LONG JOURNEY IN A SMALL WOUMB.

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LONG JOURNEY IN A SMALL WOUMB.

• Mounir M M Elhao,
• Ain Shams University.
• Cairo,Egypt.

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The crossing bridge to mysterious woumb.
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Panoramic View,Tubal ostea.
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IDENTIFICATION OF OVULATION BY PANORAMIC
HYSTEROSCOPY.

• Secretory activity diagnosed by five criteria
• Endometrial thickness.
• Vascularity.
• Prominence of glands.
• Surface roughness.
• Tubal ostea Appearance.
• Depending on the five criteria( sensitivity was
  81.9 )
• (Mounir Elhao et al,1992.)

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• Thickness.
• Vascularity.
• Surface glands
• These criteria were very sensitive.for diagnosis
  of ovulation.( sensitivity 90)
• The practice of DC in rarely needed.

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Hysteroscopic Classification of IUS.

• 844 infertile women
• Fine adhesions.No menstrual disorders.
• Coarse adhesion,oligohypomenorrhoea.
• Dense adhesions,Tubular cavity.
• Complete Occlusion,amenorrhoea.
• Main causes Curettage,CS,Infections.
• TTT.Scissors,Diathermy knife.
• (Sammour,Elhao,Yehya Saleh,March,1993)Paris

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Major and Minor IUS.

• Correction of major degree of IUS (Grade 3 4)
• With the use of electro cautary needle under
  hysteroscopic guidance resulted into very poor
  pregnancy rates.(2cases only)Both of them resuted
  into missed abortion.
• Elhao,Lamii,Elnazer, Hamza.MD Thesis(1996)

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IUS.

• In 32 cases (43.2 ) G12
• In 44 cases (56.8) G 34
• Recurrence of adhesions after surgical
  hysteroscopy was in almost 1/3 of cases.maily in
  G34,Mainly after puerpural sepsis.
• Now the use of scissors under office and routine
  hysteroscopy gives far more better
  results.(ongoing study .)

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IUS.
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Missed IUCDs.

• 50 cases of missed IUCDs threads,hysteroscopy was
  successful in extraction of 100(20 cases) of
  IUCDs While DC was successful in only 90 of
  cases.
• Maged ,Elhao et al.1989.

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Missed Threads if IUCDs,a new technique of
hysteroscopic extraction.

• New technique of Hysteroscopic extraction of
  IUCD,using the telescope oh the hysteroscope and
  a mini crocodile forceps.from 286 cases of missed
  threads,236 were found to be intrauterine,and
  were either successfully extracted (220cases)
  with diagnostic telescope and mini-crocodile
  forceps.or left in place after withdrawal of the
  threads(16 cases.)
• (Elhao,1990)

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IUCD related AUB.

• 72 patient wearing IUCDs,41 cases complaining of
  irregular uterine bleeding.while 31 cases as
  controls.
• In the group of AUB 27 cases of the 41 cases had
  local pathplogy or abnormal position of IUCDs but
  only one case of the control had local
  pathological lesion.
• Elhao et al,1989

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CS Scar.

• In 50 cases of previous CS there were
• Scar not detected 11
• Fibrotic white band 16
• Granulation tissue 13
• Minute defect. 03
• Large defect. 05
• Cervicat scar 02
• What should we do?
• Yehya,Sammour,Elhao

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The use of hysteroscopy in MFD.
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UNICORNUATE UTERUS.
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UNICORNUATE UTERUS.
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Septum resection.

• 2-3 of the population.
• 20 of repeated miscarriages.
• Since Edstrom in 1074,described hysteroscopic
  resection of uterine septum the technique was
  practiced
• Elhao,Sammour and Elgammal,MS thesis,(1993.)
• One of the most satisfactory procedures in
  hysteroscopic surgery and gynecology.

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Hysteroscopic management of MFD for over 25
years..

• First described by ELDSTROM in 1974
• Hysteroscopic management of lateral fusion
  defects,septate,suseptate ,partial bicornuate and
  uterus bicollis with or without septate vagina
  was done since early eighties.obstetric
  performance wasmarkedly improved after this
  procedure.
• Electric Knife ,loop,or cold scissors.
• Unipola or bipolar diathermy.
• With or without anesthesia.
• Mounir Elhao,Sammour (several studies.)

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MFD.

• The most satisfactory results which were achieved
  by hysteroscopy.wether by electric knife or by
  scissors.By routine resectoscope or office.

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Septum.
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Routine hysteroscopy for patients with high risk
of uterine malignancy.

• On fifty patients with high risk for uterine
  malignancy,(Diabetic,hypertensive,,obese,infertile
  ,low parity),
• The study concluded that a negative
  hysteroscopic finding was considerted conclusive
  of absence of uterine pathology
• Also the study concluded that panoramic
  hysteroscopy is a valid alternative of
  traditional D and C.
• (Sammour,Elhao,Eissa,Khalifa and Elmogazi. 1992),

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Recurrent abnormal uterine bleeding.

• Cases were 2 or more DCs were performed for
  irregular uterine bleeding.(33 patients.)
• Hysteroscopy revealed abnormal intracavitary
  pathology in 81.8 of cases examined.(10
  myomas,4 polyps, 11 hyperplasia,1 atrophy and
  cancer in 1 case.)
• Makhlouf and Elhao,1989.

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POLYP.
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Submucous fibroids.
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Menorrhagia, infertility or recurrent pregnancy
loss are frequently related to the presence of
submucosal myomas and endometrial or cervical
polyps

• .
• Traditionally, the resectoscope has played a
  major role in the resolution of these
  pathologies, forcing the hysteroscopist to use
  this large diameter instrument even in the
  presence of small lesions (Loffer, 1990 Corson
  and Brooks, 1991 Hallez, 1996 Porreca et al,,
  1996 Bettocchi et al,, 1998). The results were
  excellent, but due to the size of the instruments
  and hence the need to dilate the cervical canal,
  the use of general anaesthesia and an operating
  room were generally required.

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The use of Pour 8 (vasopressin analogue.)prior to
endometrial resection.

• Seems to have an important role during the
  procedure.Fluid absorption was less,bleeding was
  less and vision was better in the pour-8 group.
• Elhao,Fateen,Mostafa and Taha,MS degree.(1998).
• Elhao et al,

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Acetic acid vaginal pessaries prior to
hysteroscopy.

• Abdelmaaboud,Faris MD thesis.(2007)

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25 Dextrose a safe and clear distension medium.

• 76 cases done with 25 dextrose for uterine
  distetion as a safe and clear medium,However in
  recent experience its seems unsafe due to
  operative procedure opening deep sinuses and
  intravasation of the fluid and causing
  hyperglycaemia.
• Elhao,1988.

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TUBAL OSTEUM.
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PTB CANNULATION.
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Hysteroscopic catheterisation of the fallopian
tube in proximal tubal block.

• Patients infertile for at least one year with
  proven PTB by HSG and or Laparoscopy (witout
  evidence of other major explanation for their
  infertility.)were subjected to tubal
  cannulation.using one of many cannulation kits.
• The study showed recanalisation rate of 77.7
• M Sabri,K Lamii and M Elhao,(MD thesis,1996.)
• Recently,with more experience,a trial on
  antichlamidial therapy for three month is
  worthwhile before cannulation.

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Effect of preoperative GnRHa or Progestin on
endoscopic endometrial resection.

• From october 1993 to october 1996.,80 patients
  prepared for endometrial resection .25 depot
  provera,25 GnRHa and 30 patients non treatment
  group.
• Conclusions were that progestins were cheaper and
  better than no treament but with more side
  effects.GnRHa gave better control of menorrhagia
  ,more effective reduction of endometrial
  thickness and reduction of uterine size ,less
  fluid absorption.
• Shalaby,Hussein,Elhoussiny and Elhao,(1998.)
• With more experience.No Need For preoperative
  preparations.

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Amnion graft in severe IUS

• Amer (2006 ).

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O perative O ffice H ysteroscopy
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• In the last 10 years, technological improvements
  have led to the production of smaller diameter
  scopes. This has prompted the industry to develop
  sheaths which continue to have a final diameter
  of 5 mm, includes the working channel and
  continuous flow features.

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The most important requirement for successful
hysteroscopy

• is satisfactory distension of the uterus.
• While many different media have been used,
  recent advances in equipment have greatly
  simplified the use of saline for diagnostic and
  simple operative hysteroscopy.

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• Saline 0.9.Best, office,Bipolar.
• Glucose 5 .
• Glycene.Best operative Unipolar(lt1000.)
• Hyskon.Not any more.(DIC.)
• Glucose 10 ,Hyperglycaemia.

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• Another instrument, however, has revolutionized
  the way office hysteroscopy.
• The compact operative hysteroscope is a complete
  system. It is only 5-mm in diameter, and does not
  require the use of a sheath, as it has three
  built in channels. Two small channels allow the
  inflow and egress of distending media, and the
  third, which is 5-F in diameter, allows the
  insertion of operative instruments.
• This eliminates the need to change sheaths, or
  start with a larger diameter operative sheath,
  when anticipating the need to remove polyps, cut
  adhesions, or do biopsies under direct vision.

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• The risks of diagnostic hysteroscopy are quite
  low.
• Infection is uncommon, as is perforation

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• WHY OFFICE HYSTEROSCOPY ?
• MOSTLY
• I am not at the mercy of an OR schedule .

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CONCLUSIONS.

• Office hysteroscopy is a time-efficient and
  cost-effective procedure, made possible by the
  development of small instruments. Proper patient
  selection and training of office personnel are
  mandatory to minimize complications and maximize
  efficacy.

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• TECNIQUE
• using saline distension medium and
• a 5 mm continuous flow office hysteroscope
  (Bettocchi Office Hysteroscope size 5 Karl Storz
  GmbH Co., Tuttlingen, Germany). The scope is
  based on a rod lens system with a diameter of 2.9
  mm and a 30 view.

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• The continuous flow sheath has an oval profile
  and maximum 5 mm diameter
• with an incorporated 5 Fr. working channel
• the mechanical instruments used were grasping
  forceps with teeth and scissors (Karl Storz GmbH
  Co.).

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• Intrauterine pressure was maintained at a
  constant40-60 mmHg using an electronic pump for
  irrigation and aspiration (Endomat Karl Storz
  GmbH Co.).

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Distribution of the hysteroscopic findings in
examined women
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Table (3) Indications of office hysteroscopy in
four hundred cases examined.
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Pain stratification in 400 examined patients with
office hysteroscopy.
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PERFORATION DURING HYSTEROSCOPIC PROCEDURE.
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Cervical dilatation.

• Conclusion Women treated with lidocaine spray
  had significantly less pain. Uterine cavity
  abnormality might be associated with a higher
  degree of pain during hysteroscopy D. SORIANO,
  MD, S. AJAJ, MD, T. CHUONG, MD, B. DEVAL, MD, A.
  FAUCONNIER, MD and E. DARAÏ, MD, PhD
• Karim..Acetic Acid

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• .
• CONCLUSION Office hysteroscopy is a
  time-efficient and cost-effective procedure, made
  possible by the development of small instruments.
  Proper patient selection and training of office
  personnel are mandatory to minimize complications
  and maximize efficacy.
• Lindheim SR, Kavic S, Shulman SV, Sauer MV
  (2005)

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CONCLUSIONS.

• Office hysteroscopy is a very practical tool for
  an office setting.
• Minor operative procedures are possible,using
  scissors or bipolar diathermy.
• All degrees of IUS arebetter treated with mini
  scissors and office hysteroscopy.
• Hysteroscopic endometrial resection and large
  myomas are in need for General anaesthesia and
  9mm resectoscope.