[Gynecological Hysteroscopy] Hysteroscopy Operation Skills

With the continuous advancement of medical technology, in recent years, hysteroscopic surgery has become an important means of treating intrauterine diseases and abnormal uterine bleeding, and it has become more popular in clinical applications.

The advancement of hysteroscopy technology and instruments has provided more methods of minimally invasive diagnosis and treatment, which is a boon for doctors and patients. However, complications also occur from time to time. If not treated in time, it can lead to serious consequences, such as uterine perforation, massive bleeding, infection, and air embolism.

The literature reports that the incidence of complications of hysteroscopic surgery ranges from 0.28% to 2.7%, which is closely related to the special surgical environment, types of surgery and the experience of the operators.

Due to the short operation time of hysteroscopy, usually within 1 hour, it gives the illusion of a particularly simple and easy to grasp. If you are inexperienced and rush into battle, serious complications may occur.

Medical staff should be familiar with the operating characteristics of hysteroscopy, learn more surgical skills, and add more practical experience in practice to achieve the purpose of improving operating skills and reducing complications of hysteroscopy, so as to better serve patients and give themselves Reduce a lot of unnecessary disputes.

01

Operation time selection

For premenopausal women with regular menstrual cycles, the endometrial proliferative phase is the best observation period for the uterine cavity. Because the thickened endometrium during the secretory phase may resemble endometrial polyps, it is easy to be misdiagnosed. When checked during menstruation, menstrual blood may interfere with the field of vision. It is best to choose to have a check-up or surgery within a week after your period. Because the endometrium is in the early proliferative stage at this time, it is relatively thin, not only has less bleeding, but also has less mucus secretions, which is more conducive to the observation of the uterine cavity.

For women of childbearing age with irregular vaginal bleeding, there is currently no specific operation time required for the operation. The operation can be performed at any time according to the patient's condition. During hysteroscopic surgery, the blood clot in the uterine cavity can also be removed by flushing the uterine distended fluid. , mucosal debris and other tissues are flushed out to make the intraoperative field of vision clearer.

Postmenopausal women can have a hysteroscopy at any time.

02

Hysteroscopy options

Most hysteroscopes are rigid instruments, and some small diameter hysteroscopes (<5 mm) can also be semi-rigid or soft instruments. Rigid hysteroscopes have more severe intraoperative pain, but have better optics, cost less, and are easier to insert than flexible hysteroscopes.

In most cases, rigid hysteroscope can meet the needs of diagnosis and treatment, and the distal end of flexible hysteroscope can be deflected up and down, especially suitable for women with irregular uterus, such as for tubal intubation or to release adhesions near the fallopian tube.

03

Choice of dilatation fluid

The dilatation solution used in hysteroscopy can be an electrolyte solution, such as normal saline, lactated Ringer's solution, or a non-electrolyte solution, such as 1.5% glycine solution, 5% mannitol solution, 3% sorbitol solution.

Insulating fluids such as glycine are required to avoid thermal damage when performing surgical procedures with monopolar electrosurgical instruments.

Isotonic fluids (eg, saline or lactated Ringer's) can be used with bipolar electrosurgical procedures to avoid the risk of electrolyte and osmotic imbalances caused by insulating fluids. However, if the patient has diabetes, 5% mannitol solution can also be selected according to the blood sugar situation.

Diagnostic procedures can be performed using normal saline. A randomized study found that the use of normal saline during diagnostic procedures resulted in less pain, better intraoperative visual field, and a corresponding reduction in operation time.

During the operation, the pressure of uterine distention can be controlled between 130-150mmHg, and the flow rate can be controlled at 400-500ml/min, which can not only expand the uterine cavity well, but also help to obtain a clearer surgical field.

04

Prevention and treatment of uterine perforation

(1) Reasons: High-risk factors for uterine perforation include cervical stenosis, history of cervical surgery, excessive uterine flexion, small uterine cavity, and inexperienced operators.

(2) Clinical manifestations: ①The uterine cavity is collapsed and the vision is unclear. ② Ultrasound showed that free fluid around the uterus or a large amount of perfusate entered the abdominal cavity. ③hysteroscopy can be seen in the peritoneum, bowel or omentum. ④If there is laparoscopic monitoring, the uterine serous surface is clear, blisters, bleeding, hematoma or perforated wounds. ⑤The electrode enters and damages the pelvis and abdominal organs, causing corresponding complications and symptoms.

(3) Treatment: ①First, find the perforation site, determine whether the adjacent organs are damaged or not, and decide the treatment plan. ②When there is no active bleeding and organ damage, oxytocin and antibiotics can be used, and observation can be made. ③When the perforation is large in scope and may damage blood vessels or organs, laparoscopic or laparotomy should be performed immediately and corresponding treatment should be carried out.

(4) Prevention: ①Strengthen cervical pretreatment and avoid violent uterine expansion. ② Combined with ultrasound or laparoscopic surgery as appropriate. ③Improve the surgeon's surgical skills. ④Use GnRH-a drugs as appropriate to reduce the volume of fibroids or uterus, and to thin the endometrium.

05

Prevention and treatment of surgical bleeding

The vascular layer of the uterine muscle wall is located 5-6 mm under the mucosa, about one-third of the uterine muscle wall, and there are many blood vessels running through it.

When performing endometrial resection, the incision depth is 2-3 mm below the endometrium, and it is cut to the superficial myometrium, otherwise it is easy to cause massive bleeding. The "U"-shaped cutting ring is generally 5 mm deep and can be used as a sign of the cutting depth.

The submucosal superficial muscle layer is more uniform in texture and is different from the mucosa. During the resection of type Ⅱ submucosal uterine fibroids, due to electrical stimulation, the fibroids tend to protrude into the uterine cavity gradually. Excessive resection should be prevented to cause hemorrhage. For submucosal fibroids with distended blood vessels on the surface, electrocoagulation is used to stop the bleeding, and then the fibroids are resected.

Intraoperative ejection-like bleeding of small arteries can be stopped by electric coagulation with electric cutting ring, and rolling ball electrode can be used to stop bleeding in extensive wound oozing. If there is a lot of bleeding after surgery, in addition to the application of hemostatic drugs, a Foley catheter can be placed in the uterine cavity, and 15-30 ml of water can be injected to inflate the balloon for compression and hemostasis, and then removed after 6-8 hours.

06

Prevention and treatment of air embolism

The patient should remain in the supine position or in the supine position with the head elevated, and the head-lowered supine position should not be used. Avoid the use of nitrous oxide for anesthesia during anesthesia (which may increase air bubbles) and clear the lumen of gas before all catheters are inserted into the uterus. When dilating the cervix, the movement should be gentle to prevent local blood vessels from tearing and air entering the blood circulation system through the ruptured blood vessels.

Intrauterine pressure is maintained below 125-150 mmHg during surgery, reducing the number of times the hysteroscope is removed and reinserted into the uterine cavity (a process that may allow air or other gases to enter the uterus).

During fibroids resection, certain air bubbles will be generated to accumulate on the anterior wall of the uterus. Therefore, the anterior uterine wall resection should be completed at the end to prevent gas from entering the blood circulation system through the wound surface.

07

Hysteroscopic surgery operations and skills

Basic operation of hysteroscopy

1. Electric cutting: high-frequency electricity is used as the energy source, and annular or needle-shaped electrodes are used to excise or separate the lesion. It is mostly used for the excision or adhesion of intrauterine space-occupying lesions. Attention should be paid to the cutting speed and depth.

2. Mechanical separation: Micro-scissors are inserted through the hysteroscopic operation channel to separate and cut the adhesion tissue and mediastinal tissue.

3. Electrocoagulation: high-frequency electricity is used as the energy source, and spherical or cylindrical electrodes are used to coagulate and destroy the lesion. The above operation can also be performed by laser as the energy source. It is mainly used for endometrial removal or coagulation and hemostasis.

4. Fallopian tube intubation and fluid passage: The fallopian tube catheter was inserted into the interstitial part of the fallopian tube through the hysteroscopic operation channel, and methylene blue methylene blue was injected into the fallopian tube to evaluate the patency of the fallopian tube.

Hysteroscopic surgery skills

1. Hysteroscopic endometrial polypectomy: ①When excising polyps, use a ring electrode to cover the root of the polyp from the far side of the polyp and then cut it. should. ②For patients with fertility requirements, it is necessary to remove the pedicle of the polyp and to protect the normal intima around the lesion.

2. Hysteroscopic separation of intrauterine adhesions: ①Choose the separation method according to the type of adhesion and the extent of adhesion. ②Membranous adhesions can be separated with micro scissors, and muscle adhesions are mostly separated by needle electrodes or ring electrodes. ③The anatomical shape of the uterine cavity should be clear during the separation operation, and the operation should be carried out along the midline of the uterine cavity to both sides, paying attention to the symmetry of the uterine cavity. ④ Special emphasis is placed on the protection of normal endometrium during surgery. ⑤When the intrauterine adhesions are separated, ultrasound or laparoscopic monitoring can be selected according to the degree of adhesion to improve the efficacy and safety of the operation.

3. Hysteroscopic endometrial resection: ①The sequential removal or coagulation of the endometrium with annular or spherical electrodes. ②Generally, it starts from the fundus of the uterus to the uterine horns and the endometrium on both sides, and then removes the anterior and posterior endometrium of the uterus from top to bottom. ③The depth of resection or coagulation should include the full thickness of the endometrium and the muscle tissue 2-3mm below it, and the extent of resection or coagulation ends at 0.5-1.0cm above the internal cervical os (partial resection) or 0.5-1.0cm below (complete resection) . ④During the operation, attention should be paid to the destruction depth of the endometrium on the bilateral fundus and the uterine angle. If necessary, annular and spherical electrodes can be used alternately to minimize the residual endometrium.

4. Hysteroscopic hysterectomy and mediastinectomy: ①When the uterine insufficiency mediastinum is removed or separated, it should start from the tip of the mediastinum and alternate from left to right to the base of the mediastinum. ②The direction of cutting or separation of the action electrode should be along the midline level to avoid damage to the anterior or posterior myometrium tissue. ③When cutting or separating to the uterine fundus, attention should be paid to distinguish the boundary between the mediastinum and the fundus myometrium. ④While removing or separating the mediastinum, try to avoid damage to the normal uterine muscle wall tissue to avoid bleeding or perforation. ⑤In the case of complete mediastinum resection or separation, separation or resection is performed from the level of the internal cervical os to the direction of the fundus. The method is the same as that of the incomplete mediastinum. Part of the cervical mediastinum does not need to be incised and can be left in vaginal delivery or cesarean delivery.

5. Hysteroscopic myomectomy: ①The type of fibroids should be evaluated before hysteroscopic myomectomy, and the operation should be performed according to different types of fibroids. ②Type 0 submucosal fibroids: Fibroids that are estimated to be completely removed through the cervix can be removed with oval forceps after excising the root of the fibroids with a ring electrode. For those with larger fibroids, ring electrodes should be used to cut the fibroids from both sides of the fibroids to reduce the fibroid volume, and then clamped and twisted with oval forceps to remove the fibroids. For the fibroids that protrude into the vagina, the fibroids are cut off under the hysteroscope and taken out. Type I and type II submucosal fibroids: The tumor capsule is incised at the most prominent part of the fibroids with the action electrode, so that the fibroids protrude into the uterine cavity, and then excised. ③During the operation, the fibroids can be moved into the uterine cavity by using oxytocin, water separation and other methods. ④ For fibroids that cannot protrude into the uterine cavity, it is not advisable to forcibly dig into the muscle wall, and the fibroids should be excised until they are parallel to the surrounding muscle wall. The remaining part of the fibroids should be re-operated as appropriate depending on the postoperative growth. ⑤Intramural fibroids projecting into the uterine cavity: For intramural intramural fibroids that can be resected by hysteroscopy, the surgical methods and principles refer to Type 1 and Type 2 submucosal fibroids. ⑥It is recommended to use B-ultrasound monitoring during the operation to improve the safety of the operation.

6. Hysteroscopic uterine foreign body removal or resection: ①IUD: When the IUD remains, incarcerated or wrapped by adhesion tissue, it should be separated under direct hysteroscopy until it is completely exposed, and then Remove with foreign body forceps. For the IUD remaining between the muscle walls, it should be combined with ultrasound positioning as appropriate and separated and taken out according to the above method. ②Pregnancy tissue residual: According to the residual tissue type and residual location, needle-shaped or ring-shaped electrodes are selected for separation or excision as appropriate. Intraoperative attention should be paid to the protection of normal endometrium. ③When dealing with the residual tissue in the uterine corner, the depth should be grasped to avoid uterine perforation. ④The resection of the pregnancy material at the cesarean section scar (protruding into the uterine cavity) should be treated with drugs and/or uterine vascular occlusion as appropriate, and ultrasound or combined laparoscopic surgery should be selected as appropriate during the operation.

Intraoperative precautions

1. During hysteroscopic surgery, in order to better control the uterus, we will use cervical forceps to pull the cervix to assist the operation. However, under the pulling of cervical forceps, the uterus will deviate to one side, which is the asymmetry of the uterine fundus. In the process of cutting, it is necessary to pay attention to the low fundus of the pulled side, and do not cut too deep to avoid uterine perforation.

2. Because the shape of the uterus is wide at the top and narrow at the bottom, if the uterine cavity is not fully expanded, it is easy to expose the uterine angle. In this case, it may lead to missed diagnosis or omission of lesions at the uterine angle. If the preoperative B-ultrasound indicates that the lesion is at the uterine horn, we must pay attention to fully dilate the uterus, and if necessary, it can be dealt with with the assistance of intraoperative B-ultrasound.

3. Because high-frequency electrical energy is used in hysteroscopic surgery, once the operation is wrong, it is easy to cause damage to the surrounding tissue. Therefore, during the cutting process, it is necessary to keep the field of vision clear. The electric cutting ring or the electric cutting needle is always in the field of vision, so that it cannot be seen clearly and is not powered on.

4. During hysteroscopic myomectomy, if intratumoral hemorrhage occurs, it is recommended not to use electrocoagulation to stop bleeding one by one, to avoid TURP syndrome caused by increased perfusion absorption due to long operation time. In this case, the operation can be terminated as soon as possible. Immediately after the operation, a uterine balloon can be placed for compression and hemostasis.

5. For women with fertility requirements, during operations such as separation of intrauterine adhesions or mediastinal resection, not only attention should be paid to the recovery of the shape of the uterine cavity, but also to help the patient protect the remaining endometrium as much as possible.

6. The vascular layer of the uterus is located about 5-6mm below the endometrium. If the incision is too deep during the operation, it may damage the blood vessels and cause massive bleeding. Therefore, when cutting, we can use the depth of the electrical resection ring as a marker (the depth of the electrical resection ring is about 5mm), about 2-3mm below the endometrium, which can effectively reduce the amount of intraoperative blood loss.

7. Hysteroscopic surgery wants to reduce the occurrence of postoperative intrauterine adhesions. On the one hand, it is necessary to pay attention to minimize the damage to the normal endometrium during the operation. Membrane growth to reduce postoperative intrauterine adhesions.

08

Infection prevention

Hysteroscopy has a low probability of infection, and prophylactic antibiotics are not required before surgery. Routine pelvic and vaginal discharge examinations are performed before surgery. If there is inflammation, it must be controlled after surgery.

In general, hysteroscopic surgery is safe and reliable, but it should not be taken lightly because it feels simple. Strengthening technical training, monitoring during and after surgery, and improving surgical skills are the keys to ensuring the safety of hysteroscopic surgery.