a novel transvaginal surgical approach for repairing caesarean section scar defects. The study will recruit 60 symptomatic women to undergo transvaginal repair involving endometrial curettage of the scar defect cavity and suturing of the defect. Patients will be followed for 6 months with clinical and ultrasound evaluations at regular intervals to assess outcomes. The goal is to evaluate if this approach can effectively repair scar defects while avoiding complete excision of healthy myometrium.

1. Assessment of
Transvaginal Repair
of Caesarean Section
Scar Defects

2. Protocol of thesis
Submitted For Partial Fulfillment of the PhD
Degree
In Obstetrics and Gynecology
By
Mohamad Saad Bedeir Hamed
Master Degree of
Obstetrics & Gynecology, Al Azhar University
(2014)

3. Supervised By
Prof. Reffat Alsheemy
Professor of Obstetrics and Gynecology
Al Azhar faculty of medicine –Damietta
Dr. Ibrahim Ramadan Alsawy
Lecturer in Obstetrics and Gynecology
Al Azhar faculty of medicine –Damietta

5. Introduction:
Over the past decade, with the increase in cesarean
section rate and improvement in diagnostic
modalities, the incidence of previous cesarean scar
defect (PCSD) is increasing, and in random
populations it was present in 24–69% of women
evaluated with transvaginal sonography (Van der et
al., 2014).

6. Introduction:
Definition and symptoms:
Previous cesarean section scar defect (PCSD), also
known as previous cesarean scar diverticulum, is
defined as deficient uterine scars or scar dehiscence
following a cesarean section, which involves the
myometrial discontinuity at the cesarean scar
(Borges et al., 2010).
PCSD is a serious complication of cesarean
section. PCSD has been reported to be associated
with prolonged postmenstrual bleeding,
dysmenorrhea, abnormal uterine bleeding
throughout menstrual cycle, infertility and deep
dyspareunia (Tower and Frishman, 2013).

7. Introduction:
Diagnosis:
Caesarean section scar defects can be detected at
transvaginal unenhanced ultrasound examination
and the best time to visualize the cesarean section
scar defect is mid-cyclic as the cervical mucus acts as
a good contrast media (Al sheimy et al., 2014).

8. Introduction:
Diagnosis:
Saline contrast sonohysterography (SCSH) has been
shown to be useful for assessing the uterine cavity, in
particular for detecting and evaluating the
PCSD (Monteagudo et al., 2001).
Hysterosalpingography (HSG) evaluates the frequency
and appearance of uterine cavity anatomic defects in
patients with a history of cesarean section
(Krishna et al., 2008).

9. Introduction:
Diagnosis:
Hysteroscopic assessment of PCSD is also
documented to be a good way for detection and
evaluation (Fabres et al., 2003).

10. Introduction:
Treatment:
Due to the unclear pathogenesis of PCSD, its treatment
has yet been elucidated.
Although oral contraceptives (OC) may result in the
temporary improvement in symptoms but many
patients cannot their adverse effects (Tahara et al.,
2006).
An abdominal approach (laparoscopic) to repair the
uterine defect can completely correct the defect but
its invasiveness and complications significantly
restrain its wide application in clinical practice
(Demers et al., 2013)

11. Introduction:
Treatment:
Hysteroscopic treatment has been introduced in
recent years depends on electro cautery of dilated
blood vessels, endometrial like tissues, with removal
of fibrotic scar and debris in the roof of the pouch
(Feng et al., 2012) and (Li et al., 2013)
However, the clinical improvement rate is just
59.6% after hysteroscopic treatment and the cause of
failure is still unknown (Wang et al., 2011).

12. Introduction:
Treatment:
To the best of our knowledge, there are only two
wide studies have been reported in China to
investigate the transvaginal management of PCSD
(Luo et al., 2012) and (Yuqing et al., 2014).
Both studies revealed that transvaginal repair of
PCSD is a safe method but both have a leaking the
postoperative follow up and both reported removal of
the total edge of the PCSD by excision of the fibrotic
tissue during repair, A 22% failure rate was reported
in both studies.

13. Introduction:
Treatment:
In this study we will try a novel approach that
avoiding complete excision of the residual healthy
myometrium and only remove the necrotic tissues in
the cavity of the PCSD creating a row area that may
facilitate the healing process after stitching the
defect.

15. Aim of the work:
To evaluate the repair of caesarean section scar
defect in symptomatic patients through
transvaginal novel surgical approach
depending on creating a row area by
endometrial curettage to the roof of the PCSD
and follow up of the cases as regard outcome.

17. Patients and Methods:
This prospective clinical observational study will
be conducted in obstetrics and gynecology
department, Al Azhar University hospital (New
Damietta), at the period from November 2014.

18. Patients and Methods:

19. Patients and Methods:
Inclusion criteria
All women who have at least one of the following
symptoms (dysmenorrhea, pelvic pain, deep
dyspareunia, unexplained infertility for more than
two years, prolonged postmenstrual bleeding or
postmenstrual intermittent bleeding) provided that
presence of all of the following conditions:
 At least one previous caesarean section for more than one
year.
 Caesarean section scar defect measures more than 4mm
base length and 6mm depth.

20. Patients and Methods:

21. Patients and Methods:
Exclusion criteria
All women with any of the following must be excluded
 All pregnant women.
 Asymptomatic patients with PCSD.
 Irregular menstrual cycle before Caesarian section.
 Caesarian section less than one year.
 PCSD equal or less than 4mm base length and 6mm depth.
 Presence of other organic uterine pathology responsible for
abnormal uterine bleeding, such as endometrial
hyperplasia, polyps, malignancy, cervical atypia or sub
mucosal myomas.

22. Patients and Methods:
 60 women will be recruited in this study from the
outpatient gynecological clinic at Al Azhar university
hospital in New Damietta City.
 The study will be conducted after agreement of the
scientific medical and ethics committee at our
department
 Careful history taking to check for inclusion and
exclusion criteria according to a standardized
research protocol.

23. Patients and Methods:
 The diagnosis will be confirmed on the basis of
medical history, clinical symptoms (postmenstrual
spotting), transvaginal ultrasonography (TVU) and
hysteroscopy or MRI in selected cases.
 The purpose of the study will be explained to all
patients and written consent will be taken.
 Proper preparation of the patients for operation
(Basic preoperative investigation, misoprostol taking
and Pap smear if not done in the past year).

24. Patients and Methods:
Operative Procedures
Operative procedures
 All procedures will be done under general anesthesia.
 All patients will place in a dorsal lithotomy position
 Evacuation of the bladder.
 Measuring the length of the cervix by sound will be
done
 Endometrial curettage with special stress on the
cavity of the PCSD which usually identified and felt
during curettage will be done firstly for making a raw
area at the caesarian section scar defect which will
help in the process of healing.

25. Patients and Methods:
Operative Procedures
 Pair of vaginal retractors will be placed to the vaginal
wall to expose the cervix.
 A Vulsellum will be used to grasp and retract the
cervix.

26. Patients and Methods:
Operative Procedures
 An incision will be made at the anterior cervico-vaginal
junction, and the bladder will be dissected away two cm above
the level of internal os.

27. Patients and Methods:
Operative Procedures
 The anterior drawing retractor will be inserted to the
vaginal incision to retract the bladder upwards. The
defect will locate in the previous cesarean incision,
where the residual myometrium was thin.

28. Patients and Methods:
Operative Procedures
 With the guidance of a dilator or sound in the uterus, a
small hollow or depression will be identified in the
anterior wall of the lower uterus above the internal orifice
of the cervix.

29. Patients and Methods:
Operative Procedures
 Then repair of the defect will be easily by suturing in
interrupted manner by absorbable sutures.

30. Patients and Methods:
Follow up
 Clinically improvement will be observed for three
month by Telephoning the patient and transvaginal
ultrasonography twice weekly.
 Three months later hysteroscopic assessment to
evaluate the defect will be done.
 After six month post operatively all patients will be
evaluated clinically and ultrasonographicaly to
estimate the degree of women satisfaction.

31. Patients and Methods:
 The collected data will be organizing, tabulating and
statistically analyzing using Statistical Package for Social
Science (SPSS) version 16 (SPSS Inc, USA).