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UDC 618.14-007.66-089.844
AMBULATORY RECONSTRUCTIVE SURGERY BY INTRAUTERINE SEPTUM (TECHNIQUE)
South Ural State Medical University, Chelyabinsk
O.V. Safronov, Ye.V. Bryukhina, L.Ye. Safronva, L.S. Ishchenko
Anomalies in the development of female genital organs account for 4% of all congenital malformations. They can cause disorders of the menstrual cycle, infertility and complicated course of pregnancy.
One of the abnormalities of the development of the uterus is the intrauterine septum. When this pathology is combined with infertility or miscarriage, there appear a question of the need to conduct and choose the method of operative correction. The article presents a procedure for reconstructive and plastic surgery on the uterus using an office rigid hysteroscope with a diameter of 4-5 mm and a surgical laser. Key words: intrautous septum, office hysteroscopy, metroplasty, surgical laser.
Congenital abnormalities of female genital organs, according to different literature sources, constitute 4% of all congenital disorders. In recent years, there has been observed the tendency of increase of frequency of detection of genital organs development defects which is, apparently, conditioned both by the growth of morbidity and by the improvement of diagnosis methods [1, 2].
One of the types of uterus development abnormalities is the intrauterine septum. Its presence can cause early and late spontaneous miscarriage, pre-term deliveries [3, 4].
In case of combination of this pathology with infertility or pregnancy miscarriage there often arises the necessity of surgical treatment [5].
The choice of most effective reconstructive surgeries by genital development defects remains a complicated task [5]. The implementation of hysteroscopic resectoscope and incision scissors is accompanied by the risk of penetration of uterus in the fundus, as these instruments do not allow to dissect the septum to the stated depth.
Research objective: to evaluate the effectiveness of the elaborated minimal invasive ambulatory technique of intrauterine septum dissection.
Materials and methods
To evaluate the effectiveness of the elaborated method of ambulatory metroplasty there was performed the analysis of 15 ambulatory hysteroscop-ic operations.
The dissection of intrauterine septum was conducted by means of Russian junction laser "Latus-K" (Saint-Petersburg) with optical output power from 0 to 30 W, endoscopic scissors and office hard hysteroscope 4-5 mm in diameter having channels for irrigation of uterine cavity and instrumental channel 5 Fr for semi-hard instruments (K.STORZ). The broadening of cavity was made by the physiological solution of sodium chloride and hysteron-pump. The lazer energy was brought to tissues by means of optic fiber 600 mkm in diameter.
The operations were performed in ambulatory conditions, without cervical canal broadening, under intravenous anesthesia.
For metroplasty in ambulatory conditions there was used the introduced method (patent for the invention №2610542 of 13.02.2017). Before the surgery there was conducted ultrasound investigation with 3d reconstruction of uterine cavity. In terms of study there was measured the length of the whole septum and part of the septum subject to dissection (in millimeters). For the operation there was prepared optic fiber: the laser fiber consisting of quarte and covered with polymeric enclosure was uncovered. As a result, the working element of the optic fiber was formed (5 mm). The optic fiber was introduced into the cavity of the uterus through the instrument channel of the hysteroscope and was brought to the most outstanding part of the septum. The working laser element was immersed into this part of the septum and there was formed a vaporization channel 5 mm deep. Then, with the interval of 1-2 mm on the left and right there were made additional vaporization channels. The tissue of the septum between the channel was dissected by endoscopic scissors 5 Fr. Thus, the septum was dissected to the strictly stated depth - 5 mm. The described manipulations were repeated in case of further dissection need.
For the sake of control of effectiveness of the conducted metroplasy in 2 months there was made ultrasound and hysteroscopy research.
The statistical data processing was performed by means of IBM SPSS Statistics 19. Quantitative parameters are presented by mean value and standard deviation.
Results and discussion
The age of operated patients constituted 31,85±3,55 (from 25 to 38 years). The indication for surgery in 12 patients was aggravated obstetric and gynecological anamnesis: in 5 (33,33%) patients the anamnesis included two spontaneous miscarriages, in 4 (26,67%) patients - one spontaneous
miscarriage at the term of 16 weeks of pregnancy, in 3 (20%) patients - pre-term delivery at the term up to 34 weeks of pregnancy. # patients (20%) were directed to the hysteroscopic metroplasty before assisted reproductive treatment.
The analysis of duration of surgery showed that the average duration of operation constituted 15,3±3,22 minutes, blood loss - 3,92±2,33 ml.
The control ultrasound investigation conducted in 2 months revealed sufficient depth of the septum dissection, and the hysteroscopic examination showed full restoration of the endometrium structure and lack of vulnerary substrate in all patients.
Conclusion
The elaborated hysteroscopic technique of reconstructive surgery on uterus allows to totally dissect the intrauterine septum without complications, especially, to avoid the uterine penetration. The use of hard office hysteroscope does not require the cervical channel broadening which is important from the point of view of prevention of cervical insufficiency. The implementation of laser prevents the development of complications connected with electric surgery. The combined use of surgical laser and endoscopic scissors prevents the formation of vulnerary substrate in the uterine cavity and contributes to quick restoration of en-dometrium. Consequently, the current technique of surgery is effective, safe and can be recommended for use in ambulatory conditions.
References
1. Adamyan L.V., Kulakov V.I., Khashukoye-va A.Z. Defects of uterine and vaginal development. Moscow, 1998.
2. Adamyan Ye.A., Kurilo L.F., Okulov A.B., Stepanyan A.A., Bogdanova Ye.A.m Glybi-na T.M., Makiyan Z.N. "Systematization of nosological forms of female genital anomalies. Problems of reproduction. 2010; 2: 10-14.
3. Manukhin I.B., Selivanova G.B., Makiyan Z.N. Course of pregnancy in women with uterine and vaginal anomalies. Materials of I International conference in RUDN. Moscow, 2002.
4. Makiyan Z.N., Osipova A.A., Mailova K.S., Bobkova M.V. Factors of fertility disorders and their correction in women with uterine anomalies. Materials of International congress "Modern technologies in diagnosis and treatment of gynecological diseases". Moscow, 2005.
5. Makiyan Z.N., Bobkova M.V., Adamyan L.V. Defects of uterine and vaginal development. New aspects of diagnosis, patho-genesis and surgical treatment. Materials of the All-Russian Forum "Mat' I ditya". Moscow, 2009.
Contacts:
Corresponding author - Safronov Oleg Vladi-mirovich, Candidate of Medical Sciences, Associate Professor of the Department of obstetrics and gy-necology and further vocation education of South Ural State Medical University, Chelyabinsk. 454000, Chelyabinsk, Pobedy Prospekt, 287. Tel.: (3512) 7412283. Email: docsafronov@rambler.ru
