Operative hysteroscopy

After determining the nature of the intrauterine pathology using a visual examination, diagnostic hysteroscopy can be immediately followed by surgery or the operation can be performed after preliminary preparation of the patient (the tactics depend on the nature of the identified pathology and the type of the proposed operation). The level of modern endoscopic equipment and the capabilities of hysteroscopy today allow us to talk about a special section of operative gynecology - intrauterine surgery. Some types 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 on an outpatient basis if there is a one-day hospital. Simple hysteroscopic operations are carried out specifically under the control of a hysteroscope. They do not always require complex equipment; an operating hysteroscope and auxiliary instruments are more often used.

Simple operations include removal of small polyps, division of thin adhesions, removal of the intrauterine device freely located in the uterine cavity, small submucous myomatous nodes on a stalk and a thin intrauterine septum, tubal sterilization, removal of hyperplastic uterine mucosa, remnants of placental tissue and the ovum.

All other operations [removal of large parietal fibrous polyps of the endometrium, dissection of dense fibrous and fibromuscular adhesions, dissection of a wide intrauterine septum, myomectomy, resection (ablation) of the endometrium, removal of foreign bodies embedded in the uterine wall, falloposcopy] are complex hysteroscopic operations. They are performed in a hospital by experienced endoscopists. Some of these operations require preliminary hormonal preparation and laparoscopic control.

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

• when using GnRH agonists, surgery should be performed 4-6 weeks after the last injection;
• After using antigonadotropic drugs or gestagens, surgery is performed immediately after completion of treatment.

There are the following methods of operative hysteroscopy:

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

Liquid hysteroscopy is commonly used for intrauterine surgical procedures. Most surgeons believe that the liquid provides a good view, making the operation easier. Only Galliant prefers to use CO2 _to dilate the uterine cavity during laser surgery.

When performing operations using mechanical instruments, simple liquids are usually used: physiological solution, Hartmann's solution, Ringer's solution, etc. These are accessible and inexpensive media.

In electrosurgery, non-electrolyte liquids that do not conduct electric current are used; preference is given to low-molecular solutions: 15% glycine, 5% glucose, 3% sorbitol, rheopolyglucin, polyglucin.

When using a laser, simple physiological fluids are used: saline solution, Hartmann's solution, etc.

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

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

1. Fluid overload leading to pulmonary edema.
2. Hyponatremia with hypokalemia and their consequences - cardiac arrhythmia and cerebral edema.
3. Glycine is metabolized in the body to ammonia, which is highly toxic and can lead to impaired consciousness, coma, and even death.

To avoid these serious complications, it is necessary to carefully monitor the balance of injected and excreted fluid. If the fluid deficit is 1500 ml, it is better to stop the operation.

Some authors prefer to use 5% glucose and 3% sorbitol. These solutions can cause the same complications as glycine if they are significantly absorbed (fluid overload, hyponatremia, hypokalemia), but their metabolites do not include ammonia.

When using simple saline solutions, vascular overload syndrome (fluid overload) can also develop.

To prevent these complications, it is also necessary to monitor intrauterine pressure. Fluid should be supplied to the uterine cavity under minimal pressure, ensuring adequate visibility (usually 40-100 mm Hg, on average 75 mm Hg). To facilitate monitoring of pressure in the uterine cavity and fluid balance, it is better to use an endomat.

When ensuring safety in terms of both fluid overload and bleeding, the most important condition is to limit the depth of damage to the myometrium. If the myometrium is penetrated too deeply, a large diameter vessel can be damaged.

Principles of Electro- and Laser Surgery

The use of electrosurgery in hysteroscopy dates back to the 1970s, when tubal cauterization was used for sterilization. In hysteroscopy, high-frequency electrosurgery provides hemostasis and tissue dissection simultaneously. The first report of electrocoagulation in hysteroscopy appeared in 1976, when Neuwirth and Amin used a modified urologic resectoscope to remove a submucous myomatous node.

Principles of Electro- and Laser Surgery

Types of Electrosurgery

A distinction is made between monopolar and bipolar electrosurgery. In monopolar electrosurgery, the patient's entire body is a conductor. 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 alternating current, where there is no constant movement of charged particles from one pole to another, but their rapid oscillations occur. The surgeon's and patient's electrodes differ in size, area of contact with tissue, and relative conductivity. In addition, the very term "passive electrode" causes insufficient attention from doctors to this plate, which can become a source of serious complications.

Types of Electrosurgery

Preoperative preparation for surgical hysteroscopy and pain relief

Preoperative preparation for surgical hysteroscopy is no different from that for diagnostic hysteroscopy. When examining a patient and preparing for a complex hysteroscopic operation, it is important to remember that any operation can end with 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 promptly recognize and begin treatment of possible surgical or anesthetic complications.

Preparation for surgical hysteroscopy and pain relief

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.

Methodology for performing hysteroscopic operations

Resection (ablation) of the endometrium

Uterine bleeding (menorrhagia and metrorrhagia), recurrent and leading to anemia, are often an indication for hysterectomy. Hormonal therapy does not always have a positive effect, and it is contraindicated for some women. For many years, researchers have looked for various methods of treating uterine bleeding in order to avoid hysterectomy. Endometrial ablation was first proposed by Bardenheuer in 1937. Its essence consists in removing the entire thickness of the endometrium and the superficial part of the myometrium. Different approaches have been proposed over the years to achieve this. Initially, chemical and physical methods were developed. Thus, Rongy in 1947 reported on the introduction of radium into the uterine cavity. Droegmuller et al. in 1971 used cryodestruction to destroy the endometrium. This idea was later developed and improved in the works of V.N. Zaporozhan et al. (1982, 1996) and others. Shenker and Polishuk (1973) introduced chemicals into the uterine cavity to destroy the endometrium and cause uterine cavity closure. Attempts were made to introduce hot water into the uterine cavity, but this method was not used due to thermal complications.

Resection (ablation) of the endometrium

Hysteroscopic myomectomy for submucous uterine fibroids

Hysteroscopic access is currently considered optimal for the removal of submucous myomatous nodes. This operation serves as an alternative to laparotomy with minimal invasiveness and better results.

Hysteroscopic myomectomy for submucous uterine fibroids

Hysteroscopic dissection of intrauterine adhesions

The method of choice for treating intrauterine adhesions is their dissection with a hysteroscope under direct visual control.

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.

Hysteroscopic dissection of intrauterine adhesions

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