Use of visual cues in hysteroscopic management of Asherman's syndrome

  • Abstract
    The normal uterine cavity is distorted or obliterated due to severe adhesions in Asherman’s syndrome, which makes surgery difficult to perform. The high-definition vision of the camera can help to identify visual cues and clues during hysteroscopy, which can guide the surgery. The objective of this video is to demonstrate that the information gathered from various visual cues during hysteroscopy is really helpful to the surgeon. The video focuses on the use of the following seven visual cues: color of fibrous bands and endometrium which imparts a white spectrum; thread-like texture of fibrotic bands; lacunae and their dilatation in scar tissue; probing and post-probing analysis using scissors (5 French); color and appearance of myometrial fibers which impart a pink spectrum; vascularity differentiation; matching analysis with a normal uterine cavity. Various techniques described for the management of this condition include fluorescence-guided, ultrasonography-guided, and hysteroscopic adhesiolysis under laparoscopic control, which are expensive procedures. We suggest that the high-definition vision and visual cues during hysteroscopy should be initially used intraoperatively for guidance purposes before using such options. It may be sufficient to achieve the desired result in most cases.
  • 00'18" Objective
    The objective of this video is to focus on the following seven visual cues during Asherman’s syndrome surgery: the white color of fibrous bands which imparts a white color spectrum, the thread-like texture of adhesion bands, lacunae and their dilatation in scar tissue, probing and post-probing analysis using scissors, color and appearance of myometrial fibers which impart a pink spectrum, vascularity differentiation, and matching with normal uterine cavity.
  • 00'49" Vaginoscopic technique
    Hysteroscopy began with a vaginoscopic technique using 2.9mm optics and an operative office hysteroscopy sheath. After entry through the external os and the cervical canal, internal os stenosis was noted. It was managed with the advancement of the operative sheath.
  • 01'33" 1st visual cue: White spectrum
    Intrauterine adhesions imparting a white color were observed. Surgery was started using 5 French scissors in the central region. The white color of the adhesion band can be identified here.
  • 02'25" 2nd visual cue: Lacunae identification
    Lacunae can be seen developing between the adhesions. The surgeon can receive feedback through scissors with the dilatation of these lacunae, which also make the adhesions clearer to see.
  • 03'01" 3rd visual cue: Thread-like texture of fibrous bands
    Another visual cue is the thread-like texture of fibrotic bands. Here, the difference between a pinkish normal endometrium and white avascular adhesions can be seen.
  • 03'26" 4th visual cue: Probing and analysis
    At their junction, probing is performed with the tip of scissors. It contributes to a precise adhesiolysis. These visual cues constantly provide information to the surgeon and help to localize the adhesions.
  • 04'18" 5th visual cue: Vascularity differentiation
    Here, a clear difference can be noted between the avascular white thread-like fibrotic area and a normal vascular endometrium.
  • 04'43" 6th visual cue: Pink spectrum
    Myometrial fibers can be identified with the appearance of pink-colored fibers with larger caliber blood vessels. Finally, the pink spectrum of the uterine cavity is achieved when all the adhesions have been taken down.
  • 05'14" 7th visual cue: Matching analysis with normal uterine cavity
    More space is created and it is matched to the visual memory of a normal uterine cavity.
  • 05'29" Conclusion
    In conclusion, with high-definition image production, vision and magnification have become key factors in a difficult hysteroscopy. Vision and visual cues can guide surgeons during the hysteroscopic management of Asherman’s syndrome in order to achieve the desired result in most cases. Following them can prevent complications such as perforation and bleeding.
  • Related medias
    The normal uterine cavity is distorted or obliterated due to severe adhesions in Asherman’s syndrome, which makes surgery difficult to perform. The high-definition vision of the camera can help to identify visual cues and clues during hysteroscopy, which can guide the surgery. The objective of this video is to demonstrate that the information gathered from various visual cues during hysteroscopy is really helpful to the surgeon. The video focuses on the use of the following seven visual cues: color of fibrous bands and endometrium which imparts a white spectrum; thread-like texture of fibrotic bands; lacunae and their dilatation in scar tissue; probing and post-probing analysis using scissors (5 French); color and appearance of myometrial fibers which impart a pink spectrum; vascularity differentiation; matching analysis with a normal uterine cavity. Various techniques described for the management of this condition include fluorescence-guided, ultrasonography-guided, and hysteroscopic adhesiolysis under laparoscopic control, which are expensive procedures. We suggest that the high-definition vision and visual cues during hysteroscopy should be initially used intraoperatively for guidance purposes before using such options. It may be sufficient to achieve the desired result in most cases.