Operative Hysteroscopy

After determining the nature of the intrauterine pathology with the help of visual inspection from diagnostic hysteroscopy, you can immediately go to surgery or perform an operation after preliminary preparation of the patient (the tactics depend on the nature of the revealed pathology and the type of the proposed operation). The level of modern endoscopic equipment and the possibility of hysteroscopy today allow us to speak about a special section of operative gynecology - intrauterine surgery. Some kinds of hysteroscopic operations replace laparotomy and sometimes hysterectomy, which is of great importance for women of reproductive age and elderly patients with severe somatic pathology, when serious surgical interventions pose a risk to life.

Hysteroscopic operations are conventionally divided into simple and complex. Simple operations do not require special long-term preparation, can be performed during diagnostic hysteroscopy, do not require laparoscopic control, can be performed out-patient in the presence of a one-day hospital. Simple hysteroscopic operations are carried out aiming under the control of the hysteroscope. They do not always need complicated equipment, they often use an operating hysteroscope and auxiliary tools.

Simple operations include the removal of small polyps, the separation of fine synechia, the removal of free-lying IUD in the uterine cavity, small submucous myomatous nodes on the pedicle and the thin intrauterine septum, tubal sterilization, removal of the hyperplastic mucosa of the uterus, the remains of placental tissue and the fetal egg.

All other operations [removal of large marginal fibrotic polyps of the endometrium, dissection of dense fibrous and fibro-muscular synechia, dissection of the wide intrauterine partition, myomectomy, endometrial resection (ablation), removal of foreign bodies implanted in the uterine wall, phalloscopy] are complex hysteroscopic operations. Experienced endoscopists conduct them in a hospital. Some of these operations require preliminary hormonal preparation and laparoscopic control.

If there is no need for preliminary hormonal preparation, all hysteroscopic operations should be performed in the early phase of proliferation. After hormonal therapy, the timing of the operation depends on the drug used:

• when GnRH agonists are used, the operation should be performed 4-6 weeks after the last injection;
• after the use of antigonadotropic drugs or gestagenov operate immediately after the end of treatment.

The following methods of operative hysteroscopy are available:

1. Mechanical surgery.
2. Electrosurgery.
3. Laser surgery.

Fluid hysteroscopy is usually used for intrauterine surgery. Most surgeons believe that the liquid provides a qualitative overview, which facilitates the operation. Only Galliant prefers to use C0 ₂ to expand the uterine cavity in laser surgery.

In operations with the use of mechanical tools, simple liquids are usually used: saline, solutions of Hartmann, Ringer, etc. These are accessible and cheap environments.

Electrosurgery uses non-electrolyte liquids that do not conduct electrical current, preferring low-molecular solutions: 15% glycine, 5% glucose, 3% sorbitol, rheopolyglucin, polyglucin.

When using the laser, simple physiological fluids are used: saline, solution of Hartmann et al.

The use of all liquid media requires caution, since with their significant absorption into the vascular bed, a syndrome of fluid overload of the vascular bed may occur.

So, if a significant amount of glycine enters the vascular bed, the following complications are possible:

1. Liquid overload, leading to pulmonary edema.
2. Hyponatremia with hypokalemia and their consequences - violations of the heart rhythm and edema of the brain.
3. Glycine is metabolized in the body to ammonia, which is very toxic and can lead to impairment of consciousness, coma and even death.

To avoid these formidable complications, it is necessary to carefully monitor the balance of the injected and isolated liquid. If the fluid deficit is 1500 ml, it is best to stop the operation.

Some authors prefer to use 5% glucose and 3% sorbitol. These solutions can cause the same complications as glycine, with significant absorption (fluid overload, hyponatremia, hypokalemia), but ammonia is not included in their metabolites.

With the application of simple physiological solutions, the syndrome of overloading the vascular bed (fluid overload) can also develop.

To prevent these complications, it is also necessary to monitor intrauterine pressure. The fluid should be fed into the uterine cavity under minimal pressure, providing an adequate view (usually 40-100 mmHg, an average of 75 mmHg). To facilitate control of the pressure in the uterine cavity and fluid balance, it is better to use an endomat.

With safety in terms of both liquid overload and bleeding, the most important condition is to limit the depth of damage to the myometrium. At too deep introduction in a myometrium it is possible to damage a vessel of the big diameter.

Principles of Electro- and Laser Surgery

The use of electrosurgery in hysteroscopy began back in the 1970s, when tube cautery was used for the purpose of sterilization. In hysteroscopy, high-frequency electrosurgery provides hemostasis and tissue dissection simultaneously. The first report on electrocoagulation with hysteroscopy appeared in 1976, when Neuwirth and Amin used a modified urological resectoscope to remove the submucous myomatous node.

 Principles of Electro- and Laser Surgery

 Types of electrosurgery

Distinguish between monopolar and bipolar electrosurgery. With monopolar electrosurgery, the entire body of the patient is the conductor. The electric current passes through it from the surgeon's electrode to the patient's electrode. Previously, they were called active and passive (return) electrodes, respectively. However, we are dealing with an alternating current where there is no constant motion of charged particles from one pole to another, but their rapid oscillations occur. The electrodes of the surgeon and the patient differ in size, area of contact with the tissues and relative conductivity. In addition, the very term "passive electrode" causes insufficient attention of physicians to this plate, which can become a source of serious complications.

 Types of electrosurgery 

Preoperative preparation for operative hysteroscopy and analgesia

Preoperative preparation for operative hysteroscopy does not differ from that in diagnostic hysteroscopy. When examining a patient and preparing for a complex hysteroscopic operation, it must be remembered that any operation can result in laparoscopy or laparotomy.

Regardless of the complexity and duration of the operation (even for the shortest manipulations) it is necessary to have a fully equipped operating room in order to recognize and start treatment of possible surgical or anesthetic complications in time.

 Preparation for operative hysteroscopy and analgesia 

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.

 Method of hysteroscopic operations 

Resection (ablation) of the endometrium

Uterine bleeding (menorrhagia and metrorrhagia), recurrent and leading to anemia, are often an indication for the removal of the uterus. Hormonal therapy does not always give a positive effect, and it is contraindicated for some women. Over the years, researchers have searched for various methods of treating uterine bleeding to avoid hysterectomy. The ablation of the endometrium was first proposed by Bardenheuer in 1937. Its essence consists in removing the entire thickness of the endometrium and the surface part of the myometrium. To achieve this, different campaigns were proposed in different years. Chemical and physical methods were originally developed. Thus, in 1947 Rongy reported on the introduction of radium into the uterine cavity. Droegmuller et al. In 1971, cryodestruction was used to destroy the endometrium. Later this idea was developed and improved in the works of V.N. Zaporozhana and co-authors. (1982, 1996), etc. Shenker and Polishuk (1973) injected chemicals into the uterine cavity with the aim of destroying the endometrium and infecting the uterine cavity. Attempts were made to introduce hot water into the uterine cavity, but this technique was not used because of thermal complications.

 Resection (ablation) of the endometrium 

Hysteroscopic myomectomy with submucous uterine myoma

Hysteroscopic access is now considered optimal for the removal of submucous myomatous nodes. This operation serves as an alternative to la-parotomy with minimal invasive effects and better results.

 Hysteroscopic myomectomy with submucous uterine myoma 

Hysteroscopic dissection of intrauterine synechia

The method of choosing the treatment of intrauterine synechiae is their dissection with a hysteroscope under direct visual control.

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.

 Hysteroscopic dissection of intrauterine synechia

[1], [2], [3], [4]