Click here to view next page of this article

New Advances in Hysteroscopy

The advantage of using the feroblique hysterscope is that the uterine cavity is this roundish cavity and ideally what you want to try to do is cause minimal trauma, using that 30-degree angle and rotating rather than torquing around the cervix. The more you can rotate, the less trauma you do histeroscopy.

You almost always ought to have some sort of back up; I have had my instruments dropped, broken, everything that can possibly go wrong has gone wrong. It is worthwhile to check the instruments before surgery. I have had resectoscopes that if you look at the common resectoscope, at least the unipolar one, at the end of the resectoscope.

Dilators can traumatize tissue. If you are doing an office hysteroscopy, that is a problem. Ideally, you like to get in with a 3-mm, 4-mm or less instrument. We have very nice, very small hysteroscopes that you can get into almost any cervix besides the most stenotic cervix, without dilation. It is worthwhile to try to do that first, to try to visualize. Most of the hysteroscopes.

Sonohysterogram has done more for me as a preoperative test than probably any test. A lot of you have ultrasounds in your office, which makes it so easy. I use the same kind of catheter that I use for intrauterine inseminations. I catheterize, take 10 cc of saline, remove the speculum, put the vaginal probe in and it lights up intracavitary masses so well.

I limit my medical treatment now to really treating for fibroids. In the past, we had done this for endometrial ablation. I think a lot of people are moving towards balloon ablations, and this may become less of an issue. Hemoglobin can be markedly altered in patients with submucous fibroids. For diagnostic hysteroscopy patients, those seen in the office or even in the O.R.

From the standpoint of GnRH analogs and endometrial ablation and even preparation for myomectomy, that is the kind of endometrium you would like to see. The perfect patient is the postmenopausal patient, in terms of the endometrium. It is very low, very thin and very avascular. I have seen patients walk in with submucous fibroids that have had hemoglobins in the 2 to 3 range that were still out walking and talking and they had just chronically brought their hemoglobins down. The one that I can think about most recently had nothing more than a 1-cm submucous fibroid and that was the sole source of her bleeding.

The most common use of the resectoscope is removal of intrauterine lesions. Using unipolar or bipolar, you are going to create open vessels. With the pressure head that you have to create uterine distention, there is going to be enough force to be able to drive fluid into these vessels. How long does it take with a 20-gauge IV in a patient and a bag on pressure to go through one liter of fluid? It doesn't take very long at all. That is why you have to watch patients like a

All of the instruments that you use, whether it is a diagnostic hysteroscope, an operative hysteroscope or a resectoscope, ought to have continuous flow. You have to have this ability to put your media through an inner channel and then through a separate channel, create a current. Ten years ago, this did not exist. It now exits for all of our hysteroscopic instrumentation. It

As you do resections, and take a myoma that is about 70% intracavitary and 30% intramural - a classic submucous myoma - as you distend the cavity and begin the resection, what happens? Well, the uterus knows how to do one thing - it knows how to contract; it is a smooth muscle. As you put that pressure head inside, the uterus will come down on the myoma. What it does is that it will squeeze this myoma out towards you. Often times as you are doing these cases, you are getting there and at this point you are flush with the cavity. That is where I take it down to; at that point, you are safe. I don't go digging around in the intramural portion; I don't think that

There are now devices where we are able to coagulate fibroids and these are very useful. You still have to have a fragment so you can send it off for pathology, because we have seen leiomyosarcomas. You have to have continuous flow. I&O's should be checked every 10 to 15 minutes. This is the one thing I care that my nurses do; I don't need them to put together my instruments, put the tips on or plug anything in, but I need them to follow the I&O's. This is the one thing that is somewhat difficult to do while we are doing the surgery. When I get in, I am

The hardest cases are the ones that are near the ostia. A patient who has been put on a GnRH analog may have a thinned out uterine wall and it is relatively easy to get out and perforate into that area and get into trouble. Those arising from the fundus can be difficult; if you get a myoma that is coming from a fundus, it is very hard to make this motion that we like to make of bringing the instrument back towards us . If you are pulling that loop back towards yourself, it is almost impossible to perforate the uterus and cause a problem. But the ones in the fundus, you can't do

Here is the case of a patient who had come in having had an open myomectomy some years earlier. She had presented with really significant menorrhagia and had bled down to the 2 to 3-gram hemoglobin range. She had been sent home on bed rest with iron. Somehow, the case was brought back to my attention. We got her in and she did not want a hysterectomy. We transfused her and then took a look to see what was going on. It turned out that she had one relatively small intracavitary myoma, one smaller area above it, and this was the source of all of

When we looked at the numbers across the literature, some eighty-five to ninety percent of patients are well chosen are going to be successful with this type of surgery. If you have someone walk in with a 20-week uterus who also happens to have a submucous fibroid and you go after the submucous fibroid, she is probably going to end up having surgery again. So you

From an infertility standpoint, there are still not a lot of numbers. The numbers all stand around fifty to sixty percent, which is fairly close to what they are for a laparotomy myomectomy. Looking at the complications, we know that the majority of them are not reported; they are quite under reported. What we saw were some cases of fluid absorption, some cases of uterine