Submit Manuscript | http://medcraveonline.com Abbreviations: CSD, cesarean scar defect; TOLAC, trial of labor after cesarean; RA-SILS, robotic-assisted single-incision laparoscopic surgery; REI, reproductive endocrinology and infertility; HSG, hysterosalpingogram; AUB, abnormal uterine bleeding; MIGS, minimally invasive gynecological surgery Background The number of deliveries via cesarean section has increased in the United States, to a rate of 32.3%, which is almost double the global rate of 18.6%. 1 With a greater rate of deliveries via cesarean section comes increased rate of associated complications in subsequent pregnancies and longer hospital stays. 2 One complication of cesarean section is the formation of a cesarean scar defect (CSD), niche or isthmocele, which has no standard defnition but can be grossly described as a disruption or defect in the myometrium associated with uterine scar. 3–6 Approximately 1.9% of women are diagnosed with CSD, however the prevalence of CSD is diffcult to quantify, given that smaller CSDs may be asymptomatic. 4 As more women are encouraged towards a trial of labor after cesarean (TOLAC) the performance of the uterus during labor is of growing concern due to the risk of uterine rupture. 2,7 Risk factors for CSD include cesarean section during advanced stage of labor, multiple cesarean deliveries, retrofexed uterus, and uterine incision nears the cervix. 4,8–11,12 Single-layer uterine closure has also been proposed as a risk factor for CSD, but there is still no consensus on the optimal approach to uterine closure. 13,14 Small asymptomatic defects may not require treatment; however larger defects may cause pelvic pain, dysmenorrhea, intermenstrual bleeding or infertility, requiring surgical intervention. 8,15 Surgical repair has shown to be an effective treatment, providing symptom relief for most patients and resolving infertility in 92% of patients. 8,11,16 Obstet Gynecol Int J. 2018;9(4):266‒270. 266 © 2018 Zhang et al. 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Hysteroscopic assisted single-site robotic resection of cesarean scar defect (CSD): dual case reports and review of literature Volume 9 Issue 4 - 2018 Yiming Zhang, 3 Shadi Rezai, 1,6 Alexander C Hughes, 2 Juan Saucedo, 2 Ninad M Patil, 4 Elise Bardawil,6 Cassandra E Henderson, 5 Xiaoming Guan 6 1 Department of Obstetrics and Gynecology, Southern California Kaiser Permanente, USA 2 St. George’s University, School of Medicine, St. George’s, Grenada 3 Division of Reproductive Medicine, Jinan Central Hospital Group, China 4 Department of Pathology & Immunology, Baylor College of Medicine, USA 5 Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Lincoln Medical and Mental Health Center, USA 6 Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, USA Correspondence: Xiaoming Guan MD PhD, Section Chief and Fellowship Director, Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, 10th Floor, Houston, Texas, 77030, USA, Tel (832) 826-7464, Fax (832) 825-9349, Email xiaoming@bcm.edu Received: June 12, 2018 | Published: July 25, 2018 Abstract Background: The number of deliveries via cesarean section has increased in the United States, to a rate of 32.3%, which is almost double the global rate of 18.6%. With a greater rate of deliveries via cesarean section comes an increased rate of associated complications in subsequent pregnancies and longer hospital stays. One complication of cesarean section is the formation of a cesarean scar defect (CSD), niche or isthmocele which has no standard defnition but can be grossly described as a disruption or defect in the myometrium associated with uterine scar. Approximately 1.9% of women are diagnosed with CSD; however the prevalence of CSD is diffcult to quantify, given that smaller CSDs may be asymptomatic. As more women are encouraged towards trial of labor after cesarean (TOLAC), the performance of the uterus during labor is of growing concern due to the risk of uterine rupture. We present two cases 1 of Cesarean Scar Defect (CSD) repaired by hysteroscopy and robotic- assisted single-incision laparoscopic surgery (RA-SILS) for cesarean scar resection. Conclusion: Rising rates of Cesarean sections bring increased rates of complications, including infertility and pain. Fortunately, CSD can be repaired surgically with great success. With technological advances, MIGS has become the standard of care for many gynecologic surgeries, showing improved patient outcomes. There continues to be some debate over the effcacy of improved patient outcomes with robotic systems. However, these questions are often related to surgeon experience and surgical time. We have presented the frst cases of CSD repair using RA-SILS assisted by hysteroscopy. More quantitative studies with specifc measures are needed to fully understand the impact of minimally invasive gynecologic surgery and RA-SILS for CSD. Keywords: cesarean scar defect, cesarean scar dehiscence, cesarean scar diverticulum, hysteroscopic assisted, hysteroscopy, isthmocele, isthmoplasty, laparoscopy, resection, niche, laparoendoscopic single-site surgery, residual myometrial thickness, single-incision laparoscopic surgery, transvaginal repair, uterine scar dehiscence 1 A thorough case report search performed in early 2018 of Google Scholar, Pubmed, Medline, BMJ Case Reports, Wiley Online Library, and Oxford Medical Case Reports using keywords: CSD, Cesarean Scar Defect; Cesarean Scar Dehiscence; Cesarean Scar Diverticulum; Isthmocele; Isthmoplasty; Laparoscopy; Previous Cesarean Scar Defect; Niche; LESS, Laparoendoscopic Single-Site Surgery; SILS, Single-Incision Laparoscopic Surgery; Uterine Scar Dehiscence. The search produced no reported cases of CSD surgical repair using robotic single incision laparoscopic surgery with hysteroscopy. Obstetrics & Gynecology International Journal Case Report Open Access