{"id":187,"date":"2026-10-28T11:58:34","date_gmt":"2026-10-28T01:58:34","guid":{"rendered":"https:\/\/escope.ages.com.au\/november-2026\/?p=187"},"modified":"2026-11-02T13:46:11","modified_gmt":"2026-11-02T03:46:11","slug":"laparoscopic-caesarean-scar-niche-repair-a-step-by-step-guide","status":"publish","type":"post","link":"https:\/\/escope.ages.com.au\/november-2026\/laparoscopic-caesarean-scar-niche-repair-a-step-by-step-guide\/","title":{"rendered":"Laparoscopic Caesarean Scar Niche Repair: A step-by-step guide"},"content":{"rendered":"\n<h1>\n\t\t\tLaparoscopic Caesarean Scar Niche Repair: A step-by-step guide\t<\/h1>\n\t\t\t<h3>Introduction<\/h3>\t\t\t\n\t\t\t\t<p>The caesarean scar niche is becoming a more frequent referral for minimally invasive gynaecologists. A niche is an indentation in the lower segment myometrium at the caesarean section scar of at least 2mm (1). Around 60% of women develop a niche after one caesarean birth; however, most remain asymptomatic (2).<\/p>\n<p>The 2023 Delphi consensus separated the ultrasound finding from the clinical condition. Caesarean scar disorder (CSDi) is a niche plus at least one primary symptom or two secondary symptoms which affects premenopausal women for at least three months (2).<\/p>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/11-chart-001.avif\" alt=\"11-chart-001\" height=\"380\" width=\"1024\" title=\"11-chart-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n\t\t\t\t<p>This article presents a six-step laparoscopic repair of the caesarean scar niche with hysteroscopic assistance, illustrated with operative images for each step.<\/p>\n\t\t\t<h3>Patient selection <\/h3>\t\t\t\n\t\t\t\t<p>This operation should only be performed to treat symptoms, not for an incidental scan finding. The diagnosis needs at least three regular cycles after a caesarean section. Other causes of spotting need to be excluded first: e.g., cervical dysplasia, infection, endometrial pathology etc.<\/p>\n<p>Residual myometrial thickness (RMT) assists decision making around the route. Hysteroscopic resection suits an RMT above 2.5-3mm. Below that, or when the woman plans further pregnancies, laparoscopic excision and repair rebuilds the myometrial defect rather than simply resecting the scar (3, 4).<\/p>\n<p>Preoperative transvaginal ultrasound or MRI records the niche length, depth and width as well as the residual and adjacent myometrial thickness (1). Our recent cases had an RMT of 2-2.5mm and niches up to 30mm in width. One followed a caesarean scar ectopic pregnancy (see image below &#8211; following resolution of ectopic pregnancy).<\/p>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/Niche-USS-001.avif\" alt=\"Niche USS-001\" height=\"691\" width=\"1024\" title=\"Niche USS-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n\t\t\t<h3>Operative technique<\/h3>\t\t\t\n\t\t\t\t<p>The patient is set up for simultaneous hysteroscopy and laparoscopy. The repair follows six steps.<\/p>\n\t\t\t<h3>Step 1: Adhesiolysis and bladder reflection<\/h3>\t\t\t\n\t\t\t\t<p>After one or more caesarean sections, the bladder is often adherent to the lower uterine segment, and careful division is critical. Open the vesicouterine peritoneum and reflect the bladder well below the scar.<\/p>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/Bladder-Reflection-Niche-001.avif\" alt=\"Bladder Reflection - Niche-001\" height=\"681\" width=\"1024\" title=\"Bladder Reflection - Niche-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n\t\t\t<h3>Step 2: Hysteroscopic transillumination<\/h3>\t\t\t\n\t\t\t\t<p>(This step may be combined with Step 1.) Pass hysteroscope into the niche. Its light shines through the thin myometrium and outlines the defect from the abdominal side. This is the key to finding the margins, which are rarely obvious on the serosal surface.<\/p>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/Niche-Transillumination-001.avif\" alt=\"Niche Transillumination-001\" height=\"400\" width=\"604\" title=\"Niche Transillumination-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n\t\t\t<h3>Step 3: Score the outline (optional)<\/h3>\t\t\t\n\t\t\t\t<p>Score the transilluminated margin with interrupted monopolar current. The mark allows ongoing visualisation if the hysteroscope is removed or unable to remain in the same position.<\/p>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/Niche-Scoring-001.avif\" alt=\"Niche - Scoring-001\" height=\"743\" width=\"1024\" title=\"Niche - Scoring-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n\t\t\t<h3>Step 4: Excise the niche<\/h3>\t\t\t\n\t\t\t\t<p>Make a transverse incision into or just cranially to the niche. Grasp the thinned scar and excise it along the scored outline\/transillumination. Continue excising until healthy myometrium is exposed at both cranial and caudal edges.<\/p>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/Niche-Excision-001.avif\" alt=\"Niche Excision-001\" height=\"697\" width=\"1024\" title=\"Niche Excision-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n\t\t\t<h3>Step 5: Close the myometrium<\/h3>\t\t\t\n\t\t\t\t<p>Insert the hysteroscope or a uterine manipulator into the cervical canal. Before each bite, confirm the instrument is visible in the canal. Close in one or two layers depending on myometrial thickness, using a synthetic, absorbable, coated or barbed suture.<\/p>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/Screenshot-2026-10-18-at-6.52.42-pm-001.avif\" alt=\"Screenshot 2026-10-18 at 6.52.42\u202fpm-001\" height=\"807\" width=\"1024\" title=\"Screenshot 2026-10-18 at 6.52.42\u202fpm-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/Niche-Suturing-001.avif\" alt=\"Niche Suturing-001\" height=\"594\" width=\"1024\" title=\"Niche Suturing-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n\t\t\t<h3>Step 6: Close the uterovesical peritoneum<\/h3>\t\t\t\n\t\t\t\t<p>Close the peritoneum over the repair (if possible). We do this to theoretically reduce further bladder adhesions, though evidence is lacking to support this.<\/p>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/Niche-Peritoneum-001.avif\" alt=\"Niche - Peritoneum-001\" height=\"708\" width=\"1024\" title=\"Niche - Peritoneum-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n\t\t\t<h3>Post-operative care and evidence<\/h3>\t\t\t\n\t\t\t\t<p>Women are counselled to defer conception after repair for at least 6 months. In published cohorts, most subsequent births were by planned caesarean section (5).<\/p>\n<p>An observational series of laparoscopic repair reports symptom improvements in 46-100%, recurrence of 4.6-16%, and few complications (4). In a prospective cohort, RMT rose 2.0mm from baseline to the third trimester after laparoscopic resection but fell 1.6mm without surgery. Dehiscence occurred in 2% versus 19% (5).<\/p>\n<p>Fertility data are encouraging. In the LAPNICHE cohort, 62% of women wanting pregnancy had an ongoing pregnancy at two years (6). A 2025 meta-analysis reported a 72% live birth rate in women with infertility, 29% of whom had coexisting endometriosis (7).<br \/>Nonetheless, it is important to remember that the data are mostly small observational series and repair is not yet proven to improve obstetric outcomes (5). Trials against expectant management are still needed (6).<\/p>\n\t\t\t<h3>Conclusion<\/h3>\t\t\t\n\t\t\t\t<p>Laparoscopic niche repair is a reproducible operation when broken into six steps: reflect the bladder, transilluminate, score, excise to healthy tissue, close over a visible manipulator, and close the peritoneum. Careful selection by symptoms and RMT is paramount.<\/p>\n\t\t\t<h3>References<\/h3>\t\t\t\n\t\t\t\t<ol>\n<li>Jordans IPM, de Leeuw RA, Stegwee SI, et al. Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure. Ultrasound Obstet Gynecol. 2019;53(1):107-115. doi:10.1002\/uog.19049<\/li>\n<li>Klein Meuleman SJM, Murji A, van den Bosch T, et al. Definition and criteria for diagnosing cesarean scar disorder. JAMA Netw Open. 2023;6(3):e235321. doi:10.1001\/jamanetworkopen.2023.5321<\/li>\n<li>Mashiach R, Burke YZ. Optimal isthmocele management: hysteroscopic, laparoscopic, or combination. J Minim Invasive Gynecol. 2021;28(3):565-574. doi:10.1016\/j.jmig.2020.10.026<\/li>\n<li>Stavridis K, Balafoutas D, Vlahos N, Joukhadar R. Current surgical treatment of uterine isthmocele: an update of existing literature. Arch Gynecol Obstet. 2025;311(1):13-24. doi:10.1007\/s00404-024-07880-w<\/li>\n<li>Jordans IPM, Vissers J, de Leeuw RA, et al. Change of the residual myometrial thickness during pregnancy in women who underwent laparoscopic niche resection compared with controls without niche surgery: a prospective comparative cohort study. Am J Obstet Gynecol. 2022;227(6):901.e1-901.e12. doi:10.1016\/j.ajog.2022.07.011<\/li>\n<li>Vissers J, Hehenkamp WJK, Br\u00f6lmann HAM, et al. Reproductive outcomes after laparoscopic resection of symptomatic niches in uterine cesarean scars: long-term follow-up on the prospective LAPNICHE study. Acta Obstet Gynecol Scand. 2023;102(12):1643-1652. doi:10.1111\/aogs.14647<\/li>\n<li>Vidal A, Geiger J, Vinayahalingam V, et al. High live birth rates after laparoscopic isthmocele repair in infertility: a systematic review and meta-analysis. Front Endocrinol (Lausanne). 2025;16:1507482. doi:10.3389\/fendo.2025.1507482<\/li>\n<\/ol>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/Dr_David_Krones-001.avif\" alt=\"Dr_David_Krones-001\" height=\"1024\" width=\"1024\" title=\"Dr_David_Krones-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n\t\t\t\t<p><strong>Dr David Krones<\/strong> <br \/>BSc MBBS FRANZCOG, <br \/>AGES Fellow, The Royal Hospital for Women, Randwick NSW.<\/p>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/escope.ages.com.au\/november-2026\/wp-content\/uploads\/sites\/14\/2026\/10\/Basia-_-Headshot-scrubs-edited-001.avif\" alt=\"Basia _ Headshot - scrubs (edited)-001\" height=\"1024\" width=\"792\" title=\"Basia _ Headshot - scrubs (edited)-001\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t<\/figure>\n\t\t\t\t<p><strong>Dr Basia (Barbara) Lowes<\/strong><br \/>BA, LLB, MBBS, FRANZCOG, MS (AdvGynSurg), MWomHealthMed<br \/>Visiting Medical Officer, The Royal Hospital for Women, Randwick NSW<\/p>\n\n","protected":false},"excerpt":{"rendered":"<p>Laparoscopic niche repair is a reproducible operation when broken into six steps: reflect the bladder, transilluminate, score, excise to healthy tissue, close over a visible manipulator, and close the peritoneum.<\/p>\n","protected":false},"author":1,"featured_media":72,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"site-sidebar-layout":"no-sidebar","site-content-layout":"","ast-site-content-layout":"full-width-container","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[1],"tags":[],"class_list":["post-187","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorised"],"acf":[],"_links":{"self":[{"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/posts\/187","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/comments?post=187"}],"version-history":[{"count":6,"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/posts\/187\/revisions"}],"predecessor-version":[{"id":264,"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/posts\/187\/revisions\/264"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/media\/72"}],"wp:attachment":[{"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/media?parent=187"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/categories?post=187"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/escope.ages.com.au\/november-2026\/wp-json\/wp\/v2\/tags?post=187"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}