Hysteroscopic myomectomy

Also known as transcervical resection of myoma (TCRM). In 1976, Neuwirth and Amin first performed uterine myomectomy in the anterior resectoscope used in urology. Today TCRM has evolved into a mature new technology for gynecology. Compared with traditional hysterectomy and transabdominal removal of fibroids, TCRM eliminates the cumbersome laparotomy, less pain for patients, and faster recovery after surgery; usually in the clinic, more convenient for patients and medical staff; no uterus incision, extreme The earth reduces the chance of cesarean section in the future. Treatment of diseases: uterine leiomyoma uterine fibroids Indication Any patient with symptomatic submucosal fibroids, intercostal fibroids and cervical fibroids, fibroids 5 cm in diameter; submucosal fibroids and intercostal fibroids buried deep in the muscular layer need to be done twice . Contraindications Acute pelvic inflammatory disease or acute heart and lung failure, and other patients who are not qualified for surgery; cervical scar, incomplete expansion and cervical laceration or relaxation, large amount of perfusion fluid leakage; interwall muscle without causing uterine cavity deformation Tumor and subserosal fibroids. Preoperative preparation A comprehensive examination should be performed before surgery to determine the presence, number, size, location, and presence or absence of submucosal fibroids and/or interstitial fibroids and cervical fibroids. The possibility of hysteroscopic surgery should be assessed. Preoperative preparation: surgery should be arranged in the proliferative phase of the menstrual cycle. For patients with fibroids 3cm, hormone inhibitors should be given before surgery to reduce the volume of uterine fibroids, inhibit endometrial hyperplasia and angiogenesis, so that intraoperative Reduced bleeding, clear vision, reduced back absorption of perfusate. Available drugs are: GnRHa: preoperative application for 2 months, the specific dosage depends on different types of GnRHa; danazol: 400 ~ 600mg / d, a total of 6 weeks, can replace GnRHa; mifepristone: 25mg / d, a total of 3 months, amenorrhea during medication, can reduce anemia, improve systemic conditions is a promising pretreatment drug for TCRM. Correct anemia before surgery. If the patient is a minor or a small cervix, insert a seaweed stick or other absorbent material into the cervical canal before surgery. Surgical procedure Submucosal fibroids: small size can be cut with a ring electrode, gasification electrode or Nd: YAG laser, and then the tumor is clipped. 3cm diameter patients should first remove the fibroid tissue, so that the volume is reduced, then the tumor pedicle is cut off, and B-ultrasound and/or laparoscopic monitoring is required. There are submucosal fibroids: fibroids have a wide base between the muscle walls, and removal of pedicled submucosal fibroids requires B-ultrasound and/or laparoscopic monitoring. The technique of excising part of the fibroids in the cavity is the same as that of the submucosal fibroids. When the inner part of the muscle wall is removed, the interface between the fibroids and the capsule must be identified. The fibroids are white nodules, and the envelope tissue is gray and smooth. The fibroids should be completely resected from the capsule or removed to the adjacent uterine muscle wall. The fibroid tissue remaining in the muscular layer can be necrotic and ablated in the future, or discharged into the uterine cavity due to contractions. The second cut. The above technique is only applicable to those buried in the muscle layer <50%. If >50% need to be trimmed with oxytocin, the fibroids are squeezed into the uterine cavity, and then resection, and often requires multiple operations. Endoluminal fibroids: submucosal fibroids that resemble pedicles, but whose inner surface is covered with a thin layer of muscle wall tissue. Surgery often needs to be carried out in stages. The first step is to open the window. The needle tissue is used to open the muscle tissue on the surface of the covered fibroids to form a window. If the fibroid protrudes into the uterine cavity, the second step: cutting and/or gasification, the technique is the same as the submucosal fibroid; if the fibroid remains in place, the operation is stopped, and GnRH- is used after the operation. a or danazol, the second resection after 2 to 3 months. It has been reported in foreign countries that 4 cases of surgery will be used to cut fibroids. Even if there is a small amount of residual fibroids, some of them can be naturally ablated after using GnRH-a or danazol. Multiple submucosal and interstitial fibroids: For unfertile women with multiple submucosal and interstitial fibroids, it is feasible to remove hysteroscopic myomectomy, resection and gasification as before, and to remove fibroids as much as possible at one time. The intrauterine device was placed after surgery and taken out 2 months later. Cervical submucosal fibroids: the tumor pedicle is cut with a ring electrode, and the fibroid is completely unscrewed by completely removing or cutting the capsule. If the fibroids embedded in the cervical tissue are clarified, the ring electrode is used to feed the knife from the thinnest part of the embedded tissue, and after the fibroids are cut, the incision is appropriately extended, and the fibroids are completely exfoliated from the capsule. After the fibroids are removed, the tumor fossa generally does not bleed, such as a large tumor fossa or an irregular shape of the cervix. It can be sutured with an absorption gut. complication Uterine perforation: the most common and most serious complication of hysteroscopic surgery, the incidence rate of 0.25% to 25%, an average of 1.3%, 2.25% combined with intestinal damage. The surgeon has no experience, incorrect use of the working electrode, resection of the thin isthmus, uterine horn, uterine cervical intrauterine adhesion resection (TCRA), transcervical uterine septal resection (TCRS), uterus with surgical trauma history, etc. is the uterus High risk factors for perforation. Therefore, B-ultrasound or laparoscopy should be used for intensive monitoring during surgery. During B-ultrasound monitoring, the high temperature of the electric cutting ring causes the base of the cut surface to be heated and dehydrated, and a strong echo band appears on the B ultrasonic image. This special image can indicate the cutting range and depth. When the strong echo light band is close to the serosa layer, it is suggested that if the cutting is continued in this direction, there is a possibility of penetrating the uterine wall, so the B-ultrasound monitoring has a guiding effect on the positioning and cutting of the large fibroids. Once perforation occurs, B-ultrasound sees free fluid around the uterus, hysteroscopy sees the abdominal cavity, intestine or omentum, laparoscopically sees a rapid increase in fluid in the abdominal cavity, uterine serosa hemorrhage, hematoma or wounds suggest uterine perforation. B-ultrasound and/or laparoscopic monitoring can help prevent uterine perforation, but it cannot be completely avoided. The uterus after hysteroscopic surgery is at risk of ruptured uterus. The laparoscopic tube can be opened during laparoscopic monitoring to avoid damage to adjacent organs. When the wall of the electric or electrocoagulation is deep, close to the serosa layer, the local tissue is heated, the serosal surface can be blistered, or the light of the hysteroscope can be seen from the laparoscope, suggesting that the uterus is about to be perforated, and the uterus can be found immediately. Perforation, laparoscopic suture can also be performed, but laparoscopy can not monitor the posterior wall of the uterus. When the TCRM uterus is large or the TCRM fibroids are large, or when a large amount of tissue debris remains in the uterine cavity, the intrauterine echo of the B-ultrasound is disordered, and the ultrasound probe is difficult to track the sound and shadow of the electric cutting ring, and uterine perforation can still occur. The limitation of laparoscopic monitoring is that only the anterior wall and the bottom of the uterus can be observed. The posterior wall of the uterus cannot be monitored. The uterine perforation without warning can not be predicted, but the uterine perforation can be found immediately by laparoscopy, thus preventing further damage to adjacent organs. In addition, laparoscopic electrocoagulation can be performed to stop bleeding and suture. These advantages are beyond the reach of B-ultrasound. Therefore, for some hysteroscopic surgeries with high risk factors for uterine perforation, it is necessary to perform laparoscopic monitoring. If the perforation causes damage to adjacent organs such as the intestine, bladder or ureter, it should be immediately exploratory laparotomy and treated as appropriate. The syndrom of transurethal resection of the prostate (TURP): due to the absorption of a large amount of perfusate into the blood circulation, resulting in excessive blood volume and a series of symptoms caused by hyponatremia, severe cases can cause death. The preventive measures include: strict monitoring of high-risk patients, especially large fibroids, pre-treatment without drug pretreatment and uterine perforation; the exact difference between perfusion fluid volume and output. When the difference reaches 1000ml, there may be mild hyponatremia, and the operation should be terminated as soon as possible; >2000ml, there are many hyponatremia, even severe hyponatremia and acidosis; try to take low pressure perfusion. Bennett et al pointed out that the setting of perfusion fluid pressure should be lower than the average arterial pressure; Baskett proposed that the outlet of the uterine perfusion system should be connected to the negative pressure, which can reduce the risk of perfusion solution absorption; try to shorten the operation time, preferably within 1 hour. . Once TURP occurs, surgery should be stopped immediately and treated accordingly, including diuresis, sodium supplementation, correction of acid-base balance, and electrolyte imbalance. Air embolism: Gas can be derived from air bubbles generated by the inlet pipe and tissue gasification. Therefore, the monitoring should be strengthened during the operation, including continuous pre-cardiac Doppler monitoring, end-expiratory CO2 pressure monitoring (the value is reduced to the most important early signs of air embolism) and blood oxygen saturation measurement, etc. Pressure ventilation, avoid head low hip height, carefully dilate the cervical canal, can not expose the cervix and vagina to the air, pay attention to emptying the gas in the water pipe. The resuscitation measures are to prevent the gas from entering immediately, turn the patient into the left lateral position, extract the gas as much as possible, inject a large amount of physiological saline, and promote blood circulation. Pelvic infection: reports of pelvic abscess, Papillary gland abscess, liver abscess, and fallopian tube ovarian abscess after hysteroscopic surgery, but rare. Antibiotics should be routinely applied after surgery. Once an infection is found, anti-infective treatment should be given in time, and an abscess puncture or drainage should be performed if necessary. Periodic abdominal pain: uterine adhesions; residual endometrial proliferation of the fundus causes intrauterine hemorrhage; endometrial basal layer is covered by scars leading to iatrogenic adenomyosis and progressive dysmenorrhea; intrauterine pressure during surgery will be active endometrium The cells squeeze into the muscle layer, causing adenomyosis; the intima of the uterine horn is not completely destroyed. Once periodic abdominal pain occurs, an analgesic treatment can be used. For a few severe symptoms, a hysterectomy is feasible. Malignant lesions of the uterus: If the pathological examination of the removed uterine fibroids is uterine sarcoma, the whole uterus plus double attachment resection should be performed, and continued treatment should be given according to the surgical pathological stage; after the operation, if a small amount of fibroid tissue is left, it occurs. The risk of uterine sarcoma is unchanged and should be followed up. Therefore, the tissue that emphasizes hysteroscopic resection should be sent to histopathological examination.