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HYSTEROSCOPY

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OPERATIVE HYSTEROSCOPY

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HYSTEROSCOPY

  1. 1. OPERATIVE HYSTEROSCOPY Dr. Khushbu Agrawal
  2. 2. THERAPEUTIC INDICATIONS • Resection of uterine septum • Uterine synechiae • Cannulation of fallopian tubes • Uterine polyps • Submucous myomas • Endometrial ablation • Sterilization - ESSURE • IUD removal • Biopsy of intrauterine lesions • Hemangioma and A-V malformations • Foreign body removal
  3. 3. INSTRUMENTS • OPERATING SHEATH The sheath outer diameter ranging between 7 – 10 mm •to permit the passage of surgical instruments and •to provide adequate uterine distention using liquid media.
  4. 4. Operating instruments • RESECTOSCOPE •2 DIAMETERS •22 Fr – for less dilated cervix •26 Fr – for bulky uterus •ENDOSCOPE – 12o viewing angle •2 SHEATH •For continuous irrigation •Suction of distension medium •A passive spring mechanism for •CUTTING LOOP •MICROKNIVES •ELECTRODES
  5. 5. VARIOUS OPERATING ELEMENTS • CUTTING LOOP • COLLINS KNIFE • BALL ELECTRODE
  6. 6. Accessory instruments BIOPSY AND GRASPING FORCEPS SCISSORS PUNCH BIOPSY SPOON FORCEPS SCISSORS TENACULUM GRASPING FORCEPS
  7. 7. COMPLETE SET FOR OPERATIVE RESECTOSCOPY • A RESECTOSCOPE • THE VIDEO-CAMERA SYSTEM • THE COLD LIGHT SOURCE • THE ELECTROSURGICAL UNIT WITH AUTOMATIC POWER SUPPLY CONTROL AND ALARM FUNCTION
  8. 8. SPECIFIC PROCEDURES IN HYSTEROSCOPIC SURGERIES
  9. 9. Septate Uterus • Problem – – 1st & 2nd trimester losses – Premature labour – Primary Infertility • Concurrent hysteroscopy and laparoscopy: gold standard for diagnosis • Laparoscopy needed to r/o bicornuate uterus Pregnancy wastage
  10. 10. Hysteroscopic Meteroplasty • Anesthesia- GA/SA • Method – Microscissors – Nd-YAG Laser – Electrosurgery • Guidance Under – Laparoscopy – Ultrasonography
  11. 11. Technique • Panoramic view • Tubal ostium indentification in each chamber • Septum is cut from below upwards till fundus • WHEN TO STOP – Light transmission via fundus laparoscopically – Both ostia are visualized in panoramic view. • To incise – excision is not necessary to avoid undue myometrial invasion, bleeding and rupture.
  12. 12. • Resect at midpoint • Avoid to drift posteriorly to prevent bleeding • Clip the septum squarely in the middle • At thicker septa – cut from periphery inward to center.
  13. 13. •Follow-up  1-2 months postop  HSG or hysteroscopy SCAR
  14. 14. Uterine Synechiae • Asherman Syndrome – adhesions formed between anterior and posterior wall • Insult – trauma eg curettage, infection eg GTB • C/F : Hypomennorhea/ Amenorrhea/Infertile • Diagnosis: HSG, Hysteroscopy.
  15. 15. ADHESIOLYSIS • Most difficult of all hysteroscopic surgeries • Methods:- – Scissors – Resectoscope – Nd-YAG laser • Lysis opens many vascular channels – high risk of Intravascular Absorption Syndrome.
  16. 16. Technique • Thorough cavity assessment for degree of adhesions. • Filmy and central adhesions – Cut first – Use Microscissors • Marginal and dense adhesions – Cut last – Use Bipolar electrode • Post op – use of IUDs prevents readhesions
  17. 17. Catheterization of Fallopian Tubes • Indications – Unblocking of the ostium and proximal tract – Application of intratubal contraception devices • ESSURE • ADIANA
  18. 18. Cannulation in Tubal obstruction • Proximal tube – 10- 20% cases • PID • ENDOMETRIOSIS Diagnosis – HSG, Chromopertubation. • Tubal plugs – non anatomical blockage: resolve after diagnostic procedures • True anatomical occlusion – 50%
  19. 19. Technique – Modified Novy cannulation set • Introducing catheter - 5Fr - 35 CM • Inner Catheter - 3 Fr – 50 CM • Guide wire - 0.18’’ – 80 CM
  20. 20. SUBMUCOSAL MYOMATA • Complaints: – HMB, infertility, recurrent pregnancy loss • Diagnosis: – Hysteroscopy with combination of • MRI • SIS • TVUS
  21. 21. CLASSIFICATION EUROPEAN SOCIETY OF GYNE ENDOSCOPY GRADE 0(G0) Development limited to uterine cavity. Pedunculated GRADE 1(G1) Partial intramural component. >50% endocavitary. Angle of protrusion<90o GRADE 2(G2) Predominantly intamural development. <50% endocavitary Angle of protrusion >90o
  22. 22. MYOMECTOMY • ROUTE OF MYOMECTOMY – Desire for future fertility – Size of myoma – Number of myoma – Locations of myoma – Type 2 lesions – relationship with uterine serosa – Presence of other coexisting pelvic disease – Availability of appropriate equipment
  23. 23. Transcervical Myomectomy • Preferred due to – Higher efficacy – Reduction in surgical morbidity – Absence of abdominal scar • Methods of hysteroscopic myomectomy – Cutting using electrosurgical loop – Vaporization – Morcellation – Mechanical (FDA Approved)
  24. 24. Preprocedural Preparation • Use of suppressive medical therapy – Reduction of volume – Amenorrhea to built up hemoglobin and iron store – Facilitation of procedure including improved visualization – Reduced systemic absorption of the distending media – Complete resection of large myomas in one setting GnRH administration 2 months before TCRM resulted in 35% reduction of size.
  25. 25. Cervical preparation • Misoprostol – PGE1 analogue – 200-400 mcg PO/PV, 12-24 hrs before surgery • Intracervical vasopressin – 4 U in 80ml : use 10 ml to inject at 4:00, 8:00 of the cervix at the time of hysteroscopy. – Significant reduction in force for dilation of cervix – Decrease risk for absorption syndrome, bleeding.
  26. 26. Technique • LOOP ELECTROSURGICAL RESECTION – Activation of electrode with low voltage(cutting) current  strips of myoma created  removal of the fragmented tissue • BULK ELECTROSURGICAL VAPORIZATION – Activated large surface area electrode with low voltage applied over large volumes of tissue  volume reduction of tumor  removal of residual tissue with grasping forceps
  27. 27. • Results in AUB treatment – EA + TCRM : In women who do not desire fertility, it improves the success rate to decrease HMB. TCRM TCRM + EA EA Completely resected myomas 84.4% 96.7% Incompletely resected myomas 70.4% 92.3% REPEAT SURGERY RATE 34.6% 39.6% Loffer FD. Improving results of hysteroscopic submucosal mymoectomy. J Minimum Invasive Gynecol. 2005;12:254-260(II-3). SUCCESS RATE PROCEDURE
  28. 28. • Results in INFERTILITY treatment STUDY- 108 TYPE 0 TYPE 1 TYPE 2 FERTILITY RATE 49% 36% 33% STUDY - 215 TCRE DHL & BIOPSY FERTILITY RATE 63% 28% RCT – FertilSteril. 2010;94:724-729(I) Italian study- ObstetGynecol.1999;94:341-347(II-2) • Results in RECURRENT PREG LOSSES •Less evidence to support the benefit. •Mostly 1st trimester losses due to natural risk DHL: DIAGNOSTIC HYSTEROLAPAROSCOPY
  29. 29. ENDOMETRIAL POLYP • Hyperplasia: single/multiple; sessile/ pedunculated • Causes:- AUB/ Infertility/ Endometritis • DIAGNOSIS: USG/SIS/Hysteroscopy • Treatment: – Operative hysteroscope with scissors • Extraction using grasper or endobasket or simple curettage. – Resectoscope electric snare loop – for larger polyp in piecemeal
  30. 30. ENDOMETRIAL ABLATION in AUB • Described first in 1981. • Decreased cost , morbidity • Adequate preoperative counseling – Hypomenorrhea. – Rare need for hysterectomy – Not a method of contraception – No protection - endometrial Ca.
  31. 31. Preoperative preparation • EB – R/O endometrial Ca and hyperplasia • Pretreatment :6 wks with GnRH • Haemogram, Coagulogram. • Consent • 1.5% Glycine: distention media. • No need of simultaneous laparoscopy
  32. 32. AIM & ACTION OF ABLATION • AIM – To destroy the visible endometrium including the cornual endometrium • Depth – 1-2 mm. • ACTION – Heat penetrates 3-5 mm deeper, burns the superficial myometrium and coagulates the radial branches of the cavity. • No regeneration due to loss of basal and spiral arterioles. • 6-8 weeks later the uterine walls scar and shrinks
  33. 33. Technique • RESECTOSCOPE WITH MONOPOLAR LOOP ELECTRODE. • Remove the debris and blood. • Never use cutting loop over fundus and cornu
  34. 34. Technique contd. • Next – anterior and lateral walls • Last – posterior wall • Never- below the internal os into cervix • AVOID – – Prolong contact time to reduce risk of deeper injuries and perforation.
  35. 35. Views during Ablation
  36. 36. Failure of endometrial ablation • Adenomyosis • Bulky uterus • Curettage immediately prior to the procedure • No premedication with GnRH analogues
  37. 37. MISCELLANEOUS PROCEDURES • MISSING IUD REMOVAL – String grasped with – Alligator-jaw forceps – Embedded IUDs – Rigid grasping forceps used
  38. 38. COMPLICATIONS OF HYSTEROSCOPY
  39. 39. • INCIDENCE : 0.2% • 10% with major operative surgeries • SPECTRUM – Perioperative complications – Postoperative complications
  40. 40. Perioperative • Patient positioning • Anesthesia • Access to the endometrial cavity – Cervical trauma – Uterine perforation. • Gas emboli • Intraoperative bleed • Absorption of distention media syndrome. • Lower genital tract injuries, burns.
  41. 41. Post operative • EARLY – Infection – Postop bleeding • LATE – sequelea – Intrauterine adhesions – Uterine rupture during pregnancy
  42. 42. PATIENT POSITIONING • Nerve trauma • Direct trauma • Compartment syndrome • VARIOUS POSITIONS – Lithotomy position – Modified lithotomy position – Ideal position IN ALL PATIENTS WITH GENERAL ANESTHESIA – AS THEY CANT REPORT OF THEIR DISCOMFORT.
  43. 43. Dorsal lithotomy position Compartment syndrome in the lower legs. • Pathophysiology – ischemia + reperfusion injury • Sequelae – Rhabdomyolysis – Permanent disability • Events facilitating it – Leg holders – Pneumatic compression stockings – Any direct pressure
  44. 44. NERVE INJURY Femoral neuropathy Excessive hip flexion abductionext hip rotation extreme angulation of FEMORAL nerve- compression injury. Temporary – needs intensive physical therapy to resolve
  45. 45. • Sciatic nerve injury- – At sciatic notch • Common peroneal injury – At neck of fibula – FOOT DROP/ LOWER LATERAL PARAESTHESIA
  46. 46. RISK REDUCTION & MANAGEMENT • Ideal lithotomy position- moderate flexion with limited abduction and ext rotation • Avoid pressure on injury prone areas • Avoid leaning on the thigh of the patient. • Early identification and t/t of complication Compartment syn & Neuropathy
  47. 47. ANESTHESIA RELATED • Local anesthesia related – Allergic reactions – Cardiovascular complications • Awareness and avoiding – Fluid overload – Electrolyte disturbance – Signs of gas embolization
  48. 48. INTRAOP/POSTOP BLEEDING • Most common complication. • Mostly in myoma resection. • Immediate :aspirate the blood and increase the pressure of distention media above the mean arterial pressure. • Coagulate with 3mm ball electrode. • Foleys balloon compression with 3-5ml saline – kept for 6-12 hrs. • Rare – UAE/ Hysterectomy
  49. 49. Uterine perforation • Most common during – septal resection- approaching the fundus • Dangerous – lasers and electrosurgical devices. • Clue - difficult to maintain the distention. • Safeguard – simultaneous laparoscopy – alerts the assistant against impending perforation
  50. 50. Management • Non-energy instrument – Strict observation in postop period – Any hemodynamic deterioration – immediate laparotomy. • Energy instrument – Laparotomy to ensue adjacent organs injury • High risk for uterine rupture during future pregnancy
  51. 51. Prevention • Activate the foot pedal only during the return phase of electrode towards the sheath. • Never activate the device during a forward movement. • Use roller-ball based device at the cornu.
  52. 52. INTRAVASCULAR ABSORPTION SYNDROME (OHIA) • Low viscosity Liquid distention media • Incidence < 1%. • More in premenopausal women – Female sex steriods – inhibits Na-K+/ATPase pump thus water and sodium not thrown out of cells. – GnRH agonists inhibits such hormones action – may prevent this complication to occur.
  53. 53. 1.5% Glycine Low Viscosity Fluid Hypoosmolar in nature – when delivered by high pressure infusion pump – excess vascular absorption  sudden onset Acute Hyponatremia, hypo-osmolar state IN BLOOD
  54. 54. Women’s brain deficient in such mechanisms. Circulatory absorption creates a gradient between blood and the brain cells Can be overcome by pumping cations out of the cell into blood Results CEREBRAL EDEMA BRAIN CELLS VESSEL Na/K ATPase
  55. 55. • NORMAL SALINE – SAFEST – EXCESSIVE VASCULAR ABSORPTION  FLUID OVERLOAD  PULMONARY EDEMA. – NOT SUITABLE FOR MONOPOLAR SYSTEM : good conductor of electrons.
  56. 56. Media Delivery & Management • Delivery system – Simple gravity – 10mm tubing – 70-100 mmHg – height 1-1.5 m above uterus. – Automated pumps – Insufflators – for CO2 gaseous media • Volume estimation – Vol infused– Vol coming out = Vol absorbed – Measured manually by capturing & measuring.
  57. 57. DEVICES
  58. 58. PREVENTION & TREATMENT • Preprocedure – Use of GnRH analogs – Use of Vasopressin • Intraop – Work at lowest effective pressure(50-80mmHg) – Complete as quickly as possible – Baseline electrolyte – Cautious in cardiopulmonary disease
  59. 59. PREVENTION & TREATMENT • Deficit – 750ml  check electrolytes & give Inj Lasix 10-40mg • Deficit > 1500 ml  stop the procedure • If Na <125mEq/L  terminate the procedure. • Post op care of such cases in HDU. • Look for CEREBRAL OR PUL EDEMA, RHF, need for VENTILATOR support, use of diuretics. • May require use of hypertonic solutions.
  60. 60. Gas Embolus • Faulty methods – Use of laparoscopic insufflator to infuse CO2 in uterus. • Diagnosis: – Tachycardia , desaturation & Hypotension – Cog-wheel murmur (10% cases) – disappearance once the hysteroscopy stops – Rapid fall in expired CO2.
  61. 61. Precautions to prevent embolism • Avoid Trendelenburg positioning • Remove last dilator just before inserting the resectoscope • Limit repeated removal-reinsertion of the resectoscope • Vaporizing myomas eliminates the need to remove fibroid chips • Intracervical injection of vasopressin may block gas from entering circulation
  62. 62. MANAGEMENT • DURANT Maneuver – left lateral with head low position with tredelenberg position • 100% oxygen • CVC insertion or direct needle in right atrium to remove the air • May require CPR.
  63. 63. INFECTION • Avoid hysteroscopy in gross cervical infection, uterine infection & salpingitis. • Role of antibiotics controversial – Supportive studies in cases with RHD, CHD, MVP. – Suspected chronic endometritis – Submucous myomas procedure – Imbedded IUDs. ACOG guidelines do not recommend routine prophylactic antibiotics for hysteroscopy.
  64. 64. CONTRAINDICATIONS of Operative Hysteroscopy • Acute pelvic inflammatory disease • Pregnancy • Genital tract malignancies • Inability to dilate the cervix • Inability to distend the uterus to obtain visualization • Renal disease – fluid overload risk • Patient with pacemaker – avoid radiofrequency current • The patient desires and expects complete amenorrhea

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