Method of hysteroscopic operations

Method of hysteroscopic operations

Aiming biopsy of the endometrium. Usually it is performed with diagnostic hysteroscopy. After a thorough examination of the uterine cavity, biopsy forceps are inserted through the surgical channel of the hysteroscope body and a targeted biopsy of pieces of the endometrium is sent under the vision control, then directed to a histological examination. In the direction of the histologist, it is necessary to indicate the day of the menstrual-ovarian cycle (with the saved cycle), whether treatment with hormonal preparations was carried out and what, when the treatment was completed, the presence in the anamnesis of proliferative processes in the endometrium.

Removal of small polyps of the endometrium is the most common operation. Single polyps on the leg are removed with forceps or scissors inserted through the operating channel of the hysteroscope. Under the control of vision, the forceps are brought to the leg of the polyp and cut off. After removal of the polyp, a control hysteroscopy should be performed to make sure that the polyp's leg is excised completely.

It is more difficult to remove polyps, located in the area of the uterine tubes, where it is not always convenient to bring tools. To remove polyps, you can also use a resectoscope loop or a laser light guide, with which the polyp's leg is excised. A resectoscope or laser is necessary for near-wall and dense fibrous polyps, as they are difficult to remove with mechanical tools.

Removal of small (up to 2 cm) myomatous nodes on the leg is usually performed during diagnostic hysteroscopy. After the detection of the myomatous node, determination of its location and dimensions, it is possible to insert scissors through the operating channel of the hysteroscope and cut off the node leg at its small size. With a thicker and stiffer leg, a rezector, a resectoscope or a laser light guide is introduced, the leg is excised under the control of vision. Then the site is removed by abortion. After this, the control hysteroscopy is performed, the bed of the removed node is inspected, and the bleeding is determined.

Dissection of tender intrauterine synechiae is performed either with the tip of the hysteroscope or with scissors inserted through the operating channel of the hysteroscope. Gradually dissect the synechia to a depth of 1-2 mm, then examine the remainder; so gradually dissect all the synechia. After the dissection of tender synechia, there is no need for the introduction of IUD and the appointment of hormone therapy.

The small intramuscular septum is dissected by scissors, introduced through the operating channel of the hysteroscope, under the control of vision. The septum is gradually dissected until a single cavity is formed.

Removing an IUD free in the uterine cavity is a fairly simple operation. After determining the location of the IUD through the operating channel of the hysteroscope, gripping forceps are inserted, the IUD is fixed and removed together with the hysteroscope from the uterine cavity. You can remove the CMC curette or crochet according to a conventional technique, but these manipulations are dangerous and traumatic.

Removal of the hyperplastic mucous membrane of the uterus. Immediately after revealing the pathology of the curette, the hyperplastic mucous membrane of the uterus is removed, followed by monitoring (often repeatedly) after the complete removal of the pathological focus.

Removal of the remains of placental tissue and fetal eggs is usually carried out by sight with a curette or abortion with mandatory visual control. It is important to note that almost always (especially with prolonged stay in the uterus of the remains of the fetal egg), the placental tissue densely grows to the wall of the uterus, so difficulties arise when it is removed. In these situations, use an auxiliary tool (forceps), introduced through the operating channel of the hysteroscope.

Conducting complex operations requires mandatory hospitalization of the patient. For the successful implementation of complex hysteroscopic operations, it is necessary to use a video monitor, an intense light source and an endomat, since the accuracy and correctness of the operation are related to the clarity and purity of the survey. Such operations should be performed by an experienced endoscopist. When removing submucous nodes of type II, dissection of the thick intrauterine septum, dissection of intrauterine synechia of grade II or more, removal of IUDs (fragments) or bone remnants implanted in the uterine wall, when there is a risk of perforation of the uterus, laparoscopic control of the course of the operation is performed.

Hysteroscopic metroplasty

Of all the gynecological operations performed on the uterus, hysteroscopic metroplasty (surgical dissection of the intrauterine partition) is the most frequent surgical intervention since the onset of operative hysteroscopy. In the past, during this operation, it was necessary to perform a hysterotomy by laparotomy. The introduction of endoscopy allowed this operation to be transcervical through the endoscope, excluding dissection of the uterus.

The first report on the 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 changed to a more preferable direct access - a hysterotomy with a laparotomy. There are several modifications of these operations.

Disadvantages of these methods

• laparotomy and uterine dissection;
• long postoperative period;
• many women after these operations develop spikes in the small pelvis, which leads to secondary infertility; when pregnancy occurs, operative delivery (caesarean section) is indicated. The possibility of excision of the intrauterine partition under hysteroscopic control was first reported by Edstrom in 1970. The septum was gradually dissected with scissors; this method was the most simple and affordable. It is used and now with good results for septa of insignificant thickness, having poor blood supply. The advantages of using scissors are simplicity; rapidity; availability; cheapness;
• there is no need for special tools and liquids, therefore, it is possible to avoid complications associated with electro- and laser surgery. The septum is dissected gradually along the middle line, when the bottom of the uterus reaches the hemorrhage, which serves as a signal for stopping the operation.

With wide partitions it is better to use a hysteroresectoscope with a knife, a rake electrode or a loop. Advantages of the electrosurgical coagulation method prevents bleeding; The operation takes place at a good review, as tissue particles and blood are constantly removed from the uterine cavity. Such an operation is best performed under the supervision of ultrasound and laparoscopic control.

Disadvantages of electrosurgery

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

With a complete septum in the uterine cavity, many authors recommend retaining the cervical part of the septum to prevent secondary ischemic-cervical insufficiency. The dissection of the septum begins at the level of the internal pharynx. To successfully carry out this operation, a Foley catheter is injected into one cavity and inflated, and into the second cavity - an operating hysteroscope and the dissection of the septum starts from the level of the internal pharynx, gradually moving towards the bottom of the uterus. The operation is considered complete if a normal cavity is formed.

Possible and the use of a laser (Neodymium-YAG).

Advantages

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

Disadvantages of the method

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

The dissection of the septum with any of these techniques is advisable to carry out in the early phase of proliferation. To improve the conditions of the operation, preoperative hormonal preparation is shown, especially with a complete septum. For 6-8 weeks, treatment with analogues of GnRH or danoval of 600-800 mg daily.

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

The method of removal of large size endometrial polyps

When using the mechanical method of removing large polyps of the endometrium, additional expansion of the cervical canal by Gegar dilators to No. 12-13 is necessary. Then aborttsangom accurately fix the polyp and remove it by the method of unscrewing, controlling the process with the help of hysteroscopy, often repeatedly (until the polyp is completely removed). A leg of a polyp with this method is sometimes difficult to remove (if the polyp is fibrous). In such cases, you have to excise the leg of the polyp with scissors or forceps carried through the operating channel of the hysteroscope. If during the first examination it is possible to easily identify the leg of the polyp, and the endoscopist has a resectoscope and owns the technique of using it, it is better to cut it immediately with a resectoscope loop.

The mechanical method of removing endometrial polyps is simple, does not require complicated equipment. The duration of the operation, as a rule, is 5-10 minutes.

Removal of intrauterine contraceptive and its fragments

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

First, laparoscopy is performed, carefully examining the walls of the uterus and the parameters. The subsequent manipulations depend on the location of the IUD. If BMC is partially located in the abdominal cavity, it is removed with a laparoscope.

In the event that there is no perforation of the uterine cavity, after laparoscopy, hysteroscopy is performed, all parts of the uterine cavity are carefully inspected, paying special attention to the area of the tube corners. When an IUD (or its fragments) that has penetrated the uterine wall is detected, it is grasped with clamping forceps and gently removed from the uterine cavity together with the hysteroscope. All this time from the abdominal cavity the laparoscope controls the course of the operation. At the end of the operation, examine the lining of the uterus with a laparoscope to confirm its integrity and suck the fluid that has entered the abdominal cavity with hysteroscopy.

There are situations when according to ultrasound in the thickness of the myometrium the fragments of the IUD are determined, and with hysteroscopy and laparoscopy they can not be determined. In this situation, you do not need to try to extract these fragments from the wall thickness. It is necessary to leave them in the thickness of the myometrium, and a woman to warn about it and watch it.

A great experience of observing the authors of the book for such patients showed that the IUD in the thickness of the myometrium behaves like an indifferent foreign body without further complications.

Hysteroscopic sterilization

More than 20 years ago, hysteroscopic sterilization was first proposed, but so far the idea has not found wide application. 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 the significant progress of hysteroscopic surgery in the last decade, the problem of hysteroscopic sterilization is still completely unresolved.

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

Destructive operations nowadays are practically not carried out because of low efficiency (57-80%) and possible serious complications, including perforation of the uterus and burn damage to the intestine. Destructive methods include the introduction into the lumen of the uterine tube of sclerosing substances, various medical glues, electrocoagulation and cryodestruction of the isthmic department of the fallopian tube.

To obtain a sufficient effect, sclerosing agents had to be administered several times, but even so, its percentage remained low, and many physicians abandoned this technique. 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 evidence of the effect of these substances upon ingestion through the fallopian tubes into the abdominal cavity.

Medical glues (methylcyanocrylate) are preferable, because they quickly polymerize when they get to the mouth of the fallopian tube, which prevents it from flowing through the fallopian tubes into the abdominal cavity. There is also no need for repeated administration of the drug.

Destructive substances are introduced into the mouth of the uterine tube through a special catheter, conducted through the operating 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 is replaced by necrosis and irreversible fibrosis.

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

Electrosurgical destruction of the isthmic department of the fallopian tubes is carried out by a special electrode, conducted through the operating channel of the hysteroscope. Difficulties arise when determining the strength of the current and the duration of the exposure, since manipulation is carried out at a place where the thickness of the myometrium is minimal. In the first studies, the efficacy with this technique was 80%. At the same time, a high percentage of failures (up to 35), as well as serious complications, including gut burn and tubal pregnancy in the isthmic department of the tube, were noted.

Cryodestruction was also used for the purpose of pipe sterilization, and with the same efficiency as electrosurgical destruction. At the site of exposure, coagulative necrosis occurs with appropriate biochemical and biophysical changes. Long-term results showed no regeneration of the epithelium at the site of exposure and obstruction without recanalization.

There are a few studies on the use of an Nd-YAG laser for coagulation of the ostium of the fallopian tubes.

Thus, the effectiveness of the use of methods with the use of different types of energy depends on the amount of energy delivered to the site of impact. With insufficient amount of energy, destruction is inadequate, and with a considerable amount of energy, damage to adjacent organs is possible. Despite a large number of studies, thermal methods of destruction during hysteroscopic sterilization can still not be considered reliable, since the percentage of failures and complications is high.

Occlusion methods are more effective (74-98%) and less likely serious complications. But they are also far from ideal, because occlusion in many cases is incomplete and / or in the future an occlusal adaptation expires.

There are two groups of occlusal devices: in-tube spirals with a preliminary shape and means taking shape in place.

Inner tube spirals with a preliminary shape

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

The simplest model of the in-tube spiral was proposed by Hamou in 1986. It is represented by a filament of nylon (Hamou spiral) 1.2 mm in diameter, introduced through the conductor per cm into the interstitial section of the pipe. At the ends of the thread are loops to prevent the expulsion of the spiral into the uterine cavity or abdominal cavity, and also to remove it if necessary.

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

Means that take form on the spot

The silicone polymer is introduced into the tube lumen through its mouth, after which a rubber obturator is inserted into the mouth of the tube (Ovablock). This technique was proposed by Erb in 1970. This procedure presents a certain complexity, but silicone is safer than other chemical preparations, besides it does not penetrate into tissues, and since the destruction of the epithelium is minimal, such sterilization is reversible. Long-term results showed the effectiveness of such a tool 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 orifice of the uterine tube;
• inadequate examination of the uterine cavity due to mucus, blood clots, scraps of endometrium;
• various types of intrauterine pathology, interfering with access to the area of uterine corners;
• improper choice of an expanding uterus.

Thus, none of the existing methods of hysteroscopic sterilization has found wide application. Studies in this area are continuing.

Catheterization of fallopian tubes and phalloscopy

Attempts to catheterize the fallopian tubes in patients with infertility blindly began to be made in the XIX century, but often they were unsuccessful and were accompanied by complications. With the advent of hysteroscopy, it became possible to visually monitor the process of catheterization of the fallopian tubes. Initially, the procedure was performed for the occlusion of the intramural tube in order to sterilize. Subsequently, catheterization of the fallopian tubes was used to assess the patency of the interstitial department of the fallopian tubes, and then - and in the program of extracorporeal fertilization: transfer of the zygote or embryo into the lumen of the fallopian tube.

Most researchers note that in women with a tubal factor of infertility, obstruction of the uterine tubes in the proximal part is revealed in 20% of cases. Donnez and Casanas-Roux (1988) in the study of the proximal part of the fallopian tubes after reconstructive surgery or hysterectomy revealed the following types of pathology of the interstitial department of the fallopian tubes:

• nodal isthmic salpingitis;
• fibrosis;
• endometriosis;
• polyps;
• pseudocutosis (fragments of the endometrium, tissues, mucus, spasm).

It is well known that in hysterosalpingography false positive results are 20-30%, while pseudocclusion of the proximal part of the fallopian tube is often diagnosed. Catheterization of the fallopian tube was proposed to exclude or confirm this pathology.

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

At present, the following catheters are mainly used for catheterization of the fallopian tubes: Katayama hysteroscopic cateter sets, Cook hysteroscopic insemination cateter sets (COOK OB / GYN, Spencer, IN).

The catheter is inserted through the operating channel of a rigid or flexible hysteroscope, fed to the uterus of the uterine tube and then under the control of the laparoscope is carried out in the lumen of the uterine tube. If necessary, indigocarmine can be administered through this catheter to confirm the patency of the uterine tube.

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

The results obtained with tubular catheterization confirm the opinion of several researchers that this method should be the first for obstruction of the proximal part of the fallopian tubes to address the need for in vitro fertilization. The best results were obtained by Thurmond et al. (1992): the efficiency of catheterization of the fallopian tubes was 17-19%, uterine pregnancy occurred in 45-50% of cases, ectopic pregnancy - in 8%. Thus, in a number of cases, catheterization of the fallopian tubes can serve as an alternative to a microsurgical operation to restore the patency of the isthmic department of the fallopian tube.

[1], [2], [3], [4], [5], [6], [7], [8]