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Philip Thomas FRANZCOG, FRCS Edinburgh BSS Course, May 8-‐9 2010 Q: Who is it and what did he do that is s/ll unique? A: Sir Jack Brabham STILL the only man to have won a world championship in a car of his own design and manufacture 1966, BT19 History First described by Pantaleoni in 1869 But! Invented by an Irishman, Francis Cruise, in 1865. Pantaleoni improved the device’s illumination with the addition of a paraﬃn lamp. This was 10 years pre-‐Hegar, and so laminaria tents were used to prepare the cervix Pantaleoni “…she was placed as near as possible to the borders of the bed so that Dr Cruise’s light source did not set ﬁre to the curtains…a vivid red polypous vegetation was easily discovered in the posterior part of the uterine cavity… I employed silver nitrate as a caustic and looked again with the tube to certify the eﬀect of the cauterisation. I was obliged to use the caustic six or seven times” History (cont) Not used regularly until the 1970’s Fears of spread of carcinomatous cells into the uterine cavity…but Roberts, Long and Jonasson demonstrated no cells after curettage Was not to replace blind curettage until the 1980’s Now the gold standard for diagnosis…operative potential Equipment Light source Cold light source Tungsten, halogen and xenon 175W routine hysteroscopy 300W for miniature scopes Equipment (cont) Telescopes 4mm, 3mm, 2mm (usual total OD 5mm) 0, 12 and 30 degree Eyepiece, barrel and lens Fibre-‐optic bundles to convey light Contact/non contact Telescopes Equipment (cont) Diagnostic sheath 5mm diameter/ 1mm channel Operative sheaths 7-‐10mm (average 8mm) Common cavity for passage of scope and tools Isolated input and output channels (1980’s) Same 2-‐4mm scope as for diagnostic Resectoscope Double armed mono-‐polar electrode with either loop or roller-‐ ball 30 degree telescope/ angled towards the electrode (12mm) Accessory instruments Alligator grasping forceps, biopsy forceps and scissors. Semi-‐rigid Bipolar electrodes Monopolar blade electrodes Flexible hysteroscope (Fujinon, 1980’s) LASER (Argon, Nd, YAG and KTP) Lots of bother and no practical advantage Good coag but poor vapourisation properties Distension media Uterine distension usually requires at least 30-‐ 40mmHg, 70mmHg usually achieves ﬂushing through fallopian tubes Never CO2! Oﬃce procedures. Micro-‐hysteroﬂator used Gas embolism. Flattening of endometrium Distension media-‐ diagnosCc Saline/Hartmann's Safest and easiest Gravity fall 100cm height achieves 70mmHg Iv giving set with hand pump or pressure bag Aim 80-‐100mmHg Hysteromat Pre set ﬂow, input and suction pressure Generally: ﬂow pressure 200ml min, suction 0.25 Bar, outﬂow pressure 75mmHg DiagnosCc media (cont) Saline and Hartmann’s Electrolytic so not for use with diathermy Mixes easily with blood… clouding unless constant ﬂow OperaCve hysteroscopy medium Glycine 1.5% Good view, non electrolytic Hypo-‐osmolar Absorption into open blood vessels Hyponatremia… CNS swelling more pronounced in women due to progestogen eﬀects on cation pump A function of distension pressure (Mean Art Pres.) Cease if deﬁcit >1000ml or 1 hour Technique-‐ diagnosCc hysteroscopy (GA) Speak to patient, review notes and scan result, review consent, re-‐iterate complications Proliferative phase is best GA/ prep/ drape/ lithotomy Sims speculum, Vulsellum or tenaculum James Marion Sims: born early C19, Alabama. Trials with VVF repair on slaves eventually succeeded when a jeweller made him silver suture material, due to it’s inert nature Technique (2) Check equipment Positioning-‐ far enough down table (anteversion) Bladder need not be empty Stack to left/ trolley to right Connections Prime line -‐no air bubbles White balance Focus EUA/ sound/ +/-‐ dilation to 5mm ?over dilate to achieve ﬂow through (tubal ligation?) As far as internal os if necessary Technique (3) Fluid ‘on’ Approach cervix Cable down (most are anteverted) Let go of vulsellum! Dominant hand on cable, other on camera Stay in centre of lumen. Fluid full on Enter under direct vision ‘steer’ using cable Look left and right Look on the way out Photos curettage Pathology Pathology (2) Pathology (3) Pathology (4) Pathology (5) Pathology (6) AV malf Post D&C DDX , RPOC Technique-‐ LA/awake Not quite the same procedure! Get practice at GA procedures ﬁrst An exercise in smooth talking! Limited therapeutic potential Sampling rather than curettage Careful patient selection Previous cone/letz, nulliparas, elderly, obese Consider Misoprostol priming Adjunct to insertion of IUCD's etc Smaller scope somewhat limits view. Light source and cable Buscopan and Non-‐steroidal Awake hysteroscopy (2) Careful VE Develop your ‘patter’ Bivalve speculum Chlorhexidine to cervix and vaginal walls ‘no-‐touch’ technique Consider Xylocaine w. Adr (dental syringe) Tenaculum Uterine sound Fluid on but limit ﬂow/distension Have a QUICK look! Summarise ﬁndings and reassure patient Technique-‐ resecCon Diﬃculty and potential for morbidity probably underestimated Consent/ and complications including laparoscopy and incompleteness Patient preparation First half of cycle Consider Misoprostol Consider analogues Careful control of ﬂow and removal of debris Ease of entry/egress is vital The Ten Commandments for safe hysteroscopic resecCon, according to Phil Thomas Conﬁrm that it is sub-‐mucosal-‐ a saline infused scan is most informative Facilitate cervical dilatation-‐ ripen cervix with Misoprostol in nulliparas or elderley At least 50% of the ﬁbroid should be in the cavity Fibroids should be less than 5cm-‐ any more, shrink with GnRHa’s ﬁrst If concerned about distance to serosa, monitor with ultrasound intra-‐operatively, or consider laparoscopy (conCnued) Activate current ONLY when loop is moving towards you Abandon procedure if cannot see properly Limit operating time to less than 1hr, and ﬂuid deﬁcit to less than 1000ml Use bone curette or parfait spoon to remove fragments, rather than polyp forceps or sponge holders Consent should be fully informed, with all complications discussed that may inﬂuence patients decision to proceed. The last thing to go into the uterine cavity should be the ‘scope Pathology Pathology (2) Pathology (3) Pathology (4) Pathology (5) Pathology (6) Endometrial ablaCon History Vancaille, 1937: electrical Goldrath, 1981: NdYag laser Procedure more widely accepted Indications Menorrhagia/ DUB Mostly regular cavity Previous hysteroscopy or scan Hyperplasia/ carcinoma excluded Pipelle or curette **What might happen if you inadvertently ablate a carcinoma? AblaCon (2) Contraindications Excessively large or distorted cavity Wish to maintain fertility Not contraceptive Consider concurrent laparoscopy/ tubal ligation Hyperplasia/ carcinoma Other indication for hysterectomy exists Alternatives Hysterectomy Medical Mirena/ other ablations such as Novasure AblaCon (3) Preparation Consent-‐ failure rate/ years of relief Alternatives: Novasure, Thermachoice Endometrial thinning agents Immediate post-‐menstrual phase? Danazol 200 mg tds 6 weeks GnRHa-‐ ?which Continuous OCP Depo Provera Technique Roller ball or loop Check equipment 100-‐120W cutting 70-‐80W coag Use pure cut No evidence re comparative eﬀectiveness “ruling up the page” Ostia, then fundus, then pick proximal extent How deep? AblaCon Results 10% “failure” Successful reduction in 85-‐90% Normal menses in 5% Similar for laser or diathermy GnRHa’s: possibly less long term pain No clear evidence for one thinning agent over another ComplicaCons Operator dependent! Diagnostic: Perforation If with sound or scope only, no further action antibiotics Cervical laceration Failure to gain entry Gas embolism (CO2) Failure to gain view Menstrual? Perforation? Find ostia ComplicaCons (2) Operative Fluid overload Avoid >80-‐100mmHg and >30mins Beware deﬁcit >1000ml Myometrial vessles (400-‐500u) intravasation 9ml/min Larger vessels (>1mm) 400ml/min with gravity feed and 250ml/min with hysteromat ComplicaCons (3) Perforation Loss of cavity simultaneous laparoscopy mandatory Life-‐threatening due to delays.. Denial, failure to act Polyp forceps/ Rampley’s Last thing to go into the uterus is the scope! Bleeding… Foley balloon catheter 15-‐20ml for 6-‐8 hours Sepsis <2%, typically about 72 hours post op ?prophylactic antibiotics DDx perforation Returns to casualty Most morbidity and mortality due to denial and delay Let the surgeon know Full set of bloods Erect and supine abdo ﬁlms If these normal, do CT scan Iv ﬂuids antibiotics QuesCons?
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