Design: Surgical video

Setting: An academic teaching hospital

Patients or Participants: 30 year old P3023 with a history of one cesarean section complicated by cesarean scar ectopic successfully treated with methotrexate and intrauterine balloon, now presenting with pelvic pain and subsequently diagnosed with a uterine niche on imaging.

Interventions: The patient consented for a laparoscopic resection of a uterine niche. During surgery, the patient was found to have dense bladder adhesions which were dissected off to reveal the thinned-out fibrotic uterine niche in the anterior lower uterine segment. The niche was successfully resected and the defect was repaired in three layers.

Measurements and Main Results: The uterine niche was resection was repaired with no complications. The patient was discharged the same day with a normal postoperative course. The pathology showed fibromuscular tissue fragments consistent with scar tissue, chorionic villi and weakly proliferative endometrium.

Conclusion: Patients with a uterine niche who are symptomatic or desire future pregnancy should be treated. Treatment includes laparoscopic resection, with an option to combine with hysteroscopy. Key strategies for laparoscopic excision include backfilling the bladder before dissection, dilute vasopressin for reduced blood loss, use of spiral and symmetric sutures for better hemostasis and approximation respectively, and an intrauterine balloon to prevent recurrence of adhesions.