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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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