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Hysteroscopic surgery of septate uterus
Authors
Abstract
The description of the hysteroscopic surgery of septate uterus covers all aspects of the surgical procedure used for the management of septate uterus (uterine malformation).
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: adjustment of system, operative steps, special cases, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: adjustment of system, operative steps, special cases, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.
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2002-01
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E-publication
WeBSurg.com, Jan 2002;2(01).
URL: http://www.websurg.com/doi-ot02en252.htm
URL: http://www.websurg.com/doi-ot02en252.htm
Hysteroscopic surgery of septate uterus
1. Introduction
Diagnostic hysteroscopy is the gold standard for exploring the uterine cavity in cases of infertility, menometrorrhagia or repeated miscarriage. The intracavitary pathology revealed during the examination (uterine malformations, polyps, myomas and adhesions) can be treated by surgical hysteroscopy. Septate uterus is the most common uterine malformation. The development of surgical hysteroscopy has simplified the treatment of this pathology, which used to be treated by laparotomy and hysterectomy (Valle and Sciarra, 1986; De Cherney et al., 1986; March and Israël, 1987). Surgical hysteroscopy using rigid scissors attached to a channel is no longer performed. Today, this pathology is treated using monopolar electrosurgery. Bipolar electrosurgery, which was introduced more recently, seems to be as effective and results in less morbidity (Fernandez, 1998).
2. Anatomical pathology
Septate uterus is caused by an anomaly during organogenesis. It is a lack of resorption of the tissue separating the 2 embryonic halves of the uterus (the Müllerian ducts), which are joined on the midline. Normally, the resorption of this septum occurs caudad to cephalad: it begins at the level of the cervix and continues up to the uterine fundus. This resorption anomaly can occur at different stages of Müllerian duct development, between the 11th and 16th weeks of gestation, accounting for various resorption defects ranging from the completely septate uterus (sometimes with 2 cervices and a vaginal septum), partially septate uterus or simple fundic spurs. This malformation is never combined with another anomaly of the genitourinary organs.1. Round ligament
2. Uterine tube
3. Uterine septum
4. Proper ovarian ligament
5. Uterine cavity
6. Endometrium
7. Myometrium
8. Mesometrium of broad ligament
9. Uterine artery
10. Ureter
11. Cervical canal
12. Uterosacral ligament
13. External uterine opening
14. Vagina
3. Classifications
In France, the classification of Musset is most commonly used (Musset et al., 1967). Elsewhere, the 1988 classification of the American Fertility Society (AFS) is most widely accepted. These classifications may be summarized as follows:
Müllerian aplasias
The Musset classification lists Müllerian aplasias as:
- bilateral: Mayer-Rokitansky-Kuster-Hauser syndrome;
- unilateral: unicornuate uterus (without rudimentary horn), pseudo-unicornuate uterus (with rudimentary horn).
The AFS classification lists Müllerian aplasias as:
Class I: Hypoplasia, agenesis
Class II: Unicornuate uterus
Fusion defects
The Musset classification lists fusion defects as:
- dideolphys uterus (complete or partial duplication of the vagina, cervix and uterus);
- bicornuate uterus: complete (septum from fundus to cervical os), partial (septum to body of uterus), partial (septum confined to the fundus).
The AFS classification lists fusion defects as:
Class III: Dideolphys uterus
Class IV: Bicornuate uterus
Resorption defects
The Musset classification lists resorption defects as:
Septate uterus: complete, partial, to body of uterus, confined to the fundus
The AFS classification lists resorption defects as:
Class V: Septate uterus
Vb: Complete
Va: Partial
4. Indications
Formal indications- pregnancy complications such as second-trimester loss or preterm delivery
Possible indications
- recurrent first-trimester spontaneous abortion
Controversial indications
- before in-vitro fertilization (as preventative treatment)
Contraindications
- contraindications to anesthesia;
- genitourinary infections;
- pregnancy;
- bicornuate uterus.
5. Preop period
The preoperative workup is important and includes hysterography, diagnostic hysteroscopy and pelvic sonography. Vaginal sonography with accentuated contrast may be added. These exams should confirm that the patient has a septate uterus and not a bicornuate uterus, and check for other causes of infertility.During the sonography, it is essential to measure the thickness of the uterine septum, its height and the depth of the healthy myometrium above the septum up to the serosa. If the ultrasound reveals a groove in the corner facing the posterior surface of the bladder between two half-uteri, the malformation is diagnosed as a bicornuate uterus.
A 1-month preoperative progestogen treatment (eg pregnane) or the administration of GnRH analogs (gonadotropin releasing hormone) can be prescribed to prepare the endometrium. The procedure should then be performed about 28 days after starting the treatment.
6. Operating room set-up
• Patient
- general anesthesia, local-regional anesthesia or paracervical block anesthesia;- lithotomy position: legs spread at a 45° angle, thighs at a 90° angle from the surface of the table and knees bent at a 90° angle;
- perineal and cervicovaginal preparation;
- prophylactic antibiotics when anesthesia is induced to prevent endometritis;
- urinary catheter (optional).
• Team
1. The surgeon is seated between the patient’s legs.2. The assistant stands to the right of the surgeon.
3. The anesthesiologist is at the patient’s head.
• Equipment
The equipment is on the surgeon’s left:- endocamera and monitor;
- devices to control pressure and flow of distension media: a constant uterine distension must be maintained. The pressure is controlled continually by suction and irrigation pumps;
- distension medium: hyperosmolar glycine solution with monopolar cautery, saline with bipolar cautery;
- light source: the same type of Xenon light source is used for diagnostic hysteroscopy, surgical hysteroscopy and laparoscopy;
- high-frequency electrosurgical generator:
1) unipolar electrosurgery: high-frequency current is used (>300 000 Hz). Division of tissues is done with an unmodulated current that produces a rapid rise in temperature.
2) bipolar electrosurgery: saline is used as the distension medium to decrease the risk of metabolic complications. The operating channel is 5 French.
7. Instruments
Usual equipment:1. Hegar’s dilators (No. 1 to No. 10, diameter increasing from 0.5 to 1 mm);
2. Speculum with detachable valves;
3. Rigid endoscope between 2.7 and 4 mm in diameter; the direction of view normally used in hysteroscopy is 12°.
4. Resectoscope: from 7 to 9 mm with two channels, one internal (irrigation) and one external (suction) for monopolar hysteroscopy, or from 5 to 9 mm with two channels and a double current operation channel for bipolar hysteroscopy. In all cases it has an operative handle: passive (electrode in) or active (electrode out);
5. Hysteroscope;
6. Irrigation and suction channels;
7. Two Pozzi graspers;
8. Hysterometer.
8. Major principles
Cutting current is used for dissection. The septum should be divided but not removed, to avoid destroying the endometrium. The procedure is performed under constant visual guidance and consists of transversally dividing the uterine septum halfway between the 2 uterine surfaces, until the 2 tubal ostia can be visualized in the same hysteroscopic field.9. Adjustment of system
Monopolar systemThe resection techniques described use monopolar current. The suction-irrigation pump must be preset to maintain an intrauterine pressure <=100 mm Hg, a 250 mL/s flow rate, a 0.2 bar suction pressure and 45 W of power. The procedure must not last longer than 45 minutes. The total volume of glycocolle used must be limited to 6 L. Precise monitoring of the distension liquid inflow and outflow must be done, and the procedure must be stopped immediately if there is a difference between the irrigation and suction flow rates (a 500 mL difference can be allowed). If there is too much of a difference, or if the procedure lasts too long, a chemistry panel must be performed immediately after the procedure to check for metabolic complications (hyponatremia).
Bipolar system
Bipolar spray electrosurgery is a more recent system. Its efficacy seems to be equivalent to monopolar electrosurgery, with a decrease in morbidity. The suction-irrigation pump should be preset to maintain a flow of 150 mL/s, a pressure of 80 mm Hg and 100 W or less of power. There are no limits to the duration of the procedure.
Bipolar systems have the advantage of being safer, because they can be used with saline, thereby decreasing metabolic complications. In contrast to the monopolar system, which penetrates into the tissues and can be partly obscured at certain points, the bipolar system is constantly visible. This lowers the risk of uterine perforation.
10. Operative steps
• Dilation of the cervix
Bimanual examination is carried out to evaluate the position of the uterus before dilation. A speculum is inserted and the cervix is grasped with 2 Pozzi graspers placed in a 3 o’clock and 9 o’clock position to exert traction on the uterus in order to bring it into an intermediary position and to rectify an anteversion or a major retroversion. Hysterometry is routinely performed before beginning the dilation. The cervix is then dilated with Hegar’s dilators, using progressively larger dilators. Dilation of the cervix must be done carefully to avoid a uterine perforation. • Inserting the resectoscope
The endocamera, the resectoscope and the electrode are assembled and connected to the Xenon light source, the hysteroscopic unit, the electrosurgical generator and the suction-irrigation tubing. Care must be taken to remove all air bubbles from the tubing. The resectoscope is then introduced under videoscopic guidance. • Landmarks
Thorough visual exploration of the uterine cavity is essential. The 2 tubal ostia must be perfectly discerned to locate the base of the septum.• Division
The division is performed in a progressive manner using repetitive contact between the electrode and the septum. The uterine septum is divided transversally starting at its apex, halfway between its anterior and posterior surfaces, causing it to retract and become a part of the corresponding surfaces of the uterus. Distension of the uterus is progressively achieved as the septum is divided (the cavity opens like a book), and the cavity gradually acquires a normal aspect. The tissue of the septum is fibrous and does not bleed. The septum ends where healthy myometrium is revealed by the occurrence of minimal bleeding. When this bleeding occurs, the division should be stopped, because it indicates that the septum has been completely divided.
11. Special cases
Special case 1When the septum extends down to the cervix, it is first divided with cold scissors or with a cutting electrosurgical probe. The resection begins at the level of the cervix, and extends from the external ostium towards the uterus. The division of the uterine septum is continued, with care taken to preserve the plane of the tubal ostia.
Special case 2
When the uterine septum is wide, division must be stopped as soon as any bleeding occurs. The procedure is then performed in 2 phases with a second operation scheduled 2 months later to complete the procedure.
Special case 3
The operative step begins by dividing the vaginal septum using monopolar electrosurgery, with resection of the septum up to the anterior and posterior cul-de-sacs, and suture of the anterior and posterior surfaces of the vagina with interrupted absorbable suture.
The procedure is then continued as for septate uterus.
12. End of procedure
End of procedureAt the end of the procedure, it is preferable to leave a fundic spur of less than 1 cm in place, to avoid weakening the fundic myotrium. The procedure is ended when both tubal ostia are visible under the same hysteroscopic view. This is important, because the risk of perforation increases if the resection is carried out too far. Some surgeons recommend follow-up sonography to make sure that there has been no perforation.
Postoperative management
No intrauterine device is needed.
Estrogen therapy is administered for 2 months to facilitate the follow-up hysteroscopy (its therapeutic advantages have not been demonstrated, however).
During the immediate postoperative period:
- if the inflow-outflow assessment is superior to 500 mL, a chemistry panel must be performed.
After 2 months:
A follow-up diagnostic hysteroscopy is performed:
- to check for possible adhesions. It is usually easy to remove these new, fine adhesions during the diagnostic procedure with the pointed tip of the hysteroscope.
- if the remaining fundic spur is larger than 1 cm, a second procedure is indicated.
The only criterion of success is a subsequent pregnancy resulting in a viable birth.
13. Complications
Mechanical complicationsUterine perforation is the most common complication. It occurs either during dilation of the cervix or during the resection of the septum. There is a risk of visceral burns if the perforation is not detected. For this reason, some authors recommend intraoperative sonography or laparoscopy (Lin et al., 1987).
Postoperative infection
Post-hysteroscopic endometritis occurs in 1% to 5% of cases (McCausland, 1993), justifying the systematic use of intraoperative prophylactic antibiotics (cephalosporin).
Metabolic complications
The intravascular passage of a significant quantity of irrigation fluid can lead to hemodilution. This “transurethral resection syndrome” was first described by urologists (Averous et al., 1981). Preventative measures are dependent on adherence to procedural protocol, the most important of which is a meticulous monitoring of the inflow and outflow of fluids.
14. Reference
The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubalocclusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine
adhesions. Fertil Steril 1988;49:944-55.
Averous M, Guiter J, Guillaume A, Navrath H, Grasset F. Le syndrome dhémodilution après R.T.U. Le
syndrome de la résection trans uréthrale. J Urol 1981;87:700-2.
DeCherney AH, Russell JB, Graebe RA, Polan ML. Resectoscopic management of mullerian fusion
defects. Fertil Steril 1986;45:726-8.
Fernandez H. Hystéroscopie opératoire. Encycl Méd Chir (Elsevier, Paris), Techniques chirurgicales
Gynécologie 41-559, 1998, 9p.
Lin BL, Iwata Y, Miyamoto N, Hayashi S. Three-contrasts method: an ultrasound technique for
monitoring transcervical operations. Am J Obstet Gynecol 1987;156:469-72.
March CM, Israel R. Hysteroscopic management of recurrent abortion caused by septate uterus. Am J
Obstet Gynecol 1987;156:834-42.
McCausland VM, Fields GA, McCausland AM, Townsend DE. Tuboovarian abscesses after operative
hysteroscopy. J Reprod Med 1993;38:198-200.
Musset R, Muller P, Netter A, Solal R. Nécessite d'une classification globale des malformations
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cas. Gynecol Obstet (Paris) 1967;66:145-66.
Valle RF, Sciarra JJ. Hysteroscopic treatment of the septate uterus. Obstet Gynecol 1986;67:253-7.