Methods of hysteroscopic operations

Methodology for performing hysteroscopic operations

Targeted endometrial biopsy. It is usually performed during diagnostic hysteroscopy. After a thorough examination of the uterine cavity, biopsy forceps are inserted through the operating channel of the hysteroscope body and, under visual control, a targeted biopsy of pieces of the endometrium is performed, which are then sent for histological examination. In the referral to the histologist, it is necessary to indicate the day of the menstrual-ovarian cycle (if the cycle is preserved), whether treatment with hormonal drugs was carried out and which ones, when the treatment was completed, the presence of proliferative processes in the endometrium in the anamnesis.

Removal of small endometrial polyps is the most common operation. Single polyps on a stalk are removed with forceps or scissors inserted through the surgical channel of the hysteroscope. Under visual control, the forceps are brought to the stalk of the polyp and cut off. After removal of the polyp, it is necessary to perform a control hysteroscopy to make sure that the stalk of the polyp has been completely excised.

It is more difficult to remove polyps located in the area of the mouths of the fallopian tubes, where it is not always convenient to bring instruments. To remove polyps, you can also use a resectoscope loop or a laser light guide, which excise the stalk of the polyp. A resectoscope or laser is necessary for parietal and dense fibrous polyps, since they are difficult to remove with mechanical instruments.

Removal of small (up to 2 cm) myomatous nodes on a pedicle is usually performed during diagnostic hysteroscopy. After detecting a myomatous node, determining its location and size, scissors can be inserted through the surgical channel of the hysteroscope and the node pedicle can be cut off if it is small. If the pedicle is denser and thicker, a resector, resectoscope or laser light guide is inserted, the pedicle is excised under visual control. Then the node is removed with an abortion forceps. After this, a control hysteroscopy is performed, the bed of the removed node is examined, and there is no bleeding.

Dissection of delicate intrauterine adhesions is performed either with the tip of the hysteroscope or with scissors inserted through the surgical channel of the hysteroscope. Adhesions are gradually dissected to a depth of 1-2 mm, then the remaining part is examined; all adhesions are gradually dissected in this way. After dissection of delicate adhesions, there is no need to insert an IUD or prescribe hormonal therapy.

The dissection of a thin intrauterine septum of small size is performed with scissors inserted through the surgical channel of the hysteroscope, under visual control. The septum is gradually dissected until a single cavity is formed.

Removing an IUD that is freely located in the uterine cavity is a fairly simple operation. After determining the location of the IUD, grasping forceps are inserted through the surgical channel of the hysteroscope, the IUD is fixed and removed together with the hysteroscope from the uterine cavity. It is possible to remove the IUD with a curette or hook using the generally accepted method, but these manipulations are dangerous and traumatic.

Removal of hyperplastic uterine mucosa. Immediately after pathology is detected, the hyperplastic uterine mucosa is removed with a curette, then control is carried out (often repeatedly) for complete removal of the pathological focus.

Removal of the remnants of placental tissue and the ovum is usually carried out with a curette or abortion forceps with mandatory visual control. It is important to note that almost always (especially when the remnants of the ovum remain in the uterus for a long time) the placental tissue adheres tightly to the wall of the uterus, which is why it is difficult to remove it. In these situations, auxiliary instruments (forceps) are used, inserted through the surgical channel of the hysteroscope.

Complex surgeries require mandatory hospitalization of the patient. For successful performance of complex hysteroscopic surgeries, it is necessary to use a video monitor, an intense light source and an endomat, since the accuracy and correctness of the surgery are associated with the clarity and purity of the view. Such surgeries should be performed by an experienced endoscopist. When removing submucous nodes of type II, dissecting a thick intrauterine septum, dissecting intrauterine adhesions of grade II and higher, removing the IUD (its fragments) or bone remnants that have penetrated the uterine wall, when there is a risk of uterine perforation, laparoscopic control of the course of the surgery is performed.

Hysterosecopic metroplasty

Of all the gynecological operations performed on the uterus, hysteroscopic metroplasty (surgical dissection of the intrauterine septum) is the most common surgical intervention since the advent of operative hysteroscopy. In the past, this operation required a hysterotomy by laparotomy. The introduction of endoscopy has made it possible to perform this operation transcervically through an endoscope, eliminating the need for dissection of the uterus.

The first report of blind dissection of the intrauterine septum by transcervical access appeared in 1884 (Ruge). But soon, due to a large number of complications, this access was replaced by a more preferable direct access - hysterotomy by laparotomy. Several modifications of these operations are known.

Disadvantages of these methods

• laparotomy and uterine dissection are necessary;
• long postoperative period;
• Many women develop adhesions in the pelvis after these operations, which leads to secondary infertility; if pregnancy occurs, surgical delivery (caesarean section) is indicated. The possibility of excision of the intrauterine septum under hysteroscopic control was first reported by Edstrom in 1970. The septum was gradually dissected with scissors; this method turned out to be the simplest and most accessible. It is still used today with good results for septa of small thickness with poor blood supply. Advantages of using scissors: simplicity; speed; availability; cheapness;
• there is no need for special instruments and liquids, therefore, complications associated with electro- and laser surgery can be avoided. The septum is cut gradually along the midline, and when the fundus of the uterus is reached, bleeding occurs, which serves as a signal to stop the operation.

In case of wide partitions, it is better to use a hysteroresectoscope with a knife, rake electrode or loop. Advantages of the method: electrosurgical coagulation prevents bleeding; the operation is performed with good visibility, since tissue particles and blood are constantly removed from the uterine cavity. Such an operation is best performed under ultrasound and laparoscopic control.

Disadvantages of Electrosurgical Operation

• use of special liquids;
• the possibility of fluid overload of the vascular bed and other complications associated with electrosurgery.

In case of a complete septum in the uterine cavity, many authors recommend preserving the cervical part of the septum to prevent secondary isthmic-cervical insufficiency. In this case, the dissection of the septum begins at the level of the internal os. To successfully perform this operation, a Foley catheter is inserted into one cavity and inflated, and an operating hysteroscope is inserted into the second cavity, and the dissection of the septum begins at the level of the internal os, gradually moving towards the bottom of the uterus. The operation is considered complete if a normal cavity is formed.

It is also possible to use a laser (Neodymium-YAG).

Advantages of the method

1. no bleeding;
2. you can cut more precisely;
3. It is possible to use electrolyte solutions to expand the uterine cavity (saline solution).

Disadvantages of the method

1. high cost of equipment;
2. the need for special protective glasses;
3. the possibility of damage to the normal endometrium near the septum.

It is advisable to perform septum dissection in any of these methods in the early phase of proliferation. To improve the conditions for the operation, preoperative hormonal preparation is indicated, especially in the case of a complete septum. Treatment with GnRH analogues or danoval at 600-800 mg daily is performed for 6-8 weeks.

Thus, hysteroscopic resection of the intrauterine septum is the method of choice. This operation completely replaces transabdominal metroplasty. Hysteroscopic dissection of the intrauterine septum is a more gentle and less traumatic operation, significantly shortening the postoperative period, which has a smoother course. Due to the absence of a scar on the uterus after such an operation, childbirth can be carried out through the natural birth canal. According to various authors, the frequency of normal births after hysteroscopic dissection of the intrauterine septum is 70-85%.

Method of removing large endometrial polyps

When using the mechanical method of removing large endometrial polyps, additional expansion of the cervical canal with Hegar dilators up to No. 12-13 is necessary. Then, the polyp is fixed with an abortion forceps and removed by unscrewing, monitoring the process using hysteroscopy, often repeatedly (until the polyp is completely removed). The polyp stalk is sometimes difficult to remove with this method (if the polyp is fibrous). In such cases, it is necessary to additionally excise the polyp stalk with scissors or forceps passed through the surgical channel of the hysteroscope. If, during the first examination, the polyp stalk can be easily identified, and the endoscopist has a resectoscope and is proficient in its use, it is better to cut it off immediately with the resectoscope loop.

The mechanical method of removing endometrial polyps is simple and does not require complex equipment. The duration of the operation is usually 5-10 minutes.

Removal of the intrauterine contraceptive device and its fragments

If there is a suspicion of perforation of the uterine wall by the IUD, a combined examination is carried out: hysteroscopy with laparoscopy.

First, a laparoscopy is performed, carefully examining the walls of the uterus and parametrium. Subsequent manipulations depend on the location of the IUD. If the IUD is partially located in the abdominal cavity, it is removed using a laparoscope.

If there is no perforation of the uterine cavity, hysteroscopy is performed after laparoscopy, all areas of the uterine cavity are carefully examined, paying special attention to the area of the tubal angles. If the IUD (or its fragments) embedded in the uterine wall is detected, it is grasped with clamping forceps and carefully removed from the uterine cavity along with the hysteroscope. All this time, the progress of the operation is monitored from the abdominal cavity with a laparoscope. At the end of the operation, the uterine wall is examined with a laparoscope to confirm its integrity and the fluid that entered the abdominal cavity during hysteroscopy is sucked out.

There are situations when ultrasound data reveals fragments of the intrauterine membrane in the thickness of the myometrium, but hysteroscopy and laparoscopy fail to detect them. In such a situation, there is no need to try to extract these fragments from the thickness of the wall. They must be left in the thickness of the myometrium, and the woman must be warned about this and observed.

The authors of the book's extensive experience of observing such patients has shown that the IUD in the thickness of the myometrium behaves like an indifferent foreign body, without subsequent complications.

Hysteroscopic sterilization

Hysteroscopic sterilization was first proposed more than 20 years ago, but the idea has not yet found widespread use. Apparently, this is due to the fact that none of the existing methods of hysteroscopic sterilization today meets the requirements of an ideal method of contraception, which has minimal invasiveness, low cost, possible reversibility, a high percentage of effectiveness and a minimum of complications. Despite significant progress in hysteroscopic surgery in the last decade, the problem of hysteroscopic sterilization still remains completely unresolved.

Existing methods of hysteroscopic sterilization are divided into two main categories: destructive and occlusive.

Destructive operations are currently practically not performed due to low efficiency (57-80%) and possible serious complications, including perforation of the uterus and burn injuries to the intestine. Destructive methods include the introduction of sclerosing agents, various medical adhesives into the lumen of the fallopian tube, electrocoagulation and cryodestruction of the isthmic section of the fallopian tube.

To achieve sufficient effect, sclerosing agents had to be administered several times, but even despite this, its percentage remained low, due to which many doctors abandoned this method. In addition, the issue of possible toxic complications of these chemicals administered several times to achieve 80-87% efficiency has not yet been resolved. There is also no clear data on the effect of these substances when they enter the abdominal cavity through the fallopian tubes.

Medical adhesives (methyl cyanoacrylate) are preferable because they quickly polymerize when they reach the mouth of the fallopian tube, which prevents it from leaking through the fallopian tubes into the abdominal cavity. Multiple injections of the drug are also not required.

Destructive substances are introduced into the mouth of the fallopian tube through a special catheter, passed through the surgical channel of the hysteroscope. At the location of the destructive substance in the mucous membrane of the fallopian tube, an inflammatory process initially occurs, then replaced by necrosis and irreversible fibrosis.

In recent years, these catheters have been significantly improved due to their use for catheterization of the fallopian tubes in reproductive technologies.

Electrosurgical destruction of the isthmic section of the fallopian tubes is performed with a special electrode inserted through the surgical channel of the hysteroscope. Difficulties arise in determining the current strength and duration of exposure, since the manipulation is performed in a place where the thickness of the myometrium is minimal. In the first studies, the effectiveness of this method was 80%. At the same time, a high percentage of failures (up to 35) was noted, as well as serious complications, including intestinal burns and tubal pregnancy in the isthmic section of the tube.

Cryodestruction has also been used for tubal sterilization, with the same efficiency as electrosurgical destruction. Coagulation necrosis occurs at the site of action with corresponding biochemical and biophysical changes. Remote results have shown the absence of epithelial regeneration at the site of action and obstruction without recanalization.

There are isolated studies on the use of Nd-YAG laser for coagulation of the area of the mouths of the fallopian tubes.

Thus, the efficiency of using methods using different types of energy depends on the amount of energy delivered to the site of action. With insufficient energy, destruction is inadequate, and with a significant amount of energy, damage to adjacent organs is possible. Despite a large number of studies, thermal methods of destruction in hysteroscopic sterilization still cannot be considered reliable, since the percentage of failures and complications is high.

Occlusion methods are more effective (74-98%) and have a lower probability of serious complications. However, they are also far from ideal, as occlusion is often incomplete and/or expulsion of the occlusion device occurs in the future.

There are two groups of occlusal devices: pre-formed intra-tube coils and devices that take shape in situ.

Preformed In-Pipe Spirals

One of the first intra-tubal spirals was the hydrogel plug (P-block), which is a polyethylene thread 32 mm long with awl-shaped branches at the ends. A hydrogel plug is placed in its center, swelling when it enters the lumen of the tube and, as it were, growing into the wall of the fallopian tube.

The simplest model of an intratubal coil was proposed by Hamou in 1986. It is represented by a nylon thread (Hamou coil) with a diameter of 1.2 mm, introduced through a guidewire by 1 cm into the interstitial section of the tube. There are loops at the ends of the thread to prevent the coil from expulsion into the uterine cavity or abdominal cavity, as well as to remove it if necessary.

Hosseinian et al. in 1976 proposed a more complex model of an in-pipe spiral, consisting of a polyethylene plug with 4 metal spikes fixing it to the pipe wall.

Products that take shape on site

Silicone polymer is introduced into the lumen of the tube through its mouth, after which a rubber obturator is inserted into the mouth of the tube (Ovablock). This method was proposed by Erb in 1970. This procedure is somewhat complicated, but silicone is safer than other chemicals, and it does not penetrate tissue, and since the destruction of the epithelium is minimal, such sterilization is reversible. Remote results have shown the effectiveness of this agent in 74.3-82% of cases.

Along with the individual characteristics of each of the described methods of hysteroscopic sterilization, there are difficulties associated with hysteroscopy itself:

• spasm of the mouth of the fallopian tube;
• inadequate examination of the uterine cavity due to mucus, blood clots, and endometrial fragments;
• various types of intrauterine pathology that interfere with access to the area of the uterine angles;
• incorrect choice of uterine dilating agent.

Thus, none of the currently available methods of hysteroscopic sterilization have found widespread use. Research in this area continues.

Tubal catheterization and phaloscopy

Attempts to blindly catheterize the fallopian tubes in patients with infertility began in the 19th century, but they were often unsuccessful and accompanied by complications. With the advent of hysteroscopy, it became possible to visually control the process of catheterization of the fallopian tubes. Initially, the procedure was performed to occlude the intramural section of the fallopian tubes for the purpose of sterilization. Subsequently, catheterization of the fallopian tubes began to be used to assess the patency of the interstitial section of the fallopian tubes, and then in the in vitro fertilization program: transfer of a zygote or embryo into the lumen of the fallopian tube.

Most researchers note that in women with tubal factor infertility, proximal tubal obstruction is detected in 20% of cases. Donnez and Casanas-Roux (1988) in their study of the proximal tubal section after reconstructive surgeries or hysterectomy identified the following types of pathology of the interstitial section of the fallopian tubes:

• nodular isthmic salpingitis;
• fibrosis;
• endometriosis;
• polyps;
• pseudo-occlusion (endometrial fragments, tissue, mucus, spasm).

It is well known that hysterosalpingography has a false-positive rate of 20-30%, often diagnosing pseudo-occlusion of the proximal fallopian tube. Fallopian tube catheterization has been proposed to rule out or confirm this pathology.

Various models of catheters were used for catheterization of the fallopian tubes; the most optimal was a catheter borrowed from angiographic practice. This flexible catheter with an inflatable balloon at the end is inserted into the isthmic section of the fallopian tube, and the balloon is inflated. This technique is called transcervical balloon tuboplasty.

Currently, the following catheters are mainly used for tubal catheterization: Katayama hysteroscopic cateter sets, Cook hysteroscopic insemination cateter sets (COOK OB/GYN, Spencer, IN).

The catheter is inserted through the surgical channel of a rigid or flexible hysteroscope, brought to the mouth of the fallopian tube and then, under the control of a laparoscope, passed into the lumen of the fallopian tube. If necessary, indigo carmine can be introduced through this catheter to confirm the patency of the fallopian tube.

The operation is performed under endotracheal anesthesia; visual examination with simultaneous laparoscopy allows not only to control the passage of the catheter, but also to assess the condition of the pelvic organs.

The results obtained with tubal catheterization confirm the opinion of a number of researchers that this method should be the first choice for proximal tubal obstruction to resolve the issue of the need for in vitro fertilization. The best results were obtained by Thurmond et al. (1992): the effectiveness of tubal catheterization was 17-19%, intrauterine pregnancy occurred in 45-50% of cases, and ectopic pregnancy occurred in 8%. Thus, in a number of cases, tubal catheterization can serve as an alternative to microsurgical surgery to restore patency of the isthmic section of the fallopian tube.

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