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Hysteroscopic dissection of intrauterine synechiae
Last reviewed: 04.07.2025
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Hysteroscopic dissection of intrauterine adhesions
The method of choice for treating intrauterine adhesions is their dissection with a hysteroscope under direct visual control.
In 1978, Sugimoto described blunt dissection of adhesions using a hysteroscope body. This method is still successfully used today for dissection of centrally located adhesions.
Neuwirth et al. (1982) described the use of Jako microlaryngoscopic scissors, inserted into the uterine cavity near the body of the hysteroscope, for dissection of intrauterine adhesions.
After establishing the diagnosis, determining the type of intrauterine adhesions and the degree of occlusion of the uterine cavity, it is necessary to carry out treatment. The goal of treatment is to restore the normal menstrual cycle and fertility. The main method of treatment is surgical dissection of intrauterine adhesions without damaging the surrounding endometrium. This is best done under visual control at high magnification - during hysteroscopy.
If the patient still has menstruation, the operation is best performed in the proliferation phase, and in case of amenorrhea - at any time. During operative hysteroscopy, it is better to use liquid media to expand the uterine cavity. The type of liquid depends on the instruments used.
When using mechanical instruments (scissors, forceps) and a laser, it is better to use saline solution as a medium that expands the uterine cavity.
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 adhesions and the degree of occlusion of the uterine cavity.
Delicate adhesions (endometrial) are easily dissected with the hysteroscope body or mechanical instruments - scissors and forceps. More dense adhesions are dissected with scissors gradually, step by step, until the normal shape of the uterine cavity is restored. Dissection of intrauterine adhesions at grade I according to the March classification, as well as grades I and II according to the EAG, does not require laparoscopic control.
Fibrous adhesions. When cutting even denser fibrous adhesions, it is better to use a hysteroresectoscope with an "electro-knife" electrode, the electric current power is 80 W in the cutting mode. Scissors can also be used if the density of the adhesions allows it.
The operation is performed under ultrasound control in case of minor occlusion of the uterine cavity and under laparoscopic control in case of significant occlusion.
Ultrasound control facilitates orientation in the uterine cavity during surgery, since under the pressure of the injected fluid the uterine cavity expands and its contours are clearly defined.
Laparoscopic control allows avoiding injury to the uterine wall and nearby organs by electric current.
Each adhesion is gradually dissected to a small depth and the freed cavity is carefully examined, gradually, step by step, the entire operation is carried out.
It is necessary to start cutting adhesions from the lower sections and move towards the bottom of the uterus and the mouths of the fallopian tubes. Operations to cut intrauterine adhesions are classified as the highest category of complexity and should be performed by experienced endoscopists.
For the purpose of adhesiolysis, an Nd-YAG laser can also be used using the contact method described above.
When comparing various methods of dissection of intrauterine adhesions, no advantages of electro- and laser surgery over dissection with scissors were found.
Transcervical dissection of intrauterine adhesions under hysteroscope control is a very effective operation. According to various authors, it is possible to restore menstrual function and create a normal uterine cavity in 79-90% of cases, pregnancy occurs in 60-75% of observations, while pathology of placental attachment is noted in 5-31% of cases.
Considering the complexity of treating intrauterine adhesions, especially old (long-standing), much attention should be paid to preventing their occurrence. It is necessary to remember the possibility of intrauterine adhesions in women with complicated early postpartum period and after abortions; they should be given close attention. If they occur in a woman of this group with menstrual cycle disorders, it is necessary to perform hysteroscopy as soon as possible. It is easier to treat patients with early, still delicate endometrial adhesions.
Some doctors recommend, if there is a suspicion of remnants of the fertilized egg or placenta, to perform not just curettage, but hysteroscopy to clarify the location of the pathological focus and its targeted removal without damaging the normal endometrium.
Wamsteker and de Blok (1993) suggest that after curettage of the uterine cavity in the postpartum period due to bleeding or residual placental tissue, as well as repeated curettage after an abortion, a control hysteroscopy should be performed 6-8 weeks after the intervention.
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