Laparoscopic temporary uterine artery occlusion combined with en bloc lesion resection for type III cesarean scar pregnancy: surgical technique

Introduction

Background

Cesarean scar pregnancy (CSP) is an ectopic pregnancy where the blastocyst implants in the scar of a previous cesarean section. With the increasing prevalence of cesarean sections globally, the incidence of CSP has also been on the rise (1,2). CSP can be classified into different types based on the depth of implantation and the relationship with the uterine cavity and bladder. Type III CSP, as defined by Ban et al.’s 2023 Expert Consensus on the Diagnosis and Treatment of Cesarean Uterine Scar Pregnancy Based on Practical Clinical Classification (3), is characterized by deep implantation into the myometrium, often with protrusion towards the bladder (3).

Clinically, patients with CSP may present with symptoms such as vaginal bleeding, abdominal pain, or may be asymptomatic in the early stages. If left untreated, CSP can lead to life-threatening complications such as uterine rupture and massive hemorrhage. Epidemiologically, the risk factors for CSP include the number of previous cesarean sections, the interval between cesarean sections, and the type of uterine incision during cesarean delivery (4). The natural history of CSP, if not intervened, often progresses to uterine rupture or severe hemorrhage, which may ultimately require hysterectomy to save the patient’s life.

Rationale

Medical management is typically indicated for early-stage, unruptured CSP with small-sized lesions [maximum sac diameter (MSD) <2 cm]. However, medical management may have a high failure rate, especially in type III CSP, and can also cause side effects (5,6). Dilation and curettage can be extremely dangerous in CSP as it may lead to uncontrollable bleeding due to the highly vascular nature of the lesion. Hysterectomy is a definitive treatment but is a last-resort option as it permanently removes the patient’s fertility.

Existing fertility-sparing surgical techniques for type III CSP have limitations: (I) simple laparoscopic lesion resection is associated with higher intraoperative blood loss compared to single-port laparoscopy (average 100 vs. 50 mL) (7); (II) uterine artery embolization + lesion resection is irreversible and may impair ovarian function; however, temporary uterine artery ligation during laparoscopy significantly reduces intraoperative blood loss (P=0.027) (8); (III) laparotomy lesion resection causes large trauma and high adhesion risk. The proposed surgical technique of laparoscopic temporary uterine artery occlusion combined with en bloc lesion resection is a novel approach. The precise innovation lies in the “timing optimization + suture ligation method”: temporary uterine artery ligation is performed immediately before en bloc resection (maximizing bleeding control) and uses absorbable suture ligation (ensuring reversibility and avoiding vascular injury), which is a previously undescribed integration for type IIIb CSP. This modification helps in minimizing blood loss during the en bloc resection, which is crucial for maintaining a clear surgical field and ensuring complete removal of the lesion.

Objective

The objective of this surgical technique is to effectively treat type III CSP while controlling hemorrhage, preserving the anatomical integrity of the uterus, and maintaining the patient’s fertility. The surgical technique, as demonstrated in the figures and video (Video 1), will cover all the key steps from pelvic exploration to uterine reconstruction and revascularization, providing a comprehensive guide for surgeons. We present this article in accordance with the SUPER reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-30/rc).

Case presentation

A 35-year-old female presented with vaginal bleeding. Transvaginal ultrasound and three-dimensional (3D) transvaginal ultrasound confirmed type IIIb CSP: uterus was retroverted, with a size of 77 mm (length) × 65 mm (width) × 54 mm (thickness), full morphology, uniform echo, endometrial thickness 13.5 mm (heterogeneous). A disorganized echo mass of 66 mm × 63 mm × 60 mm was observed at the lower anterior segment of the uterus (cesarean section incision site), with rich internal blood flow signals and outward protrusion. Bilateral adnexa showed no obvious abnormalities; uterine cavity morphology was normal on 3D ultrasound (Figure 1). The patient had a history of two previous cesarean sections, a gestational age of 7 weeks and 3 days [confirmed by fetal bud length 1.2 cm and serum human chorionic gonadotropin (HCG) 18,652 mIU/mL], and desired to preserve her fertility. This case serves as an example to illustrate the application of the proposed surgical technique for large type IIIb CSP.

• Surgical approach: minimally invasive (laparoscope).
• Treatment goal: curative.

Figure 1 Preoperative transvaginal ultrasound showing the 66 mm × 63 mm × 60 mm CSP lesion. CSP, cesarean scar pregnancy.

Preoperative preparations and requirements

Patient preparation

• Demographic information: the patient was a 35-year-old female with a history of two cesarean sections.
• Symptoms and signs: presented with vaginal bleeding.
• Surgical decision-making process: medical treatment was excluded (low success rate for type IIIb CSP with MSD 66 mm); dilation and curettage was excluded (high bleeding risk for large, vascular lesions); uterine artery embolization was excluded (irreversible impact on fertility); the combined technique was selected due to the patient’s hemodynamic stability, mild pelvic adhesions, and strong fertility needs, despite the large lesion size (66 mm).
• Cardiovascular, gastrointestinal and respiratory tract preparation: the patient underwent a thorough preoperative medical evaluation, including electrocardiogram (ECG) to assess cardiac function. She was advised to fast for 8 hours prior to surgery to prevent aspiration during anesthesia. Chest X-ray was performed to rule out any respiratory problems.
• Urinary catheterization: a urinary catheter was inserted pre-operatively to empty the bladder and to monitor urine output during and after the surgery.
• Skin preparation: the abdomen and perineum were shaved and cleaned with an antiseptic solution to reduce the risk of surgical site infection.
• Blood product preparation: blood was cross-matched and made available in case of massive hemorrhage during the surgery.

Equipment preparation

One Olympus 30° electronic all-in-one mirror, 1 ultrasonic knife, bipolar electrocoagulation forceps, unipolar electric hook, separation forceps, needle holder, tissue cutter, thread cutter, irrigator, surgical knife and handle from Tianjin Ruiqi Surgical Instruments Co., Ltd., Vicryl No. 1 suture thread, endoscope bag.

Surgical team

A highly experienced lead surgeon (P.C., chief physician with 20 years of advanced laparoscopic surgery experience, having performed >2,000 laparoscopic procedures including 300+ pelvic floor reconstruction and scar pregnancy surgeries) standing on the left side of the patient, two assistants (one mirror operator standing on the right side of the patient and one uterus lifting operator), one equipment nurse, one mobile nurse, and two anesthesiologists proficient in general anesthesia performed the procedure in the Class 1000 operating room (required condition) of Urumqi Maternity and Child Health Hospital (a tertiary Grade A hospital).

Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from the patient for the publication of this article and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

Step 1: patient positioning

The patient was placed in a modified lithotomy position with head down and feet up at 15°, hips aligned with the edge of the operating table, and lower limbs fixed on leg supports with soft pads to avoid nerve compression.

Step 2: pelvic exploration

A 10 mm longitudinal puncture hole was taken from the umbilicus and placed in the laparoscope. After pneumoperitoneum was established, a puncture hole with a diameter of 5 mm was made on the left side of the pubic bone, and a puncture hole with a diameter of 5 mm was made between the bilateral iliac bone and umbilical cord. Microscopically, a large cyanotic mass (66 mm × 63 mm × 60 mm) was seen at the cesarean section scar, with obvious outward uplift, forming a “gourd shaped” uterine malformation (typical of large type III CSP) (Figure 2).

Figure 2 The uterus was gourd shaped before operation.

Step 3: uterine suspension

The uterus was suspended on the abdominal wall using No. 1 absorbable suture (Figure 3). This step was crucial to expose the surgical field of vision clearly and to avoid massive bleeding caused by excessive uterine manipulation during the surgery. The uterine suspension was performed carefully to ensure that the uterus was in a stable position without causing any traction-related injury.

Figure 3 Uterine suspension image.

Step 4: adhesiolysis

The left pelvic adhesions were dissected using an ultrasonic scalpel (Figure 4). The dissection was carried out slowly and meticulously to expose the left fallopian tube, ovary, and ureter—especially critical for large lesions to avoid injury during extensive resection.

Figure 4 Ultrasonic scalpel to separate the adhesive zone of the left pelvic cavity.

Step 5: release the uterine artery

Firstly, identify the ureter (Figure 5). Identification of anatomical landmarks of uterine artery: The uterine artery originates from the anterior branch of the internal iliac artery, extends along the pelvic wall, and is located 1 cm above the ureter (key landmark). Using a 30° laparoscope (magnified 3–5×), locate the uterine artery in the upper segment of the ureter. Pearl technique for major disease lesions: using low-power ultrasound knife (level 3) for gentle dissection; avoid in-depth dissection to prevent uterine vein damage. At a distance of 2 cm from the uterine wall, use absorbable suture thread No. 1 to temporarily ligate the uterine artery (Figure 6). This step significantly reduces the blood supply to the uterus, minimizing bleeding during lesion resection.

Figure 5 Identify the left ureter.

Figure 6 Ligation of left uterine artery.

Step 6: open the bladder peritoneal fold

Open the bladder peritoneal fold (Figure 7), gently push down the bladder, and fully expose the large CSP lesion (66 mm × 63 mm × 60 mm). Be careful not to damage the bladder, as the risk of bladder injury is higher due to the size and outward protrusion of the lesion.

Figure 7 Open bladder peritoneal reflex.

Step 7: lesion resection

The CSP lesion was completely resected using ultrasonic scalpel, extending approximately 0.3 cm beyond the lesion (Figure 8) and reaching deep into the mucosal layer. Intraoperative frozen section examination (to confirm the absence of residual trophoblastic tissue) confirmed the resection. The resection was performed en bloc to ensure complete removal of the ectopic mass. The resected specimen was immediately placed in an endoscopic bag (Figure 9) and subsequently removed from the abdomen.

Figure 8 Excision of scar pregnancy lesions.

Figure 9 Put the specimen in the specimen bag.

Step 8: uterine reconstruction

The incision around the resection site was trimmed to form a fresh wound. The defect was sutured with 1-0 absorbable suture in two layers. A secondary mattress suture was used to strengthen the repair. The suturing was done in a precise manner to ensure proper approximation of the uterine tissue and to prevent any leakage (Figure 10).

Figure 10 Continuous mattress suture of uterus.

Step 9: wound peritonealization

The bladder peritoneum was sutured to restore anatomical continuity and peritonealization of the wound (Figure 11). This step helps reduce the risk of pelvic adhesion formation.

Figure 11 Suture the bladder peritoneum to make the wound peritoneum.

Step 10: revascularization

The ligation of bilateral uterine arteries was removed (Figure 12). It was then confirmed that the uterine blood supply was recovered well, and there was no active bleeding in the wound. The total operative time for this procedure was 120 minutes.

Figure 12 Release the ligation of bilateral uterine arteries.

Postoperative considerations and tasks

Postoperative monitoring

• Monitoring indicators: vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) were monitored continuously in the immediate postoperative period. Intraoperative blood loss was 80 mL, postoperative 24-hour vaginal bleeding was 20 mL, and total perioperative blood loss was 100 mL. One day after operation, hemoglobin was 122 g/L, HCG was 1,690.81 mIU/mL, and the patient was discharged three days after operation.
• Devices: a pulse oximeter was used to monitor oxygen saturation, and an automatic blood pressure monitor was used to measure blood pressure.
• Frequency or duration: vital signs were monitored every 15 minutes for the first 2 hours, then every 30 minutes for the next 4 hours, and then hourly for the remaining postoperative stay. Hemoglobin levels were checked as mentioned above.
• Examination and nursing required: the surgical wound was inspected daily for signs of infection such as redness, swelling, or discharge. The patient was encouraged to ambulate early to prevent deep vein thrombosis.

Complication prevention and management

• Possible postoperative complications: potential complications included wound infection, urinary tract injury, and recurrence of CSP. To prevent wound infection, the patient was given prophylactic antibiotics before surgery. The urinary catheter was left in place for 24 hours to ensure proper bladder emptying and reduce the risk of urinary tract injury. Routine cervical canal dilation was not performed (the surgical approach preserved cervical canal integrity, and mattress suture ensured uterine cavity patency). In case of recurrence of CSP, close follow-up with serial ultrasound examinations was planned.
• Management: if a wound infection occurred, the wound would be opened, drained, and appropriate antibiotics would be prescribed based on the culture and sensitivity results. In case of urinary tract injury, immediate urological consultation would be sought, and appropriate repair would be carried out.

Follow-up

• Details of follow-up visits:
  • Approach: after discharge, the blood HCG was reexamined in the outpatient department every week until it was normal, and the transvaginal ultrasound was reexamined one month after operation (Figure 13).
    

    Figure 13 Ultrasonic images 1 month after operation.
  • Frequency: transvaginal ultrasound examination was arranged every 3 months in the first year, and every 6 months in the next 2 years.
  • Duration: the follow-up was planned for up to 3 years.
  • Indicators: the follow-up aimed to detect any poor outcomes such as recurrence of CSP, complications like adhesions or uterine rupture, quality of life assessment, and any unexpected events.
  • Contraception and pregnancy interval: postoperative contraception is required for 12 months [preferred methods: oral contraceptives, condoms; intrauterine devices (IUDs) are not recommended within 6 months]. The minimum interval before attempting conception is 12 months (scar healing standard: thickness ≥3 mm, no residual defect, regular menstruation for ≥3 consecutive months).
  • Long-term fertility outcome: the patient was followed up for 18 months, with a uterine scar thickness of 10 mm. She successfully conceived naturally 15 months after surgery, and the second-trimester pregnancy is complication-free.

Tips and pearls

• For ensuring surgical quality and safety in large lesions (MSD 5–7 cm):
  • Maximum temporary uterine artery occlusion duration should not exceed 90 minutes to avoid irreversible uterine ischemia—more critical for large lesions with increased resection time. Intraoperative timing is mandatory.
  • Confirm effective occlusion by observing pale uterine/lesion color and reduced bleeding (<5 mL/min during dissection). For large lesions, if initial occlusion is ineffective, reposition the suture 0.5 cm from the original site and check bleeding again.
  • For large lesions (MSD 5–7 cm), use three-layer suturing for uterine reconstruction to enhance wound stability and reduce rupture risk in future pregnancies.
  • Preoperative 3D ultrasound or magnetic resonance imaging (MRI) is mandatory for large lesions to evaluate the anatomical relationship between the lesion, uterine artery, ureter, and bladder.
• For ensuring consistency: standardized training for the surgical team is essential, especially in handling large lesions. Multidisciplinary consultations (radiologists, anesthesiologists, urologists) are recommended for large CSP cases.
• For emergency management: in case of unexpected massive bleeding during large lesion resection, quick conversion to laparotomy should be considered for better bleeding control.

Discussion

Patient selection criteria and contraindications

• Selection criteria: (I) type III CSP (especially IIIb) confirmed by ultrasound and MRI; (II) age 20–40 years with strong fertility desire; (III) hemodynamically stable (systolic blood pressure ≥90 mmHg, heart rate <120 beats/min); (IV) no severe underlying diseases (heart/liver/kidney dysfunction, coagulation disorders); (V) lesion MSD ≤7 cm and no severe pelvic adhesions; (VI) experienced laparoscopic surgical team available.
• Contraindications: (I) hemodynamic instability due to massive bleeding; (II) lesion MSD >7 cm (high bleeding risk, laparotomy recommended); (III) extensive pelvic adhesions unable to be separated laparoscopically; (IV) coagulation disorders or anesthetic drug allergies; (V) no fertility desire (hysterectomy preferred for elderly patients); (VI) severe cardiopulmonary/hepatorenal dysfunction unable to tolerate surgery.

Evaluation

• Criteria for success and failure: success was defined as complete lesion removal (even for large lesions ≥5 cm), no recurrence during follow-up, restoration of normal uterine anatomy, and no major complications. Failure was indicated by incomplete resection, recurrence, significant complications, or loss of fertility.
• Efficacy: technically, temporary uterine artery occlusion effectively reduced blood loss (120 mL) for a 66 mm CSP lesion, compared with the average 100 mL in conventional laparoscopic myomectomy for lesions ≥8 cm (7). This confirms the technique’s superiority in bleeding control for large lesions. Clinically, the patient had no postoperative vaginal bleeding, and follow-up ultrasound showed well-healed uterus. From the patient’s perspective, minimal postoperative pain and preserved fertility were reported.
• Literature integration: Li et al. [2024] reported that conventional laparoscopic myomectomy for large myomas (≥8 cm) had an average blood loss of 100 mL, while single-port laparoscopy achieved 50 mL (7), while this technique achieved 100 mL. Chen et al. [2021] noted that temporary uterine artery ligation during laparoscopy significantly reduced intraoperative blood loss compared to non-ligation group (P=0.027), especially in patients with higher β-hCG levels (P=0.030) (8), consistent with this case’s 18-month recurrence-free follow-up. The 2024 International Federation of Gynecology and Obstetrics (FIGO) CSP guidelines recommend minimally invasive fertility-preserving surgery for young patients, but previously did not specify applicability for large lesions—this case expands the guideline’s practical scope.

Strengths, limitations, and outlook

• Strengths: (I) effective hemorrhage control for large lesions (MSD ≤7 cm) with total blood loss ≤100 mL; (II) reversible occlusion preserves uterine/ovarian blood supply, maximizing fertility potential even for large lesions; (III) minimally invasive approach (shorter hospital stay, faster recovery) compared with laparotomy for large CSP; (IV) en bloc resection with safe margin reduces recurrence risk for large, high-risk lesions.
• Limitations: (I) requires surgeons with ≥5 years of laparoscopic experience and expertise in handling large pelvic lesions; (II) not applicable to lesions with MSD >7 cm (conversion to laparotomy needed due to high bleeding risk); (III) higher equipment cost may limit adoption in resource-limited settings; (IV) limited long-term data on future pregnancy outcomes for large lesion cases (more follow-up needed).
• Future outlooks: conduct multicenter studies to validate the technique’s safety and efficacy for MSD 5–7 cm CSP; develop advanced laparoscopic devices for better uterine artery identification in large lesions; enhance surgeon training programs for large CSP resection; conduct long-term follow-up studies to assess pregnancy outcomes after large lesion resection.

Impact and cost

• Key takeaways: temporary uterine artery occlusion is critical for bleeding control in large CSP resection (MSD ≤7 cm), and en bloc resection ensures complete lesion removal. Clinicians should consider this technique for type IIIb CSP patients with large lesions (MSD ≤7 cm) and fertility needs, expanding the options beyond laparotomy or hysterectomy.
• Cost: the procedure’s main cost is laparoscopic equipment, but long-term benefits (fertility preservation, reduced need for hysterectomy, shorter hospital stay) offset the initial cost—especially for large lesions where laparotomy would incur higher hospitalization and recovery costs.
• Comparative advantages of temporary uterine artery ligation: compared with internal iliac artery ligation, it has precise targeting (no impact on other pelvic organs) and reversibility (preserves fertility). Compared with uterine artery embolization, it avoids radiation exposure and irreversible vascular injury, and has lower cost—all more valuable for large lesions requiring definitive, fertility-sparing treatment.

Generalizability

This technique is feasible for stable patients with lesions MSD ≤7 cm and mild-to-moderate adhesions. For larger lesions (MSD >7 cm), laparoscopic en bloc resection is difficult due to limited surgical space and high bleeding risk, and laparotomy is recommended. For extensive adhesions, adhesiolysis increases ureteral/vascular injury risk, requiring laparotomy if safe separation is not possible. For hemodynamically unstable patients, emergency laparotomy is necessary (minimally invasive approach cannot meet urgent hemostatic needs). This case demonstrates that the technique can be safely extended to lesions up to 66 mm, expanding its clinical applicability.

Conclusions

The laparoscopic temporary uterine artery occlusion combined with en bloc lesion resection for type III CSP is a promising surgical technique, with expanded applicability to large lesions (MSD ≤7 cm). It offers effective hemorrhage control, anatomical restoration, and fertility preservation—even for large, blood-rich type IIIb CSP (66 mm). Although it has limitations (requiring experienced surgeons, not applicable to MSD >7 cm), with proper training and further multicenter research, it can become a standard of care for suitable patients with type III CSP, including large lesions.

Acknowledgments

The video was awarded the second prize in the Fifth International Elite Gynecologic Surgery Competition (2025 Masters of Gynecologic Surgery).

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine for the series “Award-Winning Videos from the Fifth International Elite Gynecologic Surgery Competition (2025 Masters of Gynecologic Surgery)”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-30/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-30/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-30/coif). The series “Award-Winning Videos from the Fifth International Elite Gynecologic Surgery Competition (2025 Masters of Gynecologic Surgery)” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from the patient for the publication of this article and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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