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Hysteroscopic dissection of intrauterine synechia
Last reviewed: 19.10.2021
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Hysteroscopic dissection of intrauterine synechia
The method of choosing the treatment of intrauterine synechiae is their dissection with a hysteroscope under direct visual control.
In 1978, Sugimoto described the blunt separation of the synechia with the hysteroscope body. This method is successfully used and at present for the dissection of synechia, located centrally.
Neuwirth et al. (1982) described the use of the microlaringoscopic Jako scissors for dissecting intrauterine synechiae introduced into the uterine cavity next to the hysteroscope body.
After the diagnosis is established, the type of intrauterine synechia and the degree of occlusion of the uterine cavity should be determined. The goal of the treatment is to restore the normal menstrual cycle and fertility. The main method of treatment is surgical dissection of intrauterine synechia without traumatizing the surrounding endometrium. Best of all, this is done under the control of vision with a large increase - with hysteroscopy.
If the patient has menstruation, the operation is best carried out during the proliferation phase, with amenorrhea at any time. With operative hysteroscopy, it is better to use liquid media to expand the uterine cavity. The type of liquid depends on the tools used.
When using mechanical tools (scissors, forceps) and the laser as a medium that expands the uterine cavity, it is better to use physiological saline.
When using a hysteroresectoscope, non-electrolyte solutions (high- or low-molecular) are used as a liquid medium.
The nature of the operation, its effectiveness and long-term results depend on the type of intrauterine synechia and the degree of occlusion of the uterine cavity.
Gentle synechia (endometrial) is easily dissected by the hysteroscope body or by mechanical tools - scissors and forceps. More dense synechia is dissected with scissors gradually, step by step, until the normal shape of the uterine cavity is restored. Dissection of intrauterine synechiae at grade I according to the March classification, as well as I and II degrees according to the EAG, does not require laparoscopic control.
Fibrous synechia. When cutting even more dense fibrous synechia, it is better to use a hysteroresectoscope with an electrode "elektronozh", an electric current of 80 W in cutting mode. You can use scissors, if the density of synechia allows.
The operation is performed under the supervision of ultrasound with a small occlusion of the uterine cavity and under laparoscopic control with significant occlusion.
Ultrasound control facilitates orientation in the uterine cavity during surgery, because under the pressure of the injected fluid the uterine cavity expands, its contours are well defined.
Laparoscopic control helps to avoid injury to the uterus wall and nearby organs by electric current.
Each spike is gradually dissected to insignificant depth and carefully examine the released cavity, gradually, step by step, conduct the entire operation.
Begin to dissect the synechia from the lower parts and move towards the bottom of the uterus and the ovaries of the fallopian tubes. Operations for the dissection of intramacus synechia are referred to the highest category of complexity, they must be performed by experienced endoscopists.
For the purpose of adhesion, an Nd-YAG laser can also be used by the contact technique described above.
When comparing different methods of dissection of intrauterine synechia, no advantages of electro- and laser surgery before cutting with scissors were revealed.
Transcervical dissection of intrauterine synechia under the control of a hysteroscope is a very effective operation. According to various authors, it is possible to restore the menstrual function and create a normal uterine cavity in 79-90% of cases, pregnancy occurs in 60-75% of cases, with the pathology of attaching the placenta noted in 5-31% of cases.
Given the complexity of treatment of intrauterine synechia, especially old (long-lasting), great attention must be paid to the prevention of their occurrence. It is necessary to remember the possibility of intrauterine synechia in women with a complicated course of the early postpartum period and after abortion; they should be closely watched. If a woman with this group with irregularities in the menstrual cycle occurs, hysteroscopy should be performed as soon as possible. It is easier to treat patients with early, yet tender endometrial sinuxes.
Some doctors recommend that when suspicion of the remains of the fetal egg or placenta is not just a curettage, but hysteroscopy to clarify the location of the pathological focus and targeted removal without traumatizing the normal endometrium.
Wamsteker and de Blok (1993) suggest after curettage of the uterine cavity in the postpartum period about bleeding or remnants of placental tissue, as well as re-scraping after abortion, to carry out a control hysteroscopy 6-8 weeks after the intervention.
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