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1SURGICAL MICRO HYSTEROSCOPY AT INTRAUTERINE
ADHESIONS
1Malikov A., 2Yusupov U.Yu.
1,2Republican specialized scientific and practical medical center for maternal and child health
1,2Obstetrician gynecologist https://doi.org/10.5281/zenodo.13145001
Abstract. Intrauterine sinechiae is one of the unsolved problems of gynecology. Progress in a field of endoscopy gives possibility to overcome bottle neck of the traditional technologies like invasiveness anesthesia necessity, blindness of the procedure and usage of the big diameter
instruments. A clinical case and literature review of the 3rd stage of the intrauterine sinechiae (Asherman's syndrome) is presented.
Keywords: surgical microhysteroscopy, intrauterine sinechiae, Ahserman's syndrome, diagnosis, treatment.
In modern gynecology, issues of diagnosis and treatment of intrauterine synechia seem problematic. The most severe form of intrauterine synechiae, known as Asherman's syndrome, is often the result of intrauterine manipulation or genital inflammation. Traditionally, surgical hysteroscopy has been recommended for the treatment of this pathology, which is often performed using a hysterorectoscope, which requires anesthesia, dilation of the cervical canal, and the use of large instruments.
The advent of small-diameter hysteroscopes with an operating channel and a continuous irrigation system made the procedure much less invasive. Currently, surgical microhysteroscopy is the method of choice in the treatment of such pathology.
Intrauterine synechia was first described by Heinrich Fritsch at the end of the 19th century. Clinical manifestations of intrauterine synechiae are diverse. Intrauterine synechiae can be expressed by partial or complete closure of the uterine cavity. Terms that can be used to describe such situations are as follows: Asherman's syndrome means complete obliteration of the uterine cavity and amenorrhea as the main symptom. For partial obliteration of the uterine cavity, the term intrauterine synechia (sinechiae - translated from Greek - adhesion) should be used. Clinical signs mainly include the manifestation of menstrual and reproductive diseases: irregular bleeding, hypomenorrhea, secondary dysmenorrhea, amenorrhea. Subfertility can be explained by both endometrial defects and blockage of the fallopian tubes. Intrauterine synechiae can also cause miscarriage.
The endometrium has a unique ability to regenerate the functional layer during menstruation. Various factors can cause the destruction of the endometrium down to the muscular layer. It is impossible to restore such destruction, which leads to the formation of scar tissue.
The reasons for the development of intrauterine synechiae are different: mechanical and iatrogenic disorders, pathological condition of the endometrium, idiopathic reasons - when the causative factors cannot be determined. Adhesions can vary from soft to very dense, with varying degrees of connective tissue.
There are several classifications of intrauterine synechiae: O. Sugimoto (1978), S. March, R. Israel (1981). Since 1995, Europe has used the classification adopted by the European Association of Gynecological Endoscopists (ESH, 1989), which, based on the data of
hysterography and hysteroscopy, distinguishes 5 levels of intrauterine synechia depending on the position and degree of synechia, blockage and occlusion. Fallopian tubes. Degree of endometrial damage:
Level I. Thin or delicate synechiae are easily destroyed by the body of the hysteroscope, the mouths of the fallopian tubes are empty.
Level II. A single dense synechia is a joint that connects separate, separated areas of the uterine cavity, the mouths of both fallopian tubes are usually visible and cannot be destroyed only by the body of the hysteroscope.
Level II. Synechia is only in the internal os region, the upper parts of the uterine cavity are normal.
Level III. Many dense synechiae - connect separate areas of the uterine cavity, unilaterally obliterate the area of the openings of the fallopian tubes.
IV degree. With (partial) obstruction of the uterine cavity, widespread dense synechiae - the mouths of both fallopian tubes are partially closed.
And the level. In combination with I or II degree, extensive scarring and fibrosis of the endometrium - with amenorrhea or pronounced hypomenorrhea.
Vb level. Extensive scarring and fibrosis of the endometrium in combination with III or IV degree - with amenorrhea.
According to the ESH classification, Asherman's syndrome corresponds to III - IV levels (1989). Diagnosis is based on complaints, anamnesis, sonohysterography and hysteroscopy.
The main treatment method is adhesiolysis surgery [3]. Currently, there are several technologies:
Figure 1.
Wide, mainly connective tissue, synechiae of the uterine cavity
1) blunt separation of thin adhesions during hysteroscopy with a hysteroscope tube, 2) mechanical separation of adhesions with scissors inserted into the uterine cavity through the
operating channel of the hysteroscope, 3) application of sodium-aluminum garnet laser inserted
into the uterine cavity the secret through the operating channel of the hysteroscope,
4) monopolar or bipolar energy, 5) hydrolavage, 6) intrauterine catheter, 7) fluoroscopic technique. Of particular interest is the use of office hysteroscopy for the diagnosis and treatment of this pathology. The overall complication rate reaches 7% and is mainly represented by
perforations. Adjuvant therapy with or without estrogens, intrauterine devices, intrauterine catheters, and anti-adhesion barriers are used to prevent the recurrence of adhesions in the postoperative period. Treatment results are individual and depend on the severity of intrauterine synechiae, the etiology and duration of the disease, and the technologies used for treatment. During adhesiolysis, it is very important that the uterine cavity returns to its normal size and the endometrial islands are preserved, as a result of which the inner surface of the uterine cavity regenerates and repopulates. The use of surgical microhysteroscopy with microinstruments and bipolar energy in accordance with the concept of "See and treat" with the use of additional ultrasound allows for the diagnosis and careful treatment of intrauterine synechiae and Asherman's syndrome.
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