Gynecology_Novak

Gynecology_Novak. for neoplasia and provide enough information to support an initial management strategy. In the absence of a satisfactory diagnosis or if unexplained bleeding continues without response to treatment, further investigation is appropriate, using one or a combination of ultrasound, endometrial sampling, SIS, or office hysteroscopy. For women in their earlier reproductive years who have AUB, medical or expectant management may be used initially, depending on the severity and inconvenience of the bleeding. For those who do not respond to medical treatments such as oral contraceptives, further diagnostic procedures such as transvaginal ultrasonography, SIS, or hysteroscopy with biopsy can be performed (165).


Gynecology_Novak

Gynecology_Novak. For women with infertility, hysterosalpingography is the best initial imaging step because it provides information about the patency of the oviducts. In the presence of a suspicious or identified abnormality in the endometrial cavity, hysteroscopy or sonohysterography can be performed to confirm the diagnosis, to better define the abnormality, and perhaps to direct the removal of a lesion. Some experts consider hysteroscopy or MRI mandatory for such patients because of the high occurrence of false-negative radiologic images in those with intrauterine anomalies (166). In women with previous in vitro fertilization failure, there is evidence that hysteroscopic identification and treatment of these “missed” anomalies improves pregnancy rates (167). Confirmation of patency of the oviduct is unnecessary in women who have recurrent abortions; therefore, these patients can be evaluated primarily with hysteroscopy.


Gynecology_Novak

Gynecology_Novak. Operative Hysteroscopy A number of intrauterine procedures can be performed under endoscopic direction, including adhesiolysis, sterilization, division of a uterine septum, resection of myomas and polyps, removal of retained products of conception, and endometrial destruction through Nd:YAG laser vaporization or radiofrequency resection, desiccation, or vaporization. Hysteroscopy may be used to direct the removal of foreign bodies, including imbedded intrauterine contraceptive devices (IUDs).


Gynecology_Novak

Gynecology_Novak. Foreign Body If the string of an IUD is absent, the device usually can be removed with a specially designed hook or a toothed curette (e.g., Novak). When removal is difficult or impossible, the location of the device may be confirmed by hysteroscopy, allowing removal with a grasping forceps. If the device is not seen or if only a portion is visible hysteroscopically and the remainder is imbedded in the myometrium, then individualized management is recommended, usually following appropriate imaging studies to identify the more precise location of the device.


Gynecology_Novak

Gynecology_Novak. Septum When recurrent pregnancy loss is associated with a single corpus containing a uterine septum, hysteroscopic division of the septum improves pregnancy outcome (the frequency of spontaneous abortion) at a rate comparable to abdominal metroplasty, with reduced morbidity and cost (see Chapter 33) (168–173). There are fewer data regarding infertility but there is some evidence that metroplasty does improve fecundity (174). Confirmation of the external architecture of the corpus is important and can be achieved using either MRI or three-dimensional ultrasound. One group described an office method of “see and treat” where dissection is continued until attaining two of three criteria (pain, bleeding, the visualization of myometrial fibers) to determine the end point of septal transection (175). This procedure can be successfully performed in the office setting using local anesthesia protocols, with additional 0.05% lidocaine with 1/200,000 epinephrine directly injected into the septum.


Gynecology_Novak

Gynecology_Novak. This procedure can be successfully performed in the office setting using local anesthesia protocols, with additional 0.05% lidocaine with 1/200,000 epinephrine directly injected into the septum. The procedure may be performed mechanically with scissors or with energy-based techniques such as the Nd:YAG laser or an electrosurgical knife, needle, or loop. Because most septa have few vessels, scissors can be used to avoid the minimal risk for thermal damage.


Gynecology_Novak

Gynecology_Novak. Endometrial Polyps Endometrial polyps are frequently associated with abnormal uterine bleeding and infertility. Although such polyps can be removed with blind curettage, many are missed (157,159,162,163). Therefore, known or suspected endometrial polyps are treated more successfully with hysteroscopic guidance, which usually can be performed as an office procedure. Hysteroscopy may be used either to evaluate the result of blind curettage, to determine if the polyp is avulsed, or to direct the use of grasping forceps or small caliber scissors. Alternatively, for larger polyps, special polyp snares, electrosurgical needles, mechanical morcellators, or a uterine resectoscope may be used to sever the stalk or morcellate the lesion. For patients with infertility and endometrial polyps, it is not clear whether or not polyp number and size are related to outcome (176). Consequently, removal of all accessible polyps should be attempted if the process can be completed with minimal trauma.


Gynecology_Novak

Gynecology_Novak. Leiomyomas Hysteroscopy may be used to remove selected leiomyomas that involve the uterine cavity in women with heavy menstrual bleeding, infertility, or recurrent first trimester spontaneous pregnancy loss (155,177–183). This approach is limited based on the location, size, and number of the lesions. Preoperative administration of gonadotropin-releasing hormone (GnRH) agonists may help shrink submucous myomas, facilitating their complete removal, and more importantly, reduce operating time and systemic absorption of distension media (184–186).


Gynecology_Novak

Gynecology_Novak. To help document and evaluate the results of hysteroscopically directed myoma surgery, a classification system was developed that is based on the proportion of the myoma that is in the uterine cavity. In patients with myomas that are entirely intracavitary (type 0), excision is feasible and in many instances relatively easy, depending in part on the diameter; whereas in larger type II lesions an abdominal approach with laparoscopy or laparotomy is frequently necessary. Small type 0 leiomyomas may be removed following transection of the stalk with scissors or an electrode attached to a uterine resectoscope. For larger type 0 lesions, or for type I myomas, mechanical or electrosurgical morcellation with a resectoscope is necessary before removal. For a limited number of type II myomas, careful dissection into the avascular plane interposed between the tumor and the myometrial pseudocapsule may be attempted, provided that satisfactory ultrasonography or MRI demonstrated an adequate


Gynecology_Novak

Gynecology_Novak. careful dissection into the avascular plane interposed between the tumor and the myometrial pseudocapsule may be attempted, provided that satisfactory ultrasonography or MRI demonstrated an adequate margin of myometrium between the deepest aspect of the lesion and the uterine serosa. It may be preferable to undertake such procedures with laparoscopic monitoring to verify that bowel is not adjacent to the zone of dissection. Patients should be counseled that for some type I and many type II myomas, more than one procedure might be required to complete excision (178,187). The use of intrauterine prostaglandin F2α was described to facilitate extrusion of type II myomas (188).


Gynecology_Novak

Gynecology_Novak. Endometrial Ablation Heavy menstrual bleeding that does not respond to oral medical therapy may be managed by EA using coagulation, resection, or vaporization, provided the patient is willing to forgo future fertility (51). Alternatively, or if future fertility is desired, a levonorgestrel-releasing intrauterine contraceptive device can provide virtually equal clinical outcomes (189,190). Ablation may be performed with the laser, radiofrequency electrosurgical desiccation, resection, or vaporization using a uterine resectoscope, or by any of a number of nonresectoscopic techniques, including those employing thermal balloons, cryotherapy, heated free ﬂuid, or microwave or bipolar radiofrequency systems (151,152,187,191–195). Many of these endometrial ablation devices can be used in an office setting using local anesthetic protocols.


Gynecology_Novak

Gynecology_Novak. Endometrial resection is an EA technique performed with an electrosurgical loop electrode to shave the endometrium and superficial myometrium (109,142,143,150,196,197). Vaporization utilizes specially designed electrodes that are attached to standard resectoscopes but which are capable of destroying large volumes of tissue without morcellation (187). Ablation is achieved using ball or barrel-shaped electrodes that coagulate the endometrial surface (51,152). Complications of these procedures include ﬂuid overload, electrolyte imbalances (if nonelectrolytic or even isosmotic media are used), uterine perforation, bleeding, and intestinal and urinary tract injury (198,199). The risk of uterine perforation may be reduced by using a combination of resection or vaporization and electrosurgical ablation; the latter is most suitable for the thinner areas of the myometrium in the cornu (177). The preoperative use of GnRH analogues or danazol may reduce operating time. GnRH may reduce bleeding


Gynecology_Novak

Gynecology_Novak. ablation; the latter is most suitable for the thinner areas of the myometrium in the cornu (177). The preoperative use of GnRH analogues or danazol may reduce operating time. GnRH may reduce bleeding and the amount of ﬂuid absorbed into the systemic circulation (186).


Gynecology_Novak

Gynecology_Novak. For many women, these procedures succeed in reducing or eliminating menses without hysterectomy or long-term medical therapy (51,200). Success rates vary and depend on the duration of follow-up and the definition of success. For many patients, amenorrhea is the goal, whereas for others, it is normalization of menses. About 75% to 95% of patients are satisfied with the surgical procedure after 1 year. Amenorrhea rates range from about 30% to 90% (depending in part upon the technique), but 40% to 50% of patients have amenorrhea, is a useful number to quote to patients considering the procedure. In comparative studies, there is no advantage of laser over electrosurgical techniques (198,201). The nonresectoscopic techniques have similar clinical outcomes, thus reducing the need for resectoscopic ablation. However, the nonresectoscopic approaches all have limitations defined by the size or configuration of the endometrial cavity. Consequently, for those women with heavy menstrual bleeding


Gynecology_Novak

Gynecology_Novak. ablation. However, the nonresectoscopic approaches all have limitations defined by the size or configuration of the endometrial cavity. Consequently, for those women with heavy menstrual bleeding who are not suitable for nonresectoscopic techniques because of large uteri (>12 cm sounded length), resectoscopic endometrial ablation remains a viable option (161,202).


Gynecology_Novak

Gynecology_Novak. The long-term efficacy and impact of ablation or resection on women with adenomyosis is unknown. Because some endometrium inevitably cannot be ablated, there is the potential for endometrial cancer; therefore, postmenopausal women who underwent ablation or resection should take progestin as a part of hormonal therapy (203).


Gynecology_Novak

Gynecology_Novak. Sterilization Sterilization can be performed under hysteroscopic guidance, an approach that eliminates the disadvantages and risks associated with abdominal or laparoscopic techniques (204). Two such techniques are available and others are under development. The Essure® system comprises a nickel-titanium coil with a Dacron filament that can be inserted relatively quickly in an office or procedure room setting (see Chapter 10). The Adiana® device uses a rice grain–sized porous silicon plug that is positioned in the proximal tube following the application of an aliquot of RF radiofrequency current. It is designed for office use under local anesthesia. North American protocols require that hysterosalpingography be performed 3 months after the procedure to ensure that bilateral tubal occlusion took place.


Gynecology_Novak

Gynecology_Novak. Synechiae Asherman syndrome is the presence of adhesions in the endometrial cavity that can result in infertility or recurrent spontaneous abortion with or without amenorrhea. These synechiae may be detected on a hysterogram or sonohysterogram, but are best shown with diagnostic hysteroscopy. Relatively thin, fragile synechiae may be divided with the tip of a rigid diagnostic hysteroscope (205). Thicker lesions may require division by semirigid or rigid scissors or energy-based instruments such as a resectoscope or an operative hysteroscope with either a radiofrequency electrode or an Nd:YAG laser. Reproductive outcome depends on the extent of the preoperative endometrial damage (206,207). This is another hysteroscopic procedure that is amenable to performance in the office, at least in selected cases without complete obliteration, but the surgeon must be careful to maintain orientation within the endometrial cavity.


Gynecology_Novak

Gynecology_Novak. Diagnostic hysteroscopy procedures traditionally were performed in the office or clinic settings, and operative hysteroscopy usually was performed in an operating room or hospital surgical center. Much is changing; in a number of centers, 90% of the operative hysteroscopies are performed in an office procedure room setting using local and verbal anesthesia. The patient should understand the rationale for the procedure, and the anticipated discomfort, the potential risks, and the expectant, medical, and surgical alternatives. The nature of the procedure and the chance of therapeutic success should be explained, and she should be given a realistic estimate of success based on the operator’s experience. Diagnostic Hysteroscopy: Risks


Gynecology_Novak

Gynecology_Novak. Diagnostic Hysteroscopy: Risks The risks of diagnostic hysteroscopy are few, and those complications that occur rarely have severe consequences (199). The uncommon adverse events that should be discussed with the patient include perforation, bleeding, and those related to anesthesia and the distention media. After diagnostic hysteroscopy, most patients have slight vaginal bleeding and occasionally, lower abdominal cramps. Severe cramps, dyspnea, and upper abdominal and right shoulder pain can develop if CO2 is used as the distension media and it passes through the fallopian tubes into the peritoneal cavity. Consequently, even in an office environment, the patient should be encouraged to have a friend or relative escort her home. Operative Hysteroscopy: Risks


Gynecology_Novak

Gynecology_Novak. Operative Hysteroscopy: Risks Counseling before operative hysteroscopy varies depending on the planned procedure, the type of anesthesia, and the procedure location—office or operating room. Overall, the risks of operative hysteroscopy are higher than those of diagnostic hysteroscopy, but these increased risks are largely confined to procedures such as adhesiolysis of severe intrauterine synechiae or resection of leiomyomas that are either large or that extend deeply into the myometrium.


Gynecology_Novak

Gynecology_Novak. These risks include those associated with anesthesia, which are intrinsic to all hysteroscopic procedures, and are related to the specific surgical procedure to be performed. With any hysteroscopic procedure, air embolus is a possibility, as are complications associated with the gaseous or ﬂuid distention media used. Hypotonic distension media may not be tolerated in some patients if there is significant intravascular absorption, especially in patients with underlying cardiovascular disease. The patient must be aware of the risks associated with uterine perforation, which range from failure to complete the procedure, to hemorrhage, or damage to the intestines or the urinary tract. If such complications occur, laparotomy may be necessary to repair the injury.


Gynecology_Novak

Gynecology_Novak. The equipment required for hysteroscopy depends on the reason for the procedure. The surgeon must be knowledgeable about the equipment, its mechanisms, and the technical specifications to facilitate efficiency, optimal clinical outcome, and a decreased probability of complications. A typical hysteroscopy setup for diagnostic and minor operative procedures is shown in Figures 23.24 and 23.25. Core competencies required for hysteroscopy are as follows: 1. 2. 3. 4. 5. 6. 7. Patient Positioning and Hysteroscopy is performed in a modified dorsal lithotomy position; the patient is supine, and the Cervical Exposure legs are held in stirrups. For hysteroscopic procedures performed while the patient is conscious, comfort must be considered in conjunction with the need to gain good exposure of the perineum.


Gynecology_Novak

Gynecology_Novak. Figure 23.24 Office hysteroscopy setup. Hysteroscopic procedures are facilitated with an electric examination table. Distension media may be positioned on an intravenous pole, but wide, cystoscopy tubing allows maintenance of higher intrauterine pressures suitable for viewing and performing simple procedures such as polypectomy or transcervical sterilization. A light source is necessary and a camera desirable. The camera is attached to the monitor and may be connected to a printer and/or video recorder. The camera head is attached to a ﬂexible hysteroscope. Stirrups that hold and support the knees, calves, and ankles permit prolonged procedures. “Candy cane” stirrups are inappropriate for hysteroscopic surgery and for conscious patients.


Gynecology_Novak

Gynecology_Novak. Stirrups that hold and support the knees, calves, and ankles permit prolonged procedures. “Candy cane” stirrups are inappropriate for hysteroscopic surgery and for conscious patients. The smallest speculum possible should be used to expose the cervix. A bivalve speculum hinged on only one side allows its removal without disturbing the position of the tenaculum and hysteroscope. The use of weighted specula should be avoided in conscious patients because of the discomfort involved.


Gynecology_Novak

Gynecology_Novak. Figure 23.25 Office hysteroscopy instruments. An assembled continuous ﬂow operating hysteroscope with a 5.5-mm diameter external sheath is shown in (A). A 5-French semirigid scissors occupies the working channel. An additional biopsy forceps is shown in (B). Tubing transporting media to the system is shown in (C) going into a 3-mm external diameter ﬂexible and steerable hysteroscope (D). A medical video camera is attached to the hysteroscope (F) and the light source is attached at (E). An open speculum (G) facilitates removal with instruments in place. A small dilator (H) or series of dilators will be necessary for a large number of patients. A tenaculum (I) attached to the cervix frequently facilitates both dilation and entry of the hysteroscope into the endometrial cavity.


Gynecology_Novak

Gynecology_Novak. Anesthesia The anesthetic requirements for hysteroscopy vary greatly, depending on the patient’s level of anxiety, the status of her cervical canal, the procedure, and the outside diameter of the hysteroscope or sheath. In some patients, diagnostic hysteroscopy is possible without anesthesia, especially if the patient is parous or if narrow-caliber (<3 mm in outside diameter) hysteroscopes and sheaths are used (208). In many instances the pain of cervical dilation can be avoided or minimized with the preprocedural use of oral or vaginal misoprostol (see below) or by inserting a laminaria “tent” in the cervix 3 to 8 hours before the procedure. Laminaria are thin rods of natural (slippery elm) or synthetic construction that, when passed through the internal os, expand over several hours thereby dilating the cervix. However, if laminaria are left in place too long (e.g., longer than 24 hours), the cervix may overdilate, which is can be counterproductive for CO2 insufﬂation.


Gynecology_Novak

Gynecology_Novak. For most diagnostic and many operative procedures, effective cervical anesthesia is obtained using local anesthesia, allowing the hysteroscopy to be done in an office procedure room. Evidence suggests that the paracervical block may be the most effective (208,209). Following exposure of the cervix with a vaginal speculum, a spinal needle can be used to instill about 3 mL of 0.5% to 1% lidocaine into the anterior lip of the cervix to allow attachment of a tenaculum and manipulation of the exocervix. While the exact location and depth of the injection varies with providers and studies, the uterosacral ligament location (about 4 mm deep at approximately at the 4-and 8-o’clock positions as one looks at the cervix) was demonstrated successful (210). Care must be taken to avoid intravascular injection. An alternative technique is the use of an intracervical block where the anesthetic agent is injected evenly around the circumference of the cervix, attempting to reach the level of the


Gynecology_Novak

Gynecology_Novak. injection. An alternative technique is the use of an intracervical block where the anesthetic agent is injected evenly around the circumference of the cervix, attempting to reach the level of the internal os. The efficacy of this approach is unclear based on published studies (208). Recognizing the complex innervation of the uterus, alternative or additional topical anesthesia may be applied to the cervical canal or to the endometrium, or both, using anesthetic spray, gel, or cream. It is unclear how effective these approaches are because many of the study protocols seemed to allow inadequate time between application and initiation of the procedure (211). A number of options were presented, including instillation of 5 mL of 2% mepivacaine into the endometrial cavity with a syringe, or the application of similar amounts of 2% lidocaine gel. Many operative procedures can be performed with these techniques combined, if deemed necessary, with the oral or intravenous use of anxiolytics or


Gynecology_Novak

Gynecology_Novak. application of similar amounts of 2% lidocaine gel. Many operative procedures can be performed with these techniques combined, if deemed necessary, with the oral or intravenous use of anxiolytics or analgesics, although the use of such systemic agents mandates continuous monitoring of blood pressure and oxygenation and the availability of appropriate resuscitative staff and equipment. An important component of the optimal use of local anesthesia is allowing sufficient time from the injection or application of the agents before the commencement of the procedure. While injectable local anesthetic agents such as lidocaine and mepivacaine may have an onset of action in 2 to 3 minutes, it may take up to 15 to 20 minutes to obtain a maximal effect. If local anesthesia is not deemed appropriate, regional or general anesthesia may be used in the context of a surgical center or operating room.


Gynecology_Novak

Gynecology_Novak. Cervical Dilation In many instances, and particularly in vaginally parous women, dilation of the cervix will be unnecessary, especially if narrow caliber hysteroscopic systems are used. Dilation will be necessary some of the time, and, although seemingly simple, cervical stenosis or suboptimal technique can result in perforation that compromises the entire procedure. If the objective lens of the endoscope cannot be placed in the endometrial cavity the hysteroscopy cannot be done. The process of dilation should be undertaken carefully, respecting the orientation of the cervix to the axis of the vaginal canal (version) and that of the corpus to the cervix (ﬂexion). In difficult circumstances, simultaneous ultrasound may be valuable, and difficult dilation may be facilitated directly with the hysteroscope.


Gynecology_Novak

Gynecology_Novak. There are a number of options available to facilitate cervical dilation. There is evidence that prostaglandin E1 (misoprostol) administered 400 μg orally or 200 to 400 μg vaginally, approximately 12 to 24 hours before the procedure facilitates cervical dilation (212–215). Misoprostol alone may not be effective in postmenopausal women, but one well-designed randomized trial demonstrated that vaginal estrogen, administered daily for 2 weeks before the procedure facilitates the effect of the prostaglandin in this group of patients (215). Alternatively, there is evidence that intraoperatively administered intracervical vasopressin (0.05 U/mL, 4 cc at 4 and 8 o’clock) substantially reduces the force required for cervical dilation (216). Regardless of the circumstance, the cervix should be dilated as atraumatically as possible. It is best to avoid using a uterine sound because it can traumatize the canal or the endometrium, causing unnecessary bleeding and uterine perforation.


Gynecology_Novak

Gynecology_Novak. Uterine Distention Distention of the endometrial cavity is necessary to create a viewing space. The choices include CO2 gas, high-viscosity 32% dextran 70, and a number of low-viscosity ﬂuids, including glycine, sorbitol, saline, and dextrose in water. A pressure of 45 mm Hg or higher is generally required for adequate distention of the uterine cavity and to visualize the tubal ostia. To minimize extravasation, this pressure should not exceed the mean arterial pressure. For each of the ﬂuids, there are several methods used to create this pressure by infusion into the endometrial cavity.


Gynecology_Novak

Gynecology_Novak. A rigid hysteroscope is passed into the endometrial cavity through an external sheath. The design and diameter of the sheath reﬂect both the dimensions of the endoscope and the purpose of the instrument. Typical diagnostic hysteroscopes have a sheath slightly wider than the telescope, allowing infusion of the distention media. Operative sheaths have additional channels to permit the passage or efﬂux of distention media and the insertion of laser fibers, electrosurgical instruments or semirigid scissors, biopsy devices, or grasping forceps. These sheaths are usually 5 to 8 mm in diameter, and some allow continuous ﬂow of distention media in and out of the endometrial cavity (Figs. 23.25 and 23.26).


Gynecology_Novak

Gynecology_Novak. CO2 provides an excellent view for diagnostic purposes, but it is unsuitable for operative hysteroscopy and for diagnostic procedures when the patient is bleeding because there is no effective way to remove blood and other debris from the endometrial cavity. To prevent CO2 embolus, the gas must be instilled by an insufﬂator that is specially designed for the procedure—the intrauterine pressure is kept below 100 mm Hg and the ﬂow rate is maintained at less than 100 mL per minute. Figure 23.26 Hysteroscope optics. Panoramic (0◦) and oblique (15◦ and 30◦) viewing angles. Normal saline is a useful and safe medium for procedures that do not require radiofrequency electricity from standard monopolar resectoscopes. Even if there is absorption of a substantial volume of solution, saline typically does not cause electrolyte imbalance.


Gynecology_Novak

Gynecology_Novak. Therefore, saline is a good ﬂuid for minor procedures performed in the office. The development of bipolar radiofrequency instrumentation for hysteroscopic surgery allowed the application of saline as a distending medium in even more advanced and complex procedures. Dextran 70 is useful for patients who are bleeding because it does not mix with blood. However, it is expensive and tends to “caramelize” on instruments, which must be disassembled and thoroughly cleaned in warm water immediately after each use. Anaphylactic reactions, ﬂuid overload, and electrolyte disturbances can occur.


Gynecology_Novak

Gynecology_Novak. For standard operative hysteroscopy with monopolar radiofrequency resectoscopes, low-viscosity, nonconductive ﬂuids such as 1.5% glycine, 3% sorbitol, and 5.0% mannitol are used most often. These solutions can be used with standard, monopolar radiofrequency instrumentation because there are no electrolytes to disperse the current and impede the electrosurgical effect. Each of these media is inexpensive and readily available, usually in 3-L bags suitable for continuous-ﬂow hysteroscopy. Because each ﬂuid is electrolyte-free, extravasation into the systemic circulation can be associated with electrolyte disturbances. Compared with 1.5% glycine or 3.0% sorbitol, 5% mannitol is isomolar and it functions as a diuretic, both advantages when performing resectoscopic surgery. Regardless of the electrolyte content of the ﬂuid distending media, systemic “absorption” must be monitored continuously or at least frequently (every 5 minutes) by collecting outﬂow from the sheath and subtracting it


Gynecology_Novak

Gynecology_Novak. electrolyte content of the ﬂuid distending media, systemic “absorption” must be monitored continuously or at least frequently (every 5 minutes) by collecting outﬂow from the sheath and subtracting it from the total infused volume. The fact that the manufacturer frequently fills the bags with more than the indicated 3 L makes accurate calculation of absorbed volume even more difficult (217). There are a number of machines designed to provide continuous feedback to the surgeon regarding the degree of negative ﬂuid balance. Absorbed volumes greater than 1 L mandate the measurement of electrolyte levels. The risk of ﬂuid overload is reduced by the judicious restriction of intravenous ﬂuid by the anesthesiologist. The administration of an appropriate dose of furosemide should be considered, and the surgeon should plan for the expeditious completion of the procedure. If there is more than a preset limit (1.5 to2Lofextravasated ﬂuid), the procedure should be stopped. Excessive circulating


Gynecology_Novak

Gynecology_Novak. and the surgeon should plan for the expeditious completion of the procedure. If there is more than a preset limit (1.5 to2Lofextravasated ﬂuid), the procedure should be stopped. Excessive circulating sorbitol may cause hyperglycemia, and large volumes of glycine may elevate levels of ammonia in the blood (218).


Gynecology_Novak

Gynecology_Novak. Syringes can be used for office diagnostic procedures and are especially good for infusing dextran solution. The syringe can be operated by the surgeon and is either connected directly to the sheath or attached by connecting tubing. Because this technique is so tedious, it is suited only for simple operations. Continuous hydrostatic pressure is effectively achieved by elevating the vehicle containing the distention media above the level of the patient’s uterus. The achieved pressure is the product of the width of the connecting tubing and the elevation—for operative hysteroscopy with 10-mm tubing, intrauterine pressure ranges from 70 to 100 mm Hg when the bag is between 1 to 1.5 m above the uterine cavity. A pressure cuff may be placed around the infusion bag to elevate the pressure in the system. Caution must be exercised because this technique causes increasing extravasation if intrauterine pressure rises above the mean arterial pressure.


Gynecology_Novak

Gynecology_Novak. A variety of infusion pumps is available, ranging from simple devices to instruments that maintain a preset intrauterine pressure. Simple pump devices continue to press ﬂuid into the uterine cavity regardless of resistance, whereas the pressure-sensitive pumps reduce the ﬂow rate when the preset level is reached, thereby impeding the efﬂux of blood and debris and compromising the view.


Gynecology_Novak

Gynecology_Novak. Hysteroscopes are available in two basic types—ﬂexible and rigid. Flexible hysteroscopes are self-contained in that they do not require a sheath; the single integrated channel is used to transmit gas or ﬂuid to the endometrial cavity for distention. As a result, these instruments are generally of smaller diameter than rigid systems. In addition, they can be designed to be “steerable,” allowing angled viewing. Flexible hysteroscopes utilize fiberoptic bundles rather than lenses to transmit the image to the observer and, consequently, have lower resolution than rigid instruments of a similar diameter and typically do not have a channel with a caliber suitable for most hand instruments. Rigid hysteroscopes are more durable and provide a superior image. The most commonly used hysteroscopes are 3 to 4 mm in diameter, although those using fibers can be smaller than 2 mm in diameter.


Gynecology_Novak

Gynecology_Novak. Rigid endoscopes require an angled (fore-oblique) lens to provide the angled view useful for operative hysteroscopy and are available in 0-degree, 12-to 15-degree, and 25-to 30-degree models (Fig. 23.26). The 0-degree telescope provides a panoramic view and is best for diagnostic procedures. Hysteroscopes with 25-to 30-degree angles are most often used for cannulation of the fallopian tubes or placement of sterilization devices, whereas 12-to 15-degree designs are a suitable compromise useful for diagnosis and ablation or resection. The utility of endoscopes with larger fore-oblique views may be offset by the tendency of resectoscopic electrodes to leave the visual field on full extension.


Gynecology_Novak

Gynecology_Novak. Adequate illumination of the endometrial cavity is essential. Because it runs from a standard 110-or 220-volt wall outlet, the light source requires no special electrical connections. For most cameras and endoscopes, the element must have at least 150 watts of power for direct viewing and preferably 250 watts or more for video and operative procedures (219). Although diagnostic hysteroscopy may be performed with direct visualization, it is best to use video guidance for prolonged operations. Video imaging is important for teaching and recording pathology and procedures. The camera must be sensitive because of the narrow diameter of the endoscope and the frequently dark background of the endometrial cavity, particularly when it is enlarged or when blood is in the field. (Fig. 23.25).


Gynecology_Novak

Gynecology_Novak. A small video camera can be used to teach and to coordinate the procedure with the operating room team. It allows the acquisition of still or video images for future reference or teaching. When a video recorder is used, the camera should be attached directly to the recorder to preserve the image quality. A number of video recording formats are available, each with inherent advantages and disadvantages. Some video printers provide images suitable for a medical record. Newer high-definition digital cameras provide high-quality video still images as well as high-resolution digital video, suitable for publication or teaching. Figure 23.27 Resectoscope. The assembled resectoscope is shown, with two electrodes in the foreground. Manipulation of the electrode is via the white handle in the proximal portion of the device.


Gynecology_Novak

Gynecology_Novak. Figure 23.27 Resectoscope. The assembled resectoscope is shown, with two electrodes in the foreground. Manipulation of the electrode is via the white handle in the proximal portion of the device. The instruments available for use through operative hysteroscopes include biopsy, grasping, cutting, and punch-biopsy devices. These tools are narrow and ﬂexible enough to navigate the 1-to 2-mm diameter operating channel (Fig. 23.25). Although their value is limited by their small size and ﬂimsy construction; the scissors can divide adhesions, the biopsy forceps can sample targeted lesions, and the grasping forceps can remove small polyps or intrauterine devices. Some operative hysteroscopes are designed to allow passage of fibers for the conduction of Nd:YAG laser energy, although this modality is generally superseded by electrosurgical electrodes.


Gynecology_Novak

Gynecology_Novak. The uterine resectoscope is similar to the one used in urology and is designed to apply radiofrequency electrical current to the endometrial cavity (Fig. 23.27). An understanding of the principles of electrosurgery is mandatory for safe and effective use of this instrument. By sliding the “working element,” one of a variety of electrode tips can be manipulated back and forth within the cavity. Tissue can be divided with a pointed electrode, excised with a loop, or desiccated with a rolling ball or bar. An electrode with multiple tips or edges can vaporize tissue, provided higher wattage generator outputs are used. A clear operative field is maintained by the continuous ﬂow of nonconductive distending media in and out of the cavity. Although basic design modifications made the resectoscope more useful in gynecology, extraction of resected fragments is time consuming. The most effective approach is the periodic use of a uterine curette or specially designed polyp or myoma forceps


Gynecology_Novak

Gynecology_Novak. more useful in gynecology, extraction of resected fragments is time consuming. The most effective approach is the periodic use of a uterine curette or specially designed polyp or myoma forceps inserted after removal of the hysteroscope. Alternatively, much of the myoma or endometrium can be vaporized, thereby minimizing the need for periodic but time-consuming removal of tissue “chips.” If vaporization is used, it is important to obtain representative samples of the endometrium or myoma for pathological analysis.


Gynecology_Novak

Gynecology_Novak. Other Instrumentation For any hysteroscopic procedure, it is necessary to have available a cervical tenaculum, dilators, uterine curette, and appropriate-sized vaginal specula. When using the resectoscope, it is helpful to have a solid-state, isolated circuit electrosurgical generator capable of delivering both modulated and nonmodulated radiofrequency current. Laparoscopy or laparotomy may be necessary for emergencies secondary to uterine perforation.


Gynecology_Novak

Gynecology_Novak. Complications The potential risks of positioning a hysteroscopic system in the endometrial cavity solely for viewing (“diagnostic hysteroscopy”) are largely limited to cervical trauma and uterine perforation. Other adverse events such as infection, excessive bleeding, and complications related to the distention media are extremely uncommon when the procedure is short and does not involve instrumentation of the myometrium (0% to 1%) (199). The risks of operative hysteroscopy are related to one of five aspects of the procedure performed: (i) anesthesia, (ii) the distention media, (iii) perforation, (iv) bleeding, and (v) thermal trauma (198,199).


Gynecology_Novak

Gynecology_Novak. Anesthesia Local anesthetic protocols typically include the intracervical or paracervical injection of 0.5% to 2% lidocaine or mepivacaine solution, with or without a local vasoconstrictor such as adrenaline. Overdosage is prevented by ensuring that intravascular injection is avoided and by not exceeding the maximum recommended doses (lidocaine, 4 mg/kg; mepivacaine, 3 mg/kg). The use of a dilute vasoconstrictor such as epinephrine 1/200,000 reduces the amount of systemic absorption of the agent, virtually doubling the maximum dose that can be used and facilitates the onset of action of local anesthetic agents (220).


Gynecology_Novak

Gynecology_Novak. Complications of intravascular injection or anesthetic overdose include allergy, neurologic effects, and impaired myocardial conduction. Allergy is characterized by the typical symptoms of agitation, palpitations, pruritus, coughing, shortness of breath, urticaria, bronchospasm, shock, and convulsions. Treatment measures include administration of oxygen, isotonic intravenous ﬂuids, intramuscular or subcutaneous adrenaline, and intravenous prednisolone and aminophylline. Cardiac effects related to impaired myocardial conduction include bradycardia, cardiac arrest, shock, and convulsions. Emergency treatment measures include the administration of oxygen, intravenous atropine (0.5 mg), and intravenous adrenaline and the initiation of appropriate cardiac resuscitation. The most common central nervous system manifestations are paresthesia of the tongue, drowsiness, tremor, and convulsions. Options for therapy include intravenous diazepam and respiratory support.


Gynecology_Novak

Gynecology_Novak. Carbon dioxide is highly soluble in blood; consequently such emboli as occur are usually clinically insignificant; however, in rare instances, CO2 emboli may result in serious intra-operative morbidity and even death (221–223). These risks can be eliminated by avoiding the use of CO2 with operative procedures, by ensuring that the insufﬂation pressure is always lower than 100 mm Hg, and that the ﬂow rate is lower than 100 mL per minute. The insufﬂator used must be especially designed for hysteroscopy; it is difficult to set laparoscopic insufﬂator ﬂow rates below 1,000 mL per minute.


Gynecology_Novak

Gynecology_Novak. Dextran 70 is a hyperosmolar medium that, rarely, can induce an allergic response or coagulopathy (224,225). Similar to other types of distention media, if sufficient volumes are infused, vascular overload and heart failure can occur (226,227). Because dextran is hydrophilic, it can draw six times its own volume into the systemic circulation. Consequently, the volume of this agent should be limited to less than 300 mL.


Gynecology_Novak

Gynecology_Novak. The low-viscosity ﬂuids—1.5% glycine, 3% sorbitol, and 5.0% mannitol—are used commonly because of their low cost, compatibility with standard electrosurgery, and availability in large-volume bags. However, should these electrolyte free and usually hypotonic media be absorbed to excess in the systemic circulation, they can create serious ﬂuid and electrolyte disturbances, a potentially dangerous complication that can result in pulmonary edema, hyponatremia, heart failure, cerebral edema, and even death. There are a number of published guidelines describing the steps required to reduce the risk of ﬂuid overload at the time of hysteroscopy (228). 1.


Gynecology_Novak

Gynecology_Novak. 1. Before undertaking anything but simple operative procedures using these agents, baseline serum electrolyte levels should be measured. Women with cardiopulmonary disease should be evaluated carefully. The selective preoperative use of agents such as GnRH agonists may reduce operating time and media absorption. Intracervical injection of 8 mL of a dilute vasopressin solution (0.01 U/mL) immediately prior to surgery is effective at reducing the amount of systemic absorption of distending media (229). The duration of this effect may be limited to approximately 20 to 30 minutes, so repeat dosing may be useful for optimal effect. 2.


Gynecology_Novak

Gynecology_Novak. 2. In the operating room, media infusion and collection should take place in a closed system to allow accurate measurement of the “absorbed” volume. The volume should be measured continuously with a device specifically designed for the purpose or, if such a system is not available, calculated every 5 minutes by support staff who are trained in these calculations and unencumbered by duties that may interfere with this task. 3.


Gynecology_Novak

Gynecology_Novak. 3. The lowest intrauterine pressure necessary for adequate distention should be used to complete the operation, preferably at a level that is below the mean arterial pressure. A good range for operative procedures is 70 to 80 mm Hg, which can be achieved with a specially designed pump or by maintaining the meniscus of the infusion bag 1 m above the level of the patient’s uterus. If greater intrauterine pressure is needed for adequate distention, the anesthesiologist may temporarily raise the mean arterial pressure by administration of a vasoactive agent such as phenylephrine.


Gynecology_Novak

Gynecology_Novak. 4. Deficits of more than 1 L require repeat measurement of serum electrolyte levels and consideration of intravenous furosemide in a dose appropriate to the patient’s renal function. When such a deficit exists, the procedure should be completed expeditiously. If the deficit reaches a preset limit (1.5 to 2 L), the procedure should be terminated, and a diuretic such as mannitol or furosemide should be used as needed. Patients with cardiovascular compromise will typically have a lower tolerance for ﬂuid deficits, a circumstance that mandates setting a lower limit for systemic absorption and consequent termination of the procedure (230).


Gynecology_Novak

Gynecology_Novak. Perforation Perforation may occur during dilation of the cervix, positioning of the hysteroscope, or as a consequence of the intrauterine procedure. With complete perforation, the endometrial cavity typically does not distend, and the visual field is generally lost. When perforation occurs during dilation of the cervix, the procedure must be terminated, but, because of the blunt nature of the dilators, usually there are no other injuries. If the uterus is perforated by the activated tip of a laser, or electrode, there is a risk for bleeding or injury to the adjacent viscera. Therefore, the operation must be stopped and laparoscopy or laparotomy should be performed. Injury to the uterus is relatively easy to detect with a laparoscope. However, mechanical or thermal injury to the bowel, ureter, or bladder is more difficult to detect and laparoscopy is frequently inadequate to make a complete evaluation. If the patient’s condition is managed expectantly, she should be advised of the


Gynecology_Novak

Gynecology_Novak. ureter, or bladder is more difficult to detect and laparoscopy is frequently inadequate to make a complete evaluation. If the patient’s condition is managed expectantly, she should be advised of the situation and asked to report any symptoms of bleeding or visceral trauma such as fever, increasing pain, nausea, and vomiting.


Gynecology_Novak

Gynecology_Novak. Bleeding Bleeding that occurs during or after hysteroscopy generally results from trauma to the vessels in the myometrium or injury to other vessels in the pelvis. Myometrial vessels are more susceptible to laceration with resectoscopic techniques that require myometrial dissection for procedures such as endometrial resection or type II myomectomy.


Gynecology_Novak

Gynecology_Novak. In planning operations that involve deep resection, autologous blood can be obtained before surgery. The risk for bleeding may be reduced by the preoperative injection of diluted vasopressin into the cervical stroma (229). The risk of injury to branches of the uterine artery can be lowered by limiting the depth of resection in the lateral endometrial cavity near the uterine isthmus, where ablative techniques should be considered. When bleeding is encountered during resectoscopic procedures, the ball electrode can be used to desiccate the vessel electrosurgically. Intractable bleeding may respond to the injection of diluted vasopressin or to the inﬂation of a 30-mL Foley catheter balloon or similar device in the endometrial cavity (177). Thermal Trauma Thermal injury to the intestine or ureter may be difficult to diagnose, and symptoms may not occur for several days to 2 weeks. Therefore, the patient should be advised of the symptoms that could indicate peritonitis. 1.


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Gynecology_Novak. 1. Nezhat C, Hood J, Winer W, et al. Video laseroscopy and laser laparoscopy in gynaecology. Br J Hosp Med 1987;38:219–224. 2. Pierre SA, Ferrandino MN, Simmons WN, et al. High definition laparoscopy: objective assessment of performance characteristics and comparison with standard laparoscopy. J Endourol 2009;23:523– 528. 3. Stovall TG, Ling FW, Gray LA. Single-dose methotrexate for treatment of ectopic pregnancy. Obstet Gynecol 1991;77:754–757. 4. Ellstrom M, Ferraz-Nunes J, Hahlin M, et al. A randomized trial with a cost-consequence analysis after laparoscopic and abdominal hysterectomy. Obstet Gynecol 1998;91:30–34. 5. Bhiwandiwala PP, Mumford SD, Feldblum PJ. A comparison of different laparoscopic sterilization occlusion techniques in 24,439 procedures. Am J Obstet Gynecol 1982;144:319–331. 6. Ryder RM, Vaughan MC. Laparoscopic tubal sterilization. Methods, effectiveness, and sequelae. Obstet Gynecol Clin North Am 1999;26:83–97. 7.


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Gynecology_Novak. 6. Ryder RM, Vaughan MC. Laparoscopic tubal sterilization. Methods, effectiveness, and sequelae. Obstet Gynecol Clin North Am 1999;26:83–97. 7. Lipscomb GH, Gomez IG, Givens VM, et al. Yolk sac on transvaginal ultrasound as a prognostic indicator in the treatment of ectopic pregnancy with single-dose methotrexate. Am J Obstet Gynecol 2009;200:338 e1–e4. 8. Potter MB, Lepine LA, Jamieson DJ. Predictors of success with methotrexate treatment of tubal ectopic pregnancy at Grady Memorial Hospital. Am J Obstet Gynecol 2003;188:1192–1194. 9. Hajenius PJ, Mol F, Mol BW, et al. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2007;1:CD000324. 10. Maruri F, Azziz R. Laparoscopic surgery for ectopic pregnancies: technology assessment and public health implications. Fertil Steril 1993;59:487–498. 11. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: medical management of ectopic pregnancy. Obstet Gynecol 2008;111:1479–1185. 12.


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Gynecology_Novak. 11. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: medical management of ectopic pregnancy. Obstet Gynecol 2008;111:1479–1185. 12. Gomel V. Management of ectopic gestation: surgical treatment is usually best. Clin Obstet Gynecol 1995;38:353–361. 13. Gomel V, Taylor PJ. Diagnostic and operative laparoscopy. St. Louis: CV Mosby; 1995. 14. Canis M, Mage G, Pouly JL, et al. Laparoscopic diagnosis of adnexal cystic masses: a 12-year experience with long-term follow-up. Obstet Gynecol 1994;83:707–712. 15. Mecke H, Lehmann-Willenbrock E, Ibrahim M, et al. Pelviscopic treatment of ovarian cysts in premenopausal women. Gynecol Obstet Invest 1992;34:36–42. 16. Medeiros LR, Rosa DD, Bozzetti MC, et al. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database Syst Rev 2009;2:CD004751. 17.


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Gynecology_Novak. 16. Medeiros LR, Rosa DD, Bozzetti MC, et al. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database Syst Rev 2009;2:CD004751. 17. Lehner R, Wenzl R, Heinzl H, et al. Inﬂuence of delayed staging laparotomy after laparoscopic removal of ovarian masses later found malignant. Obstet Gynecol 1998;92:967–971. 18. Vergote I. Role of surgery in ovarian cancer: an update. Acta Chir Belg 2004;104:246–256. 19. Parker WH, Berek JS. Management of selected cystic adnexal masses in postmenopausal women by operative laparoscopy: a pilot study. Am J Obstet Gynecol 1990;163:1574–1577. 20. Parker WH, Levine RL, Howard FM, et al. A multicenter study of laparoscopic management of selected cystic adnexal masses in postmenopausal women. J Am Coll Surg 1994;179:733–737. 21.


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Gynecology_Novak. 20. Parker WH, Levine RL, Howard FM, et al. A multicenter study of laparoscopic management of selected cystic adnexal masses in postmenopausal women. J Am Coll Surg 1994;179:733–737. 21. Jacobs I, Oram D, Fairbanks J, et al. A risk of malignancy index incorporating CA125, ultrasound and menopausal status for the accurate preoperative diagnosis of ovarian cancer. Br J Obstet Gynaecol 1990;97:922–929. 22. Harry VN, Narayansingh GV, Parkin DE. The risk of malignancy index for ovarian tumours in northeast Scotland—a population based study. Scott Med J 2009;54:21–23. 23. van den Akker PA, Aalders AL, Snijders MP, et al. Evaluation of the Risk of Malignancy Index in daily clinical management of adnexal masses. Gynecol Oncol 2010;116:384–388. 24. Howard FM. Surgical management of benign cystic teratoma. Laparoscopy vs. laparotomy. J Reprod Med 1995;40:495–499. 25.


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Gynecology_Novak. 24. Howard FM. Surgical management of benign cystic teratoma. Laparoscopy vs. laparotomy. J Reprod Med 1995;40:495–499. 25. Savasi I, Lacy JA, Gerstle JT, et al. Management of ovarian dermoid cysts in the pediatric and adolescent population. J Pediatr Adolesc Gynecol 2009;22:360–364. 26. Galinier P, Carfagna L, Delsol M, et al. Ovarian torsion. Management and ovarian prognosis: a report of 45 cases. J Pediatr Surg 2009;44:1759–1765. 27. Kavallaris A, Mytas S, Chalvatzas N, et al. Seven years’ experience in laparoscopic dissection of intact ovarian dermoid cysts. Acta Obstet Gynecol Scand 2010;89:390–392. 28. Rhode JM, Advincula AP, Reynolds RK, et al. A minimally invasive technique for management of the large adnexal mass. J Minim Invasive Gynecol 2006;13:476–479. 29. Anonymous. Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Operative Laparoscopy Study Group. Fertil Steril 1991;55:700–704. 30.


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Gynecology_Novak. 29. Anonymous. Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Operative Laparoscopy Study Group. Fertil Steril 1991;55:700–704. 30. Pellicano M, Bramante S, Guida M, et al. Ovarian endometrioma: postoperative adhesions following bipolar coagulation and suture. Fertil Steril 2008;89:796–799. 31. Mage G, Canis M, Manhes H, et al. Laparoscopic management of adnexal torsion. A review of 35 cases. J Reprod Med 1989;34:520– 524. 32. Vancaillie T, Schmidt EH. Recovery of ovarian function after laparoscopic treatment of acute adnexal torsion. A case report. J Reprod Med 1987;32:561–562. 33. Cohen SB, Oelsner G, Seidman DS, et al. Laparoscopic detorsion allows sparing of the twisted ischemic adnexa. J Am Assoc Gynecol Laparosc 1999;6:139–143. 34. Gjonnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril 1984;41: 20–25. 35.


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Gynecology_Novak. 34. Gjonnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril 1984;41: 20–25. 35. Huber J, Hosmann J, Spona J. Polycystic ovarian syndrome treated by laser through the laparoscope. Lancet 1988;2:215. 36. Kovacs G, Buckler H, Bangah M, et al. Treatment of anovulation due to polycystic ovarian syndrome by laparoscopic ovarian electrocautery. Br J Obstet Gynaecol 1991;98:30–35. 37. Farquhar C, Lilford RJ, Marjoribanks J, et al. Laparoscopic “drilling” by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev 2007;3:CD001122. 38. Gurgan T, Kisnisci H, Yarali H, et al. Evaluation of adhesion formation after laparoscopic treatment of polycystic ovarian disease. Fertil Steril 1991;56:1176–1178. 39. Naether OG, Fischer R. Adhesion formation after laparoscopic electrocoagulation of the ovarian surface in polycystic ovary patients. Fertil Steril 1993;60:95–98. 40.


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Gynecology_Novak. 39. Naether OG, Fischer R. Adhesion formation after laparoscopic electrocoagulation of the ovarian surface in polycystic ovary patients. Fertil Steril 1993;60:95–98. 40. Bedient CE, Magrina JF, Noble BN, et al. Comparison of robotic and laparoscopic myomectomy. Am J Obstet Gynecol 2009;201:566 e1–e5. 41. Palomba S, Zupi E, Falbo A, et al. A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: reproductive outcomes. Fertil Steril 2007;88:933– 941. 42. Seracchioli R, Rossi S, Govoni F, et al. Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy. Hum Reprod 2000;15:2663–2668. 43. Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2009;145:14–21. 44.


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Gynecology_Novak. 43. Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2009;145:14–21. 44. Day Baird D, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003;188:100–107. 45. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril 2009;91: 1215–1223. 46. Luciano AA. Myomectomy. Clin Obstet Gynecol 2009;52:362–371. 47. Sutton C, Diamond MP. Endoscopic surgery for gynecologists. St. Louis: CV Mosby, 1993. 48. Munro MG, Deprest J. Laparoscopic hysterectomy: does it work? A bicontinental review of the literature and clinical commentary. Clin Obstet Gynecol 1995;38:401–425. 49.


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Gynecology_Novak. 48. Munro MG, Deprest J. Laparoscopic hysterectomy: does it work? A bicontinental review of the literature and clinical commentary. Clin Obstet Gynecol 1995;38:401–425. 49. Summitt RLJ, Stovall TG, Lipscomb GH, et al. Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol 1992;80:895–901. 50. Munro MG, Parker WH. A classification system for laparoscopic hysterectomy. Obstet Gynecol 1993;82:624–629. 51. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009;3:CD003677. 52. Johns DA, Carrera B, Jones J, et al. The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital. Am J Obstet Gynecol 1995;172:1709–1715; discussion 15–19. 53.


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Gynecology_Novak. 53. Walsh CA, Walsh SR, Tang TY, et al. Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis. Eur J Obstet Gynecol Reprod Biol 2009;144:3–7. 54. Marana R, Busacca M, Zupi E, et al. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol 1999;180:270–275. 55. Munro M, Gomel V. Fertility-promoting laparoscopically-directed procedures. Reprod Med Rev 1994;3:29–42. 56. Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med 1997;337:217–222. 57. Parazzini F. Ablation of lesions or no treatment in minimal-mild endometriosis in infertile women: a randomized trial. Gruppo Italiano per lo Studio dell’Endometriosi. Hum Reprod 1999;14:1332–1334. 58.


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Gynecology_Novak. 58. Jacobson TZ, Duffy JM, Barlow D, et al. Laparoscopic surgery for subfertility associated with endometriosis. Cochrane Database Syst Rev 2010;1:CD001398. 59. Filmar S, Jetha N, McComb P, et al. A comparative histologic study on the healing process after tissue transection. I. Carbon dioxide laser and electromicrosurgery. Am J Obstet Gynecol 1989;160:1062– 1067. 60. Filmar S, Jetha N, McComb P, et al. A comparative histologic study on the healing process after tissue transection. II. Carbon dioxide laser and surgical microscissors. Am J Obstet Gynecol 1989;160:1068– 1072. 61. Munro MG, Fu YS. Loop electrosurgical excision with a laparoscopic electrode and carbon dioxide laser vaporization: comparison of thermal injury characteristics in the rat uterine horn. Am J Obstet Gynecol 1995;172:1257–1262. 62. Van Holsbeke C, Van Calster B, Guerriero S, et al. Endometriomas: their ultrasound characteristics. Ultrasound Obstet Gynecol 2010;35:730–740. 63.


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Gynecology_Novak. 62. Van Holsbeke C, Van Calster B, Guerriero S, et al. Endometriomas: their ultrasound characteristics. Ultrasound Obstet Gynecol 2010;35:730–740. 63. Hart RJ, Hickey M, Maouris P, et al. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev 2008;2:CD004992. 64. Chapron C, Dubuisson JB. Management of deep endometriosis. Ann N Y Acad Sci 2001;943:276–280. 65. Chapron C, Jacob S, Dubuisson JB, et al. Laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum. Acta Obstet Gynecol Scand 2001;80:349– 354. 66. Miklos JR, Kohli N. Laparoscopic paravaginal repair plus Burch colposuspension: review and descriptive technique. Urology 2000;56:64–69. 67. Ross JW. Multichannel urodynamic evaluation of laparoscopic Burch colposuspension for genuine stress incontinence. Obstet Gynecol 1998;91:55–59. 68.


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Gynecology_Novak. 67. Ross JW. Multichannel urodynamic evaluation of laparoscopic Burch colposuspension for genuine stress incontinence. Obstet Gynecol 1998;91:55–59. 68. Paraiso MF, Walters MD. Laparoscopic pelvic reconstructive surgery. Clin Obstet Gynecol 2000;43:594–603. 69. Canis M, Pouly JL, Wattiez A, et al. Laparoscopic management of adnexal masses suspicious at ultrasound. Obstet Gynecol 1997; 89:679–683. 70. Fowler JM, Carter JR. Laparoscopic management of the adnexal mass in postmenopausal. J Gynecol Tech 1995;1:7–10. 71. Possover M, Krause N, Plaul K, et al. Laparoscopic para-aortic and pelvic lymphadenectomy: experience with 150 patients and review of the literature. Gynecol Oncol 1998;71:19–28. 72. Homesley HD, Boike G, Spiegel GW. Feasibility of laparoscopic management of presumed stage I endometrial carcinoma and assessment of accuracy of myoinvasion estimates by frozen section: a gynecologic oncology group study. Int J Gynecol Cancer 2004;14:341– 347. 73.


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Gynecology_Novak. 82. Nezhat CH, Nezhat F, Brill AI, et al. Normal variations of abdominal and pelvic anatomy evaluated at laparoscopy. Obstet Gynecol 1999;94:238–242. 83. Hurd WW, Bude RO, DeLancey JO, et al. The relationship of the umbilicus to the aortic bifurcation: implications for laparoscopic technique. Obstet Gynecol 1992;80:48–51. 84. Brill AI, Cohen BM. Fundamentals of peritoneal access. J Am Assoc Gynecol Laparosc 2003;10:286–298. 85. Giannios NM, Gulani V, Rohlck K, et al. Left upper quadrant laparoscopic placement: effects of insertion angle and body mass index on distance to posterior peritoneum by magnetic resonance imaging. Am J Obstet Gynecol 2009;201:522 e1–e5. 86. Vilos GA, Ternamian A, Dempster J, et al. Laparoscopic entry: a review of techniques, technologies, and complications. J Obstet Gynaecol Can 2007;29:433–465. 87. Vilos GA, Vilos AG. Safe laparoscopic entry guided by Veress needle CO2 insufﬂation pressure. J Am Assoc Gynecol Laparosc 2003;10:415–420. 88.


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Gynecology_Novak. 87. Vilos GA, Vilos AG. Safe laparoscopic entry guided by Veress needle CO2 insufﬂation pressure. J Am Assoc Gynecol Laparosc 2003;10:415–420. 88. Audebert AJ, Gomel V. Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion. Fertil Steril 2000;73:631–635. 89. Brill AI, Nezhat F, Nezhat CH, et al. The incidence of adhesions after prior laparotomy: a laparoscopic appraisal. Obstet Gynecol 1995;85:269–272. 90. Fader AN, Rojas-Espaillat L, Ibeanu O, et al. Laparoendoscopic single-site surgery (LESS) in gynecology: a multi-institutional evaluation. Am J Obstet Gynecol 2010;203:501e1–e6. 91. Fader AN, Cohen S, Escobar PF, et al. Laparoendoscopic single-site surgery in gynecology. Curr Opin Obstet Gynecol 2010;22:331– 338. 92.


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Gynecology_Novak. 227. Golan A, Siedner M, Bahar M, et al. High-output left ventricular failure after dextran use in an operative hysteroscopy. Fertil Steril 1990;54:939–941. 228. Loffer FD, Bradley LD, Brill AI, et al. Hysteroscopic ﬂuid monitoring guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc 2000;7:167– 168. 229. Phillips DR, Nathanson HG, Milim SJ, et al. The effect of dilute vasopressin solution on blood loss during operative hysteroscopy: a randomized controlled trial. Obstet Gynecol 1996;88:761– 766. 230. Istre O. Fluid balance during hysteroscopic surgery. Curr Opin Obstet Gynecol 1997;9:219–225. Tommaso Falcone Thomas G. Stovall Hysterectomy is one of the most commonly performed surgical procedures in the United States. Vaginal hysterectomy is the procedure of choice in parous women unless this route is contraindicated.


Gynecology_Novak

Gynecology_Novak. Hysterectomy is one of the most commonly performed surgical procedures in the United States. Vaginal hysterectomy is the procedure of choice in parous women unless this route is contraindicated. Laparoscopic hysterectomy is associated with faster postoperative recovery and shorter hospital stay compared with abdominal hysterectomy. There are no randomized clinical trials demonstrating an advantage of robotic or single-port hysterectomy over conventional laparoscopic hysterectomy. There appears to be no advantage to the routine use of supracervical hysterectomy when compared with total hysterectomy. Salpingo-oophorectomy at the time of hysterectomy for benign disease in premenopausal women at average risk for ovarian malignancy is associated with an increase in long-term patient mortality from cardiovascular disease, and ovarian conservation should be strongly considered in these patients.


Gynecology_Novak

Gynecology_Novak. Hysterectomy is one of the most common surgical procedures performed. After cesarean delivery, it is the second most frequently performed major surgical procedure in the United States (1). According to the National Hospital Discharge survey, the rate of hysterectomy during the 5-year study period was 5.4 per 1,000 women per year in 2000 and declined to 5.1 per 1,000 per year in 2004. These data do not represent hysterectomies performed in ambulatory settings.


Gynecology_Novak

Gynecology_Novak. The highest rate of hysterectomy is between the ages of 40 and 49 years with an average age of 46.1 years (1). The highest rates of hysterectomy are for women living in the southern United States and they occur at a younger age. The lowest rates are consistently in the northeastern portion of the United States. Lower socioeconomic status is associated with increased hysterectomy rates (2). Hysterectomy rates are higher for black women (3). Reports on the effect of physician gender conﬂict with data that shows no overall impact (4). Bilateral salpingo-oophorectomy decreased between 2000 and 2004 from 53.8% to 49.5% (1). The frequency was the highest with abdominal hysterectomy and the lowest with vaginal hysterectomy.


Gynecology_Novak

Gynecology_Novak. The indications for hysterectomy are listed in Table 24.1. Uterine leiomyomas are consistently the leading indication for hysterectomy. As expected, the indications differ with the patient’s age (1). Hospitalization rates for hysterectomy in women between the ages of 15 and 54 years decreased from 1998 to 2005 for all indications except for menstrual disorders (5).


Gynecology_Novak

Gynecology_Novak. Leiomyomas The proportion of hysterectomies performed for leiomyomas decreased over time (1) (see Chapter 15). Fertility-preserving surgical management (myomectomy) is possible in most patients with leiomyomas. The decision to perform a hysterectomy for leiomyomas is usually based on the need to treat symptoms—abnormal uterine bleeding, pelvic pain, or pelvic pressure. Other indications for intervention have included “rapid” uterine enlargement, ureteral compression, or uterine growth after menopause. There is no clearly reproducible definition of rapid growth. The concept of rapid growth was challenged because these patients did not demonstrate clearly malignant conditions (6). Refuted reasons for hysterectomy in patients with leiomyomas are size greater than 12 weeks of gestation without symptoms, inability to palpate the ovaries on bimanual examination, and increased morbidity at hysterectomy with increased uterine size. If the procedures are performed abdominally, there is no


Gynecology_Novak

Gynecology_Novak. symptoms, inability to palpate the ovaries on bimanual examination, and increased morbidity at hysterectomy with increased uterine size. If the procedures are performed abdominally, there is no difference in surgical morbidity between patients with a 12-week-sized uterus and those with a 20-weeksized uterus (7). Therefore, hysterectomy for leiomyomas should be considered only in symptomatic patients who do not desire future fertility (7).


Gynecology_Novak

Gynecology_Novak. To reduce uterine size before hysterectomy, patients with large leiomyomas may be pretreated with a gonadotropin-releasing hormone (GnRH) agonist (8,9). In many cases, the reduction of uterine size is sufficient to permit vaginal hysterectomy when an abdominal hysterectomy would otherwise be necessary. In one prospective trial, premenopausal patients with leiomyomas the size of 14 to 18 weeks’ gestation were randomized to receive either 2 months of preoperative depot GnRH agonist or no GnRH agonist (8). Treatment with a short course (8 weeks) of leuprolide acetate before surgery enabled the procedures to be converted safely from an abdominal hysterectomy to a vaginal hysterectomy (9). This preoperative regimen was associated with a rise in hematocrit before surgery and a shorter hospital stay and convalescent period because patients were more likely to have a vaginal rather than an abdominal hysterectomy.


Gynecology_Novak

Gynecology_Novak. Excessive uterine bleeding is the indication for about 20% of hysterectomies. Dysfunctional uterine bleeding assumes abnormal bleeding without an obvious anatomic cause (see Chapter 14). Anovulatory uterine bleeding is typically associated with polycystic ovary syndrome (PCOS), a condition in which anovulatory cycles are common. The bleeding can be controlled by medical intervention with progestin, estrogen, or a combination of progestin and estrogen given as oral contraceptives. Ovulatory abnormal uterine bleeding can be controlled by nonsteroidal anti-inﬂammatory agents, hormonal intervention, tranexamic acid, or the levonorgestrel intrauterine device. In these patients, endometrial sampling should be performed before hysterectomy (10). Dilation and curettage is not an effective means of controlling bleeding and is not necessary before hysterectomy. Hysterectomy should be reserved for Table 24.1 Indications for Hysterectomy (Percentage): United States 2000–2004 Endometriosis 17.7