Hysteroscopy is the process of viewing and operating in the endometrial cavity from a transcervical approach. It is a minimally invasive intervention that can be used to diagnose and treat many intrauterine and endocervical problems. The first scientist to conduct light into the human body was Bozzini in 1805. The hysteroscope as we know it today is similar to the early cystoscope described and presented in 1877 by Nitze. The instruments and technique of endoscopy underwent advances by people such as Heineberg (1914), Rubin (1925), Mickulicz-Radecki (1927), and Norment (1949).

Newer technique of Hysteroscopy have enabled us to perform procedures like submucous myomectomy, submucous Polypectomy, Intrauterine septal resection, and lot more which required open surgeries in past. Also hysteroscopy has proved as boon in field of Reproductive Medicine and enhancing IVF results.

In this chapter I am trying to cover, in the most practical way, how to optimize myomectomy results while performing Hysteroscopy.

ESGE: Classification of submucous myomas

Type 0       Entirely within endometrial cavity No myometrial extension (pedunculated) (Fig.2) Type I        <50% myometrial extension (sessile), 90-degree angle of myoma surface to uterine wall (Fig.3) < 90-degree angle of myoma surface to uterine wall   Type II       >50% myometrial extension (sessile) R90-degree angle of myoma surface to uterine wall Fig.4) > 90-degree angle of myoma surface to uterine wall

Modified from Wamsteker et al. Obstet Gynecol. 1993;82:736–740

Fig.1 Classification of Submucous Myoma Pre-Operative evaluation

• Transvaginal ultrasound (TVS) should be performed to confirm the diagnosis and to assess number, size and location of the myomas.
• It must indicate the extent of myomal intra-mural extension.

Pre-Operative Preparation

• It is preferred to do the procedure in immediate post- menstrual period.
• It does not require any particular preparation of the patient.

Important equipment

• Resectoscope with forward bend loop.
• Hysteromat/pressure bag.
• Glycine 1.5%.

Technique

1. Diagnostic hysteroscopy is performed to confirm the ultrasonographic findings.
2. Cervix is further dilated to accommodate the resectoscope. Ensure the free movement of resectoscope.
3. For leiomyoma resection, a 26 Fr resectoscope is normally used with 30° telescope. After cervical dilatation, the resectoscope with the electrosurgical working element (90° cutting loop) is introduced.
4. Distension of the uterine cavity is obtained with glycine.
5. Irrigation is controlled with an electronic suction and irrigation pump, which automatically controls both intra-uterine pressure and flow rate. The system also ensures constant suction and allows us to calculate the precise amount of fluid loss.
6. Intra-uterine pressure should be adjusted such that it gives adequate distension and clear vision.
7. Following settings are generally used: Flow rate of approximately 250 mL/minute, pressure of 80–100 mmHg, monopolar electricity generator at 60–100 watts and suction pressure of 0.25 bar. Fluid balance is recorded by measuring the infused and drained fluid from continuous flow resectoscope.
8. Resection is performed by placing the electrical loop behind the myoma to be resected and retracting it toward the distal lens of hysteroscope. Myoma is shaved down with slicing technique (Fig. 5).

   

9. Type 0: It is systematically shaved off with the resectoscope loop until the pedicle is reached. There is no need for hydrostatic massage. In case of large fibroids, too much crowding of pieces can be tackled by removing them with ovum forceps intermittently (Fig. 6).

 

10. Type I and type II: Resection is done by placing the loop behind the myoma and retracting it toward the scope. Myoma is shaved down with slicing technique with cutting loop to the level of myometrium till myoma becomes flat. After having dissected the portion of myoma protruding into the cavity, an attempt is made to remove the part nested deep in the myometrial wall (Fig. 7).

This can be achieved by 2 techniques:

1. By giving hydromassage by controlled variation of endo-cavitary pressure (opening and closing the endo-uterine aspiration system), myoma will start protruding in the cavity which can be sliced off. Like this we may be able to remove myoma completely in the same sitting. Usually we are able to see pink capsule on myometrium 
as end result.
2. Cold-knife technique which consists of simple, 
mechanical passage of the resectoscope loop along the capsule lining of the myoma, detaching if from the fibrous bridges that anchors it to the uterine wall, without any electrocoagulation.

The operation can be considered complete when only myometrium can be seen throughout the entire surgical area. Utmost care should be taken to prevent damaging the smooth muscle fiber bundles. If it is impossible to totally remove the intra-mural fibroid in one sitting, inspite of trying the above techniques, because of it is too deep location and/or technical difficulties, the remaining myoma can be coagulated until dry. This effect is achieved by placing the loop in direct contact with remaining wall of the myoma and applying a high coagulation current for approximately 30 seconds. The fibroid can then be treated at a later date (2–3 months later) as over the period intra-mural component of myoma migrates into the uterine cavity.

     

Tips 1. Meticulous attention to intraoperative fluid balance is imperative, if fluid deficit more than 1 to 1.5 liters is detected, serum sodium is measured and hyponatremia, if present, should be treated. For every liter of electrolyte free fluid that is absorbed the sodium will go down approximately 10 mEq /lit. This helps surgeon to determine when to stop a case. If deficit is approximately 1500cc it is advisable to put in a Foley’s catheter and give diuretic. 2. Absorptionoflargevolumesofelectrolytefree,lowviscosity fluid especially with large myoma is the trigger of some systemic changes during the operation. Myomectomy of large myomas is liable to hyponatremia, hypo-osmolality, increased CVP, increased PT and aPTT and increased most of the cardio dynamic parameters. These changes deserve performing the procedure by an experienced hysteroscopic surgeon using a quick technique with least possible Glycine volume and minimal intrauterine pressure to achieve the goal of a safe minimal access surgery. 3. It is advisable not to remove big anterior and posterior fibroids in the same sitting to avoid intra-uterine adhesions/ synechie formations. 4. Type 0 myoma should never be dislodged at the base first, which is the most tempting thing to do. One should avoid this as removal of floating myoma from uterine cavity creates a great problem. 5. While resecting Type I and Type II myoma particular care is taken regarding the intra-uterine pressure. If pressure is very high, fibroids will be pushed deep into the wall making resection difficult and also it may increase the intravasation of fluid. To prevent this, minimal least pressure is kept that gives adequate distension and clear vision.

  Fig. 2: Type 0 myoma (intracavitatory-completely in the cavity) Fig. 3: Type I myoma (>50% in cavity) Fig. 4: Type II myoma (<50% in cavity) Fig. 5: Resection of myoma Resection of Type 0 Myoma Fig. 6: Resection till pedicle base Hysteroscopic Myomectomy 6 Resection of Type II Myoma Fig.7:(Photographs courtesy: Ruby Hall IVF and Endoscopy Center)