Cesarean scar defects (CSD), also referred to as isthmoceles or cesarean scar niches, are increasingly being recognized as causes of postmenstrual bleeding, dysmenorrhea, chronic pelvic pain, and secondary infertility [1,2]. With increasing cesarean delivery rates, the clinical relevance of CSD has increased. Surgical repair is considered for symptomatic patients, particularly those with reproductive wishes or persistent abnormal uterine bleeding [2].

Various minimally invasive surgical approaches for CSD repair have been described, including laparoscopic, robotic, hysteroscopic, and combined techniques [3-7]. Robotic surgery offers advantages such as dexterity and intracorporeal suturing, which are valuable for multilayer uterine reconstruction [8]. Earlier single-site robotic platforms were limited by reduced instrument articulation. The da Vinci single-port (SP) system (Intuitive Surgical, Sunnyvale, CA, USA) was developed to address these limitations by incorporating fully articulated instruments and an articulating endoscope through a single access port [9].

Accurate intraoperative localization of the true extent of the defect is a critical step in CSD repair. Inaccurate assessment may lead to incomplete excision of the fibrotic tissue or excessive resection, potentially compromising uterine reconstruction. Visualization of the abdominal side alone may be insufficient. This technical and educational video demonstrates a SP robot-assisted approach for CSD repair using the da Vinci SP system (Intuitive Surgical), focusing on an intraoperative visualization strategy that combines hysteroscopy and near-infrared imaging with a simultaneous multi-image display to support the accurate identification and marking of the excision margin.

This report presents a single-patient surgical video. A 39-year-old gravida 2, para 1 woman with obesity and a history of cesarean delivery presented with postmenstrual bleeding, dysmenorrhea, and secondary infertility. Pelvic magnetic resonance imaging (MRI) revealed a CSD with a residual myometrial thickness of 1.6 mm. After counseling regarding treatment options, surgical repair was planned, and written informed consent for video recording and publication was obtained.

SP access was established through a 2.5-cm vertical umbilical incision and a SP access device was placed. The da Vinci SP system (Intuitive Surgical) was docked and robotic instruments were introduced. The bladder was carefully dissected and mobilized caudally to expose the anterior uterine wall and secure the operative field.

Concurrent hysteroscopy was performed by a second surgeon to visualize the isthmocele in the uterine cavity. Resection of the cervical-side anterior wall improved the visualization of the defect margin, allowing clear delineation of the target area. Near-infrared imaging (Firefly^®; Intuitive Surgical) was subsequently activated to assist in identifying the defect from the abdominal side. Indocyanine green was not required for this technique, as the purpose of nearinfrared imaging was not vascular assessment but the detection of transillumination from hysteroscopic light through the thinned myometrium. This allowed for indirect visualization of the defect on the abdominal side. Because near-infrared visualization alone may lead to misinterpretation of the excision margin, a simultaneous multi-image display (TilePro™; Intuitive Surgical) was used to allow real-time comparison of hysteroscopic and intra-abdominal views. This combined visualization enabled informed and deliberate marking of the resection line before excision [10,11] (Fig. 1).

The defect was incised and excised using curved monopolar scissors. Particular care was taken to remove the fibrotic tissue while preserving the surrounding healthy myometrium. Uterine reconstruction was performed in a multilayered manner. The first layer of the uterine defect was closed using modified Gambee sutures with 2-0 Biosyn™ (Medtronic, Dublin, Ireland) and the second layer was closed using continuous sutures with 2-0 V-Loc™ 90 (Medtronic) [12]. Both round ligaments were sutured with Ti-Cron™ (Medtronic) to antevert the uterus and reduce tension at the repair site. An adhesion barrier (Seprafilm^®; Baxter International, Deerfield, IL, USA) was placed over the reconstructed area before completion.

The postoperative course was uneventful. Three months after surgery, pelvic MRI demonstrated an improvement in the residual myometrial thickness compared with the preoperative value.

This video demonstrates the technical feasibility of single-port robot-assisted repair of CSD and highlights key considerations for accurate intraoperative localization and uterine reconstruction. Although various minimally invasive approaches for CSD repair have been reported, precise identification of the defect margin remains a critical determinant of reliable excision and repair [4,5-7].

More importantly, the da Vinci SP system (Intuitive Surgical) robotic platform should be distinguished from earlier single-site robotic systems. Unlike single-site platforms, which are limited by reduced instrument articulation and compromised ergonomics, the da Vinci SP system (Intuitive Surgical) provides fully articulated instruments and an articulating endoscope through a single-access port. These features allow for improved visualization, enhanced dexterity, and stable intracorporeal suturing while maintaining a single incision. Previous reports have shown that the da Vinci SP platform (Intuitive Surgical) offers operative functionality comparable to conventional multiport robotic systems while preserving the cosmetic benefits associated with a single umbilical incision [8]. These characteristics facilitated precise dissection and multilayer suturing within a confined surgical field.

Accurate localization of the excision margin is particularly important during CSD repair because underestimation may result in incomplete excision, whereas overestimation may unnecessarily increase surgical complexity. Near-infrared imaging is increasingly used to support intraoperative localization in various surgical fields. Notably, Takahashi et al. [11] reported that near-infrared imaging combined with simultaneous multi-image display enabled the accurate localization of rectal cancer by integrating endoscopic and intraabdominal views. Based on this concept, a similar strategy was adopted in this case.

In this video, near-infrared imaging provided complementary information regarding the defect location from an abdominal perspective, whereas hysteroscopy allowed direct visualization of the isthmocele from the uterine cavity. The simultaneous display of both views using the TilePro mode (Intuitive Surgical) enabled real-time confirmation of the excision margin, facilitating deliberate and anatomically oriented excision and repair without compromising cosmetic integrity.

Reconstruction of the uterine wall was performed using a multilayer closure technique. The uterine defect was closed in the first layer using modified Gambee sutures with a monofilament absorbable suture, followed by a second continuous layer using a barbed suture, as previously reported [12]. This approach allowed a secure approximation of the myometrial edges under robotic visualization and contributed to stable reconstruction after excision.

This video is an educational resource that illustrates a reproducible surgical workflow rather than establishing superiority over other minimally invasive approaches. Nevertheless, combining the da Vinci SP platform (Intuitive Surgical) with simultaneous visualization guided by hysteroscopy and near-infrared imaging may represent a practical strategy for achieving precise excision and reconstruction during minimally invasive CSD repair. Although postoperative MRI demonstrated anatomical improvement, the 3-month followup period was insufficient to evaluate long-term clinical outcomes, including sustained symptom relief, improvement in dysmenorrhea, and reproductive outcomes, such as subsequent pregnancy. Further studies involving larger cohorts are warranted to evaluate the long-term clinical and reproductive outcomes.