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Operative hysteroscopy
- 1. OPERATIVE HYSTEROS COPY Dr Meenakshi Sharma MD (Obs& Gynae) (AIIMS), FICMCH Senior Consultant Obs & Gynae Yashoda Superspeciality Hospitals, Kaushambi Shanti Mukund Hospital, Delhi
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- 3. PREREQUISITES FOR OPERATIVE HYSTEROSCOPY Should beperformed as in patient or day care hospital Minor surgical procedures can be done as office hysteroscopy procedures but advisable to perform in well equiped OT where anaesthesia facility available A thorough physical exam is essential prerequisite for surgical hysteroscopy. Improper patient selection and poor technique are the most frequent causes of complications during surgery
- 4. CONTRAINDICATIONS FOR SURGICAL HYSTEROSCOPY Pelvic inflammatoryDisease Acute cervicovaginitis Intense Metrorrhagia Pregnancy
- 5. INSTRUMENTATION The complete setof resectoscopic surgery instruments consists of Resectoscope Camera equipment Light source Endomat / Hysteromat Unipolar high frequency electrosurgical generator with automatically controlled output and acoustic control
- 6. INSTRUMENTATION Rigid Hysteroscope witha diameter of 7 mm and eqipped with 2 channels – one for distension media, the other for introduction of ancillary instruments including probes, catheters, miniature rigid or semi rigid scissors and various biopsy forceps Procedures done with operative hysteroscope are adhesions, thin septum, small polyp and guided biopsy and removal of foreign body
- 7. RESECTOSCOPE 90% of allhysteroscopic surgery is performed using resectoscope 26 Fr resectoscope with ancillary instruments It has provisions for connection to hysteromat, connection to electrosurgical generator, connection to light source and camera equipment The resectoscope with continuous flow sheath for distension of uterine cavity increases the options available to the surgeon in the removal of submucous and intramural myomas
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- 9. DISTENSION MEDIA Carbon dioxideand high viscosity dextran solution not used in hysteroscopic surgery Saline for nonelectrosurgical procedures Sorbitol or mannitol Glycine – most commonly used distension media where electrosurgery used
- 10. INDICATIONS OF SURGICAL HYSTEROSCOPY •Endometrial ablation •Surgeryof uterine malformations – septum •Treatment of intrauterine adhesions •Myomectomy – submucous fibroid •Fallopian tube catheterisation •Removal of foreign bodies and IUD
- 11. HYSTEROSCOPIC ENDOMETRIAL ABLATION Indications –Drug resistantHMB with malignancy ruled out limited with use of LNG IUS, and GnRH Performed under GA and even LA Preoperative thinning of endometrium by Danazol or GnRH for 2-3 months or therapeutic D&C- better success
- 12. HYSTEROSCOPIC ENDOMETRIAL ABLATION Technique Entire endometrium mustbe ablated without leaving islands of normal endometrium Ablation deep into myometrium to be avoided to prevent adhesion formation Endometrium in isthmic region is spared to prevent asherman syndrome 3-5 mm deep endometrial slices are resected with resectoscope loop using cutting current and resection should stop at level of fasciculated myometrium
- 13. ENDOMETRIAL ABLATION – ROLLER BALLOR CUTTING LOOP
- 14. HYSTEROSCOPY FOR UTERINE MALFORMATION Arcuate Uterus SeptateUterus Bicornuate Uterus Uterus Didelphys Septate uterus presents with reproductive difficulty and need corrective surgery Diagnosis – Two hemicavities with clear central division or y shaped cavity on HSG Concomitant laparoscopy should be done to distinguish bicornuate uterus and septate uterus
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- 16. HYSTEROSCOPIC UTERINE SEPTUM RESECTIONSemi rigidscissors 5-7Fr Semi rigid scissors perfect for thin uterine septum as they produce required force and small enough to pass through operating sheath of the hysteroscope and along cervical canal without any difficulty or risk. Blades can be opened wide enough for resection of even thick septa. Continuous flow irrigation to be used Vision clear if only no bleeding Resection till level of ostia Resectoscope with collens knife Cutting current 30-40W/s (KTP/532), (Nd:YAG), or Argon Lasers Laser beam with glass fibers of 0.6 micron diameter Septum vaporised as a result of the fibers contacting the target tissue
- 17. HYSTEROSCOPIC UTERINE SEPTUM RESECTION Goal ofSeptum Resection -Satisfactory uterine cavity Resection to be stopped at the level of osita... Both ostia will be visible in panoramic view to prevent perforation and adhesion formation Cautery near ostia must be avoided Preoperative treatment with Danazol or GnRH can be given for better vision If Uterocervical septum –complete resection with inclusion of cervical part is mandatory Follow up after 2 months with HSG or hysteroscopy Full term pregnancy rate 70-80%, no need of LSCS
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- 19. HYSTEROSCOPIC CORRECTION OF ARCUATE UTERUS PRIORTO IVF?Measurement by sonohysterography Fm (fundal myometrial thickness) Cm (cornual myometrial thickness) Incision of the incomplete septum. Fm >11 mm Fm-Cm >5 mm, Meta-analyses of five studies Improving result in subsequent IVF cycle (relative risk = 1.75, 95% CI 1.51-2.03).
- 20. HYSTERSCOPIC MYOMECTOMYSubmucous myoma -5.5-16.6% of all fibroids AAGL in 2012 -submucous fibroid contribute to infertility and its removal improves fertility rates European Society of Hysteroscopy (ESH) Type 0 - completely within the cavity Type I - extend < 50 % into the myometrium Type II - extend >50 % within the myometrium Indications AUB
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- 23. HYSTEROSCOPIC MYOMECTOMY – SURGICAL TECHNIQUESelection ofCase Myoma within uterine cavity _ pedunculated or limited implant base Myoma with partial intramural development , endocavitary component >50%. Angle of protrusion between myoma and uterine wall <900 Operative hysteroscope, resectoscope 26Fr Working element with electrosurgergical instrument – thermal loops or vaporising electrode and mechanical instruments – cold loops or intrauterine morcellator device can be attached Monopolar electrodes require non conducting distension media glycine 1.5%. Bipolar electrodes can be used with saline distension media Cold loops used mechanically to enucleate intramural portion of myoma Excision of only intracavitary component of fibroid Preoperative GnRH therapy if submucous fibroid >2
- 24. HYSTEROSCOPIC MYOMECTOMY - CHALLENGES Large submucousmyoma Thorough preop evaluation with mapping of fibroid by TVS, office hysteroscopy, to prevent incomplete resection and complications during procedure Complete excision may be done in two step procedure for large submucous myoma after 4 weeks to resect intracavitary migration of fibroid
- 25. HYSTEROSCOPIC MYOMECTOMY – SURGICAL TECHNIQUE FORLARGE FIBROIDOne step procedure – first resect intracavitary portion of fibroid by usual slicing, then using cold loop mechanically intramural portion of fibroid is resected by enucleation and blunt dissection. Enucleation is followed by excision and resection of intramural component of the fibroid Litta’s technique –elliptical incision given at junction of endometrium and its reflectiom on uterine wall till cleavage zone of fibroid is reached. Connecting bridges between fibroid and surrounding mycytes is slowly resected Lasmar’s technique –used collins L shaped knife to dissect endometrium around fibroid followed by direct mobilization of fibroid in all directions coagulating only bleeding vessels Hydromassage Manual massage
- 26. Lasmar Classification forhysteroscopic operability
- 28. HYSTEROSCOPIC MYOMECTOMY - PREVENTING COMPLICATIONSGenital tractburns due to monopolar current minimised by Maintain contact of external sheath of resectoscopewith cervix Avoid activation of electrosurgical unit when electrode is not in contact with tissue Ensure integrity of insulation of the electrode Minimize use of high voltage (coagulation) current during myomectomy Use concomitant laparoscopy in case of type 2 deep seated myomas Fluid overload Careful selection of fibroid large fibroid –two stage procedure Uterine perforation Detect early and stop procedure Minimise adhesion formation by opposing tissue should not be resected during single surgery Second look hyateroscopy effective for postoperative adhesions
- 29. HYSTEREOSCOPIC MYOMECTOMY - POSTOP CARE PostoperativeGnRH analogs can be continued for 2-3 months if the intramural portion of fibroid was not fully removed and a two step procedure can be planned Intraoperative antibiotics are administered to all patients. Patients discharged same day Very few patient require 24 hour observation for fluid overload Follow up hysteroscopy planned after 2-3 months
- 30. Case 24 yearold P0L0 MF 6 months with HMB with history of laparotomy
- 31. Case 50 yearlady with postmenopausal increased ET on scan, no PM
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- 33. HYSTEROSCOPIC MORCELLATORS ADVANTAGES Operate inSaline Decreased risk of fluid overload Mechanical No thermal injury Remove Tissue Pieces Clear visual field Decreases risks of multiple instrument placement Uterine perforation, false passageway and air embolus Are Easy to Use Facilitate Removal Type 0 and I Myomas Decreased operative time and fluid deficit Small Diameter Can Be Used in the Office
- 34. HYSTEROSCOPIC MORCELLATORS DISADVANTAGES No electrosurgeryfor hemostasis IOGYN Mistral has electrosurgery Type 2 myomas are difficult Fundal pathology is difficult Cost of fluid management system Mistral is incorporated into device
- 36. COMPLICATIONS OF HYSTEROSCOPIC MYOMECTOMY Electrolyte abnormalitieswith non-electrolyte media Excessive bleeding Incomplete resection Need for additional procedure Increased operative time Wamsteker K, 1993
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- 38. INTRAUTERINE ADHESIONS Trauma Missed orincomplete abortion, postpartum hemorrhage, or retained placental remnants Genital tuberculosis Classifications Endometrial adhesions - filmsy adhesions Myometrial adhesions – dense adhesions Connective fiber synechiae Goal – Restore normal anatomy Scissors Resectoscope collins knife for dense adhesions
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- 40. RETAINED FETAL BONES Iatrogenic secondaryinfertility caused by residual intrauterine fetal bone after midtrimester abortion. An intrauterine device-like effect
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- 46. HYSTEROSCOPIC CANNULATION Intramural portion oftube initial 1 cm rectilinear, later 1.5 cm irregular and sometimes difficult to cannulate Indications For proximal tubal occlusion Transfer of gametes or embryos in some ART Placement of intratubal devices for reversible sterilization GIFT PTO account for 10-25% of tubal factor infertility Cooks cannulation set 9 Fr outer catheter and 3 Fr inner catheter with guide wire
- 47. "CHROMOHYSTEROS COPY" 5 ml of1% methylene blue dye Group I: 19 patients focal dark staining 10 cases of endometritis Group II: 15 patients diffuse light blue staining normal histopathology
- 48. HYSTEROSCOPIC STERILISATION •Hysteroscopic placement of radiopaqueinserts in the proximal portion of the fallopian tube •Tissue ingrowth occurs through the insert creating natural barrier Device Length: ~3.85 cm • PET Fiber Length: ~1.75 cm • Expanded Outer Diameter: 1.5 – 2.0 mm • Inserts are visible by X-Ray, Ultrasound, MRI and CT Scan
- 49. CONCLUSION Diagnostic hysteroscopy shouldbe a routine procedure during diagnostic laparoscopy in infertile women Office mini-hysteroscopy should be incorporated in infertility work up