OPERATIVE HYSTEROSCOPY

Dr. Khushbu Agrawal

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

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.

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

VARIOUS OPERATING ELEMENTS

• CUTTING LOOP

• COLLINS KNIFE

• BALL ELECTRODE

Accessory instruments

BIOPSY AND GRASPING FORCEPS

SCISSORS

PUNCH

BIOPSY SPOON FORCEPS

SCISSORS

TENACULUM GRASPING FORCEPS

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

SPECIFIC PROCEDURES INHYSTEROSCOPIC SURGERIES

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

Hysteroscopic Meteroplasty

• Anesthesia- GA/SA

• Method

– Microscissors

– Nd-YAG Laser

– Electrosurgery

• Guidance Under

– Laparoscopy

– Ultrasonography

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.

• 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.

•Follow-up 1-2 months postop HSG or hysteroscopy

SCAR

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.

ADHESIOLYSIS

• Most difficult of all hysteroscopic surgeries

• Methods:-

– Scissors

– Resectoscope

– Nd-YAG laser

• Lysis opens many vascular channels

– high risk of Intravascular Absorption Syndrome.

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

Catheterization of Fallopian Tubes

• Indications

– Unblocking of the ostium and proximal tract

– Application of intratubal contraception devices

• ESSURE

• ADIANA

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%

Technique –Modified Novy cannulation set

• Introducing catheter - 5Fr - 35 CM

• Inner Catheter - 3 Fr – 50 CM

• Guide wire - 0.18’’ – 80 CM

SUBMUCOSAL MYOMATA

• Complaints:

– HMB, infertility, recurrent pregnancy loss

• Diagnosis:

– Hysteroscopy with combination of

• MRI

• SIS

• TVUS

CLASSIFICATIONEUROPEAN 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

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

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)

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.

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.

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

• 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

• Results in INFERTILITY treatment

STUDY- 108 TYPE 0 TYPE 1 TYPE 2

FERTILITYRATE

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

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

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.

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

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

Technique

• RESECTOSCOPE WITH MONOPOLAR LOOP ELECTRODE.

• Remove the debris and blood.

• Never use cutting loop over fundus and cornu

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.

Views during Ablation

Failure of endometrial ablation

• Adenomyosis

• Bulky uterus

• Curettage immediately prior to the procedure

• No premedication with GnRH analogues

MISCELLANEOUS PROCEDURES

• MISSING IUD REMOVAL

– String grasped with – Alligator-jaw forceps

– Embedded IUDs – Rigid grasping forceps used

COMPLICATIONS OF HYSTEROSCOPY

• INCIDENCE : 0.2%

• 10% with major operative surgeries

• SPECTRUM

– Perioperative complications

– Postoperative complications

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.

Post operative

• EARLY

– Infection

– Postop bleeding

• LATE – sequelea

– Intrauterine adhesions

– Uterine rupture during pregnancy

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.

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

NERVE INJURY

Femoral neuropathy

Excessive hip flexionabductionext hip rotation extreme angulation of FEMORAL nerve- compression injury.

Temporary – needs intensive physical therapy to resolve

• Sciatic nerve injury-

– At sciatic notch

• Common peroneal injury

– At neck of fibula – FOOT DROP/ LOWER LATERAL PARAESTHESIA

RISK REDUCTION & MANAGEMENT

• Ideal lithotomy position- moderate flexionwith 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

ANESTHESIA RELATED

• Local anesthesia related

– Allergic reactions

– Cardiovascular complications

• Awareness and avoiding

– Fluid overload

– Electrolyte disturbance

– Signs of gas embolization

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

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

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

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.

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.

1.5% Glycine

Low Viscosity Fluid

Hypoosmolar in nature – when delivered by high pressure infusion pump – excess vascular absorption

sudden onset Acute Hyponatremia, hypo-osmolarstate IN BLOOD

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

• NORMAL SALINE

– SAFEST

– EXCESSIVE VASCULAR ABSORPTION FLUID OVERLOAD PULMONARY EDEMA.

– NOT SUITABLE FOR MONOPOLAR SYSTEM : good conductor of electrons.

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.

DEVICES

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

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.

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.

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

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.

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.

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