Hysteroscopic Metroplasty - Complications, Procedures, and Benefits

Introduction

Infertility is one of the biggest gynecological problems of recent times. Around 10 percent of women of reproductive age suffer from different types of infertility. Congenital malformations encompass 10 percent of these cases. Also, congenital abnormalities of the uterus are responsible for miscarriage. Septate uterus is an abnormality related to women's infertility and repeated miscarriage. The hysteroscopy procedure in cases can be useful in removing septa. The surgical removal of septa with the help of hysteroscopy is called hysteroscopic metroplasty.

What Is Septate Uterus?

This is characterized by a thin membrane in the uterus that divides the uterus into two parts. 2 out of every 1000 women suffer from this condition. This is a congenital malformation form due to the failure of resorption of the tissue connecting the two paramesonephric (Mullerian) ducts (structures that form female reproductive ducts) before the 20th week of fetal life. The tissue in the membrane can be fibrous or muscular. Based on the extent, this can be classified into the following types:

1. Complete Septate Uterus- In this condition, the septum divides the uterus and the cervix into two parts.

2. Incomplete or Partial Septate Uterus- In this condition, the septum does not extend into the cervix.

There is also a third condition in which the septum divides the uterus and the cervix, extending to the vagina.

What Are the Complications Associated With Septate Uterus?

The complications associated with the septate uterus are:

1. Pain during the menstrual cycle.

2. Repeated miscarriage.

3. Initiation of labor pain before the stipulated time.

4. Breech presentation - In this condition, instead of the head baby’s legs or buttocks come out first during delivery.

What Is Hysteroscopy Procedure?

This procedure was first performed by Pantaleoni in the year 1869 using a device called a cystoscope. In this procedure, a flexible telescope-like device is inserted into the uterus through which internal anatomy can be visualized with the help of a distending media.

• The hysteroscope instrument can be of several types. But based on rigidity, they have been classified into flexible or rigid types. The viewing angle of this instrument varies from 0 to 70 degrees, and fluid channels, a light source, and a video monitoring system are attached to it. Different Hysteroscope in use are:

1. STORZ Bettocchi Integrated In-Office Hysteroscope - The diameter of this hysteroscope ranged between 4 to 5 millimeters. The tip is oval-shaped and can be passed easily through the cervix. The diameter of the optical portion of the instrument is 2.1 millimeters or 2.9 millimeters with a viewing angle of 0 to 30 degrees. There is also a working channel present that can insert different semi-rigid instruments through it.

2. STORZ Campo Trophyscope - The diameter of this type of hysteroscope is 2.9 millimeters with a viewing angle of 30 degrees. The smaller diameter helps the passage of the instrument much more easily. This hysteroscope is passed through a channel with a diameter of 3.7 millimeters. The channel contains provisions for semi-rigid instruments and bipolar electrodes passing through it.

3. Olympus Flexible Hysteroscope - The diameter of such a hysteroscope is 3.7 millimeters with a viewing angle of 100 degrees.

• One of the major components of the hysteroscopy procedure is the distension medium. Carbon dioxide is a gaseous distension medium. But these types of medium may cause low visibility and bleeding. This problem can be solved with the use of a fluid distension medium. But fluid distension medium interferes with the electrical current loops used for dissection. Monopolar current instruments interfere with fluid distension medium and cause dispersal to surround tissues. That is why bipolar current instruments must be used while using fluid distension mediums like normal saline. The function of such a medium is:

1. Better visualization.

2. Control bleeding and fluid secretion.

3. Provide necessary irrigation.

4. Retraction of the internal structures.

• During the hysteroscopy procedure, additional instruments are required. These instruments are:

1. Metal Speculum - Used to open up the vagina widely.

2. Cervical Tenaculum - This single-toothed instrument is used for stabilization and traction and allows the descent of the uterus.

3. Cervical Dilators - This osmotic device opens the cervix before gynecological procedures. This helps to access the uterus and fallopian tube.

4. Ring Forceps - This instrument contains a pair of ring-shaped jaws that helps encircle the tissue.

What Is the Surgical Procedure?

The surgical steps of hysteroscopic metroplasty are as follows:

• The most important step of this procedure is patient positioning. The patient is positioned on a flat table in the dorsal lithotomy (lying on the dorsum with the knees and the hips flexed at 90 degrees and abducted at 30 degrees, pads support calves).

• The procedure is performed under local anesthesia. A 25 or 27-gauge needle is used to administer anesthesia into the cervix. 1 percent or 2 percent lidocaine with or without epinephrine is used for anesthesia.

• A bimanual examination of the patient should be done, and the patient's urinary bladder should be empty. A catheter can be used to drain urine.

• The hysteroscope is inserted into the vagina through the vaginoscopic entry technique. This is also known as the touch technique. In this approach, no speculum nor a tenaculum is used the vagina is distended through the application of a distension medium through the hysteroscope placed into the lower vagina.

• After this, the cervix and the cervical opening of the vagina are identified.

• After identifying the cervical opening of the vagina, the posterior fornix is located, and gradually, the probe enters the uterus through the internal os (opening of the uterus).

• Within the uterine cavity, the septum can be visualized. Because of the effect of the distension medium, the septa stretch away from the uterine walls. As a result, blood circulation is reduced in this area. The septum is removed with the help of scissors and lasers. Scissors reduce the chance of thermal injury, and the lasers are responsible for less bleeding after the procedure.

What Are the Advantages?

Previously laparoscopic techniques such as the Tompkins procedure were used to treat the septate uterus. But nowadays, hysteroscopic metroplasty is getting popular. The advantages of this technique are:

1. No abdominal or myometrial incision is required.

2. It is done in the outpatient department, and the patient can be discharged within a few hours.

3. Post-operative reduction in the uterine cavity size is not noticed.

4. Less post-operative complications.

Conclusions

Septate uterus is a congenital malformation of the uterus. The presence of septum is responsible for several gynecological complications like the abnormal menstrual cycle, miscarriage, and infertility. Hysteroscopic procedures are safe and rapid. Post-operative complications are also less. This technique can also avoid complications associated with the traditional laparoscopic procedure.