子宫纵隔宫腔镜手术（图文演示）

9. Adjustment of system

Monopolar system
The resection techniques described use monopolar current. The suction-irrigation pump must be preset to maintain an intrauterine pressure <=100 mm Hg, a 250 mL/s flow rate, a 0.2 bar suction pressure and 45 W of power. The procedure must not last longer than 45 minutes. The total volume of glycocolle used must be limited to 6 L. Precise monitoring of the distension liquid inflow and outflow must be done, and the procedure must be stopped immediately if there is a difference between the irrigation and suction flow rates (a 500 mL difference can be allowed). If there is too much of a difference, or if the procedure lasts too long, a chemistry panel must be performed immediately after the procedure to check for metabolic complications (hyponatremia).

Bipolar system
Bipolar spray electrosurgery is a more recent system. Its efficacy seems to be equivalent to monopolar electrosurgery, with a decrease in morbidity. The suction-irrigation pump should be preset to maintain a flow of 150 mL/s, a pressure of 80 mm Hg and 100 W or less of power. There are no limits to the duration of the procedure.
Bipolar systems have the advantage of being safer, because they can be used with saline, thereby decreasing metabolic complications. In contrast to the monopolar system, which penetrates into the tissues and can be partly obscured at certain points, the bipolar system is constantly visible. This lowers the risk of uterine perforation.

10. Operative steps
&#8226; Dilation of the cervix

Bimanual examination is carried out to evaluate the position of the uterus before dilation. A speculum is inserted and the cervix is grasped with 2 Pozzi graspers placed in a 3 o’clock and 9 o’clock position to exert traction on the uterus in order to bring it into an intermediary position and to rectify an anteversion or a major retroversion. Hysterometry is routinely performed before beginning the dilation. The cervix is then dilated with Hegar’s dilators, using progressively larger dilators. Dilation of the cervix must be done carefully to avoid a uterine perforation.

&#8226; Inserting the resectoscope

The endocamera, the resectoscope and the electrode are assembled and connected to the Xenon light source, the hysteroscopic unit, the electrosurgical generator and the suction-irrigation tubing. Care must be taken to remove all air bubbles from the tubing. The resectoscope is then introduced under videoscopic guidance.

&#8226; Landmarks

Thorough visual exploration of the uterine cavity is essential. The 2 tubal ostia must be perfectly discerned to locate the base of the septum.

&#8226; Division

The division is performed in a progressive manner using repetitive contact between the electrode and the septum. The uterine septum is divided transversally starting at its apex, halfway between its anterior and posterior surfaces, causing it to retract and become a part of the corresponding surfaces of the uterus. Distension of the uterus is progressively achieved as the septum is divided (the cavity opens like a book), and the cavity gradually acquires a normal aspect.
The tissue of the septum is fibrous and does not bleed. The septum ends where healthy myometrium is revealed by the occurrence of minimal bleeding. When this bleeding occurs, the division should be stopped, because it indicates that the septum has been completely divided.

11. Special cases
Special case 1
When the septum extends down to the cervix, it is first divided with cold scissors or with a cutting electrosurgical probe. The resection begins at the level of the cervix, and extends from the external ostium towards the uterus. The division of the uterine septum is continued, with care taken to preserve the plane of the tubal ostia.

Special case 2
When the uterine septum is wide, division must be stopped as soon as any bleeding occurs. The procedure is then performed in 2 phases with a second operation scheduled 2 months later to complete the procedure.

Special case 3
The operative step begins by dividing the vaginal septum using monopolar electrosurgery, with resection of the septum up to the anterior and posterior cul-de-sacs, and suture of the anterior and posterior surfaces of the vagina with interrupted absorbable suture.
The procedure is then continued as for septate uterus.

12. End of procedure
End of procedure
At the end of the procedure, it is preferable to leave a fundic spur of less than 1 cm in place, to avoid weakening the fundic myotrium. The procedure is ended when both tubal ostia are visible under the same hysteroscopic view. This is important, because the risk of perforation increases if the resection is carried out too far. Some surgeons recommend follow-up sonography to make sure that there has been no perforation.

Postoperative management
No intrauterine device is needed.
Estrogen therapy is administered for 2 months to facilitate the follow-up hysteroscopy (its therapeutic advantages have not been demonstrated, however).
During the immediate postoperative period:
- if the inflow-outflow assessment is superior to 500 mL, a chemistry panel must be performed.
After 2 months:
A follow-up diagnostic hysteroscopy is performed:
- to check for possible adhesions. It is usually easy to remove these new, fine adhesions during the diagnostic procedure with the pointed tip of the hysteroscope.
- if the remaining fundic spur is larger than 1 cm, a second procedure is indicated.
The only criterion of success is a subsequent pregnancy resulting in a viable birth.

13. Complications
Mechanical complications
Uterine perforation is the most common complication. It occurs either during dilation of the cervix or during the resection of the septum. There is a risk of visceral burns if the perforation is not detected. For this reason, some authors recommend intraoperative sonography or laparoscopy (Lin et al., 1987).

Postoperative infection
Post-hysteroscopic endometritis occurs in 1% to 5% of cases (McCausland, 1993), justifying the systematic use of intraoperative prophylactic antibiotics (cephalosporin).

Metabolic complications
The intravascular passage of a significant quantity of irrigation fluid can lead to hemodilution. This “transurethral resection syndrome” was first described by urologists (Averous et al., 1981). Preventative measures are dependent on adherence to procedural protocol, the most important of which is a meticulous monitoring of the inflow and outflow of fluids.

14. Reference
The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal
occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine
adhesions. Fertil Steril 1988;49:944-55.
Averous M, Guiter J, Guillaume A, Navrath H, Grasset F. Le syndrome d&#146;hémodilution après R.T.U. Le
syndrome de la résection trans uréthrale. J Urol 1981;87:700-2.
DeCherney AH, Russell JB, Graebe RA, Polan ML. Resectoscopic management of mullerian fusion
defects. Fertil Steril 1986;45:726-8.
Fernandez H. Hystéroscopie opératoire. Encycl Méd Chir (Elsevier, Paris), Techniques chirurgicales &#150;
Gynécologie 41-559, 1998, 9p.
Lin BL, Iwata Y, Miyamoto N, Hayashi S. Three-contrasts method: an ultrasound technique for
monitoring transcervical operations. Am J Obstet Gynecol 1987;156:469-72.
March CM, Israel R. Hysteroscopic management of recurrent abortion caused by septate uterus. Am J
Obstet Gynecol 1987;156:834-42.
McCausland VM, Fields GA, McCausland AM, Townsend DE. Tuboovarian abscesses after operative
hysteroscopy. J Reprod Med 1993;38:198-200.
Musset R, Muller P, Netter A, Solal R. Nécessite d'une classification globale des malformations
utérines. Les malformations urinaires associées. Intérêt de certaines particularités à la lumière de 141
cas. Gynecol Obstet (Paris) 1967;66:145-66.
Valle RF, Sciarra JJ. Hysteroscopic treatment of the septate uterus. Obstet Gynecol 1986;67:253-7.