Operative Hysteroscopy: The Essentials Linda D. Bradley, MD Vice Chair Obstetrics & Gynecology, Women’s Health Institute Director, Center for Menstrual Disorders, Fibroids, & Hysteroscopic Services Cleveland Clinic Cleveland, Ohio USA [email protected]
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Operative Hysteroscopy: The Essentials
Linda D. Bradley, MD
Vice Chair Obstetrics & Gynecology, Women’s Health Institute
Director, Center for Menstrual Disorders, Fibroids, & Hysteroscopic
imaging, and determination of depth of penetration of
leiomyoma
Aslam, M. et al. Comparison of TVS and SIS in Women with AUB: Correlation with Hysteroscopy and
Histopathology. International Journal of Health Sciences. 1(1):17-24, 2007.
0 I
II
Hysteroscopic Classification System (European Society)
The straight catheter is
inserted to the fundus.
In the case of an anteverted uterus the
ultrasound wand touches the uterus through the
anterior vaginal wall. In the case of a retroverted
uterus it would be inserted against the posterior
vaginal wall.
C. A 10 ml syringe of normal saline (or 1%
lidocaine when local anesthesia is
required and there is no allergy) is
attached to the catheter after removal of
the speculum.
What Else Do I Want to Know On the Day of
Hysteroscopic Surgery?
• Last menstrual period
• Herpes prodrome?
• Did she remember to take Cytotec?
• Does she plan on having children?
• Surgical Time Out?
– Right patient?
– Right procedure?
– Instruments needed all present?
– Informed consent and complications reviewed with patient
• Anesthesiologist
Operative Hysteroscopy:Technical Considerations
• Operate during early proliferative phase or with endometrial thinning
• Attempt resection of Type 0 and 1 fibroids only
• Always advance the electrode towards yourself
• Visualize all landmarks throughout the case
• Restrict resection to endometrial surfaces
– if deep intramural lesion noted--be patient!! Often once the pseudocapsule is breached, the uterus will contract and expel the myoma into the field
– intermittently decrease intra uterine pressure to prevent “disappearing phenomenon”
• Beware of progressive myometrial eversion
• End resection at capsular level
• Uterine decompression ---and wait--reinspect
General Principles of Operative Hysteroscopic Myomectomy
• Deflate the endometrium as you resect
• Uterine massage
• Reinspect endometrial cavity 2-3 minutes after removing hysteroscope
• Endometrial suppression not needed, try to schedule post-menses or early proliferative phase
• Sharp curettage can be performed if copious endometrial debris, blood, or copious endometrium
• Consider post op office hysteroscopy in patients desiring fertility within 7-10 days
– Consider estrogen therapy to aid in re-epithealization of endometrium in patients desiring fertility
– Or placement of a 30 mL intrauterine foley catheter
Intrauterine Surgical Techniques
• Resectoscopic Myomectomy
– consider oral, vaginal misoprostol or laminaria in nulliparous, multiple C/S, menopausal, or those with prior cone biopsies, since cervix must be dilated to 22F-31 F with hysteroscope
– use concomitant laparoscopy if concerned about perforation
– use of dilute solution of pitressin intracervically (to decrease absorption of fluid and facilitate cervical dilation) 20u/100ml saline
Intrauterine Surgical Techniques
• Know your landmarks
• Movement – Move wrists
– Move your hysteroscope
• Vary the intrauterine pressure
• Open and close outflow valve when needed
• Remove clots and debris when poor visualization occurs
Operative Hysteroscopy: Toolkit
• Ovum forceps
• Polyp forceps
• Ring forceps
• Myoma (Corson) graspers
• Suction curette
• Sharp curette
• Cutting loop
Intra-operative safety precautions
• Flat
– Do not use Trendlenberg
• Position legs in Allen
stirrup’s or Candy cane
• Collect fluids with
drapes/pouches
• Monitor end tidal CO2
• Watch light sources
Fluid Pumps: Use Them!!!
Fluid balance is an important issue during hysteroscopy!
• When asked to estimate amount of fluid on the floor, experienced OR nurses had a difficult time, commenting: ”we are totally unable to estimate the amount of fluid on the floor” .
Estimate of Fluid on Floor (cc)
0
200
400
600
800
1000
1200
Trial Number
Actual
Nurse 1
Nurse 2
Nurse 3
Nurse 4
Puddle Vac AKA“Sucky Ducky”
How Big of an Intracavitary Fibroid Can You
Tackle?
• Issues
–Fluid absorption
–Chip management
–Navigation within
the uterine cavity
–Uterine walls
collapsing
–Cervix
42
Size of Intracavitary Lesion Determines
Surgical Time
22.45
14.14
8.18
4.19
1.770.520.07
33.51
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
0 1 2 3 4
Diameter (cm)
Sur
gery
tim
e (m
in)
Surgery Time vs. Size*
• As diameter of myoma increases, volume increases cubically (v= 4/3r3 ),
increasing operating time
• Surgeons should be aware of this dynamic and plan accordingly for overall
procedure time
* Emanuel, MH. (2005). Presentation to Smith & Nephew
Remember Volume
• 4/dr3
• 1 cm =1/2 cubic cm tissue
• 2 cm = 4 cubic cm tissue
• 3 cm = 14 cubic cm tissue
• 4 cm = 33 cubic cm tissue
As you increase the size of the lesion for operative hysteroscopy, the volume of
Resected tissue dramatically increases.
This affects length of surgery, amount of fluid used, and ability to complete the surgery.
Cytotec: Use It
• Misoprostol (cytotec)
– Synthetic methyl analogous of PGE2
– Acts on cellular matrix, dissolving collagen, increases
hyaluronic acid, increased cervical water by increasing
vascularity permeability
– Interleukin-8 is affected, increasing collagenase and thus
cervical softening
– Activates smooth muscle contractions
Ribeiro A. Use of Misoprostol Prior to Hysteroscopy in Postmenopausal
Women: A Randomized, Placebo-Controlled Clinical Trial. J Minim Invasive
Gynecol.2008;15:67-73.
Cytotec: Use It
• Studies demonstrate
– 100, 200, 400 mcg (micrograms)
– Sublingual, oral, vaginal, or rectal helpful
• Rapid absorption orally
– Peak plasma levels in 30-60 minutes
– 85% bound to proteins
– 90% excretion in 8 hrs (64% kidneys, 15% feces)
– Bioavailability of vaginally administered misoprostol is 3
times higher than by mouth
Cytotec: Use It
• Side effects
– Genital bleeding, pain, diarrhea, vomiting
• Facilitates cervical dilation, reduces pain, and
decreases complications of hysteroscopy
• Increases myometrial contractility facilitating full
enucleation
Ribeiro A. Use of Misoprostol Prior to Hysteroscopy in Postmenopausal
Women: A Randomized, Placebo-Controlled Clinical Trial. J Minim Invasive
Gynecol.2008;15:67-73
Use Cytotec: It Works
• Options
– Cytotec 200-400 mcg by mouth or intra-vaginally at
bedtime prior to procedure
– If very tight cervix suspected, then begin above regimen 2
days before procedure as well as at bedtime prior to
procedure
Ribeiro A. Use of Misoprostol Prior to Hysteroscopy in Postmenopausal
Women: A Randomized, Placebo-Controlled Clinical Trial. J Minim Invasive
Gynecol.2008;15:67-73
Consider Vasopressin
• Preparation: 20 u/100 saline = 0.2 u/cc
• Direct intra-cervical stromal injection of 5 mL at 12, 3, 6 and
9 o’clock
– Alert anesthesiologist
– Aspirate before injection
– Administer 5 cc/side = 4 units
– Assess for cardiovascular response before
second injection
MMeeaassuurreemmeenntt pp vvaalluuee
BBLLOOOODD LLOOSSSS << ..0055
IINNTTRRAAVVAASSAATTIIOONN << ..0055
OOPPEERRAATTIINNGG TTIIMMEE << ..0055
Intracervical Vasopressin
Effects During Operative Hysteroscopy Adapted from Phillips D et al. Obstet Gynecol. 1996; 88:761-766.
2Anderson RJ et al. Ann Intern Med. 1985;102:164-168.
3Hoorn EJ et al. Nephrol Dial Transplant. 2009;2(suppl III):iii5-11.
Effects of Hyponatremia on the Brain
Adapted from Adrogue HJ & Madias NE. N Engl J Med. 2000;342:1581–9.
Immediate effect
of hypotonic state
Rap
id
ad
ap
tatio
n
Slow adaptation Improper therapy
(rapid correction)
Pro
pe
r th
era
py
(slo
w c
orr
ec
tio
n)
Water gain
(low osmolality)
Loss of sodium,
potassium,
and chloride
(low osmolality)
Normal brain
(normal osmolality)
Osmotic
demyelination
Loss of organic
osmolytes
(low osmolality)
Water
Diagnosis • Signs and symptoms
• Patient history
• Physical assessment
Signs and Symptoms
• Headache
• Confusion
• Lethargy
• Fatigue
• Appetite loss
• Nausea and vomiting
• Loss of consciousness
• Restlessness
• Irritability
• Seizures
• Muscle weakness,
cramps, spasms
Avoiding Complications of Hysteroscopy
• Careful history and physical examination
• Pre operative assessment of intracavitary abnormalities with
– office hysteroscopy
– saline infusion sonography (SIS)
• Advance hysteroscope in a clear view
• Strict adherence to fluid deficits
• Stop and reschedule surgery if fluid deficit is reached or if full resection can not be completed
Mechanisms of Fluid Absorption
• Intravascular
• Trans tubal
• Peritoneal
• Surgery is associated with increased endogenous
arginine vasopressin causing retention of water
6 Factors Which Increase Risk of Fluid Overload
• Cervical lacerations
• Intrauterine pressure
• Degree of damage to endometrium
• Preparation of the endometrium
• Depth of myometrial resection
• Open vascular sinuses with deep myometrial resection
What To Do If You Perforate?
• Blunt dilator versus electrosurgical energy
• Determine if intra-peritoneal bleeding
• If electrosurgical device used, determine if bowel or
visceral injury
– Laparoscopy vs laparotomy
– Need to have expert ability to evaluate the bowel
–General surgery or colorectal surgery intra-operative consult
• Inform the patient and family
• Frequent post operative assessment essential
Avoiding Complications
• Do not exceed recommended infusion pressures
• Monitor input/output frequently
• Recognize signs & symptoms of fluid overload and
hyponatremia
Reducing Risks
• Preoperative mapping
• Endometrial preparation
• Volume reduction
• Extra caution near cervix, cornua, and fundus
• Activate electrode under clear visualization
• Strict monitoring of fluid deficit
• Set deficit limit and adhere to it!!
Don’t Play Peek a boo or Telephone Medicine
• See and examine the
patient
• Order appropriate
laboratory and imaging
tests
• Don’t hope the problem
away
• Re-assess until the
problem has resolved
Reimbursement
1 American Medical Association, CPT® 2010, Professional Edition and HCPCS 2010, Professional Edition. 2 Physician relative value units are based on a correction notice to the 2011 Physician Fee Schedule Final Rule published in the Federal Register on December 30, 2010. The National Average Medicare Rates are based on the 2011 conversion factor of $33,9764. Actual payment to a physician will vary based on geographic location. Payment for a given procedure in a given locality is available in the Medicare Physician look up file posted in the Physician Center of the CMS website. The payment rates could be further revised if Congress were to enact legislation that would change the conversion factor which has typically occurred in recent years. 3 Medicare 2011 Outpatient Final Rule published in the Federal Register, November 2, 2010. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. CPT® is a trademark of the AMA. No fee schedules, basic units, relative or related listings are included in CPT. The AMA assumes no liability for the data contained herin. Applicable FARS/DFARS Restrictions apply for government use.
Discharge instructions
• Expect serious discharge 1-2 weeks
• bloody discharge 7-21 days
• cramping 24-48 hours
• no intercourse for one week
• call if persistent pain or fever
Outcome of Case Study
• Pt underwent a operative hysteroscopic myomectomy – Same day surgery
– 45 minute procedure
– 40 grams myoma resected
– No fluid overload
– Discharged home
– Back to work in 2 days
• Normal menstrual cycles and resolution of dysmenorrhea
Summary
• Excellent pre-operative evaluation is essential to determine, size, number and location of fibroids
• Excellent hysteroscopic skills with attention to fluid management is necessary
• Superb clinical outcome and minimal complications noted with operative hysteroscopy in appropriately selected patients