INDICATIONS
abnormal uterine bleeding
infertility
recurrent pregnancy loss
abnormal hysterosalpingogram revealing intrauterine adhesions, polyps,
fibroids, septum
possible intrauterine foreign bodies
CONTRAINDICATIONS
pregnancy
heavy uterine bleeding
pelvic inflammatory disease
cervical malignancy
recent uterine perforation
DELIVERY DEVICES
maximum recommended intrauterine operating pressure is 150 mm Hg
intrauterine pressure is a function of inflow pressure and outflow
pressure
inflow pressure may be produced by gravity, pressured cuffs with (pressure)
gauges, or approved pumps
DISTENDING MEDIA
Group A: Isotonic Ionic Solutions (Normal Saline, Ringer's Lactate)
Group B: 5% Dextrose in Water
Group C: 1.5% Glycine, Sorbitol, Cytal
Group D: Hyskon (32% Dextran 70)
FLUID MONITORING
1) it is the role of the circulating nurse to maintain a flow sheet
recording inflow and outflow of hysteroscopic media during the case
2) for Groups A, B and C the inflow and outflow must be estimated
for every 500 cc of fluid used and measured at the conclusion of each
bag of distending media
3) for Group D the inflow and outflow must be measured for every 100
cc of fluid used
4) the operating surgeon will be informed of fluid balance status
as it is recorded on the flow sheet
5) spillage should be avoided and quantitated whenever a significant
spill occurs
6) use of a table drape to collect excess fluid for accurate recording
of fluid output is required
EXCESSIVE FLUID ABSORPTION
The recommended volume of input to output discrepancy at which point
the surgeon must assess serum electrolytes (especially sodium concentration)*
is
Group A: 1 liter
Group B: 1 liter
Group C: 1 liter
Group D: 250 mL
Once these volumes of discrepancy have been reached, serum electrolytes
must be obtained and the operating surgeon has the option of:
a) terminating the case
b) awaiting the results of the electrolyte levels and proceeding accordingly
c) administering Lasix IV and judiciously proceeding with the case
until the results are available
* IMPORTANT NOTES:
- The volumes that are recommended in this section are not based on
established "standards of care" since such standards have
not yet been clearly formalized. For example, I use 1 Liter as a cut
off for D5W while some of the world's leading hysteroscopic surgeons
use 3 Liters. There is no established limit for the volume of D5W
that can safely be given as an IV solution being directly infused
into the circulation of a healthy person. I have found no reports
of major morbidity associated with the use of D5W in the literature.
- Additional patient assessment following a large volume discrepancy
between input and output may immediately involve determination of
serum electrolytes. If a significant time has passed since the (presumed)
absorption of fluid, other clinical parameters (if available) may
become more informative (evidence of tissue edema, an increase in
cardiac output associated with volume overload, change in pulse oximetry
or ventilation parameters, change in patient temperature if room temperature
fluid is used)
I use a resectoscope with continuous flow and a loop electrode to
perform most of my hysteroscopic surgery. I have not found a pumping
system for distending media that is sufficiently accurate, rapid in
response (so as to maintain a constant pressure), affordable, and easy
to use. Many pumps are available and as this technology develops I anticipate
that a great pumping system will become available. At present, I use
a simple system of placing a blood pressure cuff around each one liter
bag of D5W solution to be used and apply 150 mm Hg pressure (as measured
on a gauge attached to the cuff) to the pressure cuff. This is connected
to the inflow port on the resectoscope and flow is then adjustable using
a stop cock on this port. Outflow from the resectoscope is via a tubing
that connects directly to a suction canister under full wall suction.
The outflow port also has a stopcock that can be used to adjust the
outflow.
The circulating nurse's primary responsibility during the operative
hysteroscopy is to maintain pressure on the pressure cuff and watch
the inflow and outflow balance. The nurse might appropriately report
this balance to the surgeon and anesthesiologist every 15 minutes or
whenever there is a significant volume of use (say 500cc).
The resectoscope's monopolar electrocautery loop is attached to an
electrical generator with variable power (wattage) settings. For any
given power setting selected, there are also various blends of cutting
or coagulation that can be chosen. I typically use blend 1 which applies
current 80% of the time and gives just a little coagulation as compared
to pure cutting. For most resectoscopic use, I use 50-80 Watts on blend
1 and coagulate bleeders (if not initially controlled with the blend
1 settings) using 50 Watts at pure coagulation.
Once the hysteroscopic portion of the case is completed, I request
a final tabulation of inflow and outflow volumes for the distending
media.
I direct my attention to the laparoscopy once the hysteroscopy
is complete. A uterine manipulator is placed through the cervix, I typically
invert the umbilicus and insert a Verres needle through this site (while
holding up the umbilicus). Alternative sites for Verres needle insertion
(rarely used) include the left infracostal midclavicular line or the
left periumbilical midclavicular line. Insufflation of the abdomen with
CO2 gas so as to create a pneumoperitoneum is accomplished after "confirming
the proper placement" of the Verres needle. Note that absolute
certainty of placement of the Verres needle is not possible given the
blind nature of its entry. Many of the laparoscopic injuries that occur
do so at the time of Verres needle insertion. Failure to achieve an
adequate pneumoperitoneum is the most common reason for procedural failure.
Once the pneumoperitoneum is created, the Verres needle is replaced
by a trocar and sleeve. Again, the trocar insertion is blind and the
direction of insertion is typically towards the hollow of the sacrum.
The diameter of the umbilical (main) trocar is 10-12 mm so that this
instrument can cause considerable injury if not placed properly and
atraumatically into the abdominal cavity. The presence of adhesions
(scar) that elevates the bowel to the anterior abdominal wall is a consistent
source of concern for laparoscopic surgeons. I always try to enter the
trocar through the abdominal wall (while holding the inverted umbilicus
up with clamps) so that the tip of the trocar and its outer sheath are
just inside the inner abdominal wall and then confirm an atraumatic
entry with the laparoscope before going on.
If abundant adhesions are anticipated such that the surgeon believes
that the complication rate with the blind Verres needle and trocar insertion
is unacceptably high, then "open laparoscopy" may be chosen.
Hasson introduced this technique in 1971, in which the direct insertion
of the trocar without the creation of a prior pneumoperitoneum is accomplished
by performing a cut down under direct observation of the layers of the
abdominal wall. Suture holds the layers of the inner abdominal wall
(fascia and peritoneum) to the trocar sleeve to prevent the release
of gas through the incision site during the case. Extreme care must
be exercised in making the peritoneal incision since bowel injury to
adherent bowel may occur under direct observation as well.
Accessory trocar sites are usually required during the laparoscopic
case. Typically I use two additional sites for placement of 5 mm (or
uncommonly 10 mm) trocars in the suprapubic midline and left lower quadrant.
All accessory trocars have the advantage of being able to be inserted
under direct observation so injury is less common. One injury associated
with placement of the accessory trocars is laceration of the deep inferior
epigastric vessels (which may be difficult to see either directly or
via transillumination). Injury to the inferior epigastric vessels can
be consistently avoided by placement of the additional trocars either
lateral to the internal inguinal ring or medial to the umbilical ligaments
(two structures that are usually easy to identify under direct laparoscopic
observation).
Tools that are selected for the performance of the laparoscopic surgery
should allow the surgeon to minimize postoperative adhesion formation.
The surgical principles as discussed above are very important in terms
of achieving the desired outcome. Gentle tissue handling during laparoscopy
takes a great deal of time to develop. Avoidance of bleeding with gentle
tissue handling is important and so is careful hemostasis using (selective)
bipolar cautery. Continuous irrigation and aspiration of the tissues
to remove char and minimize drying should be second nature to the laparoscopic
infertility surgeon. Use of cutting instruments that minimize lateral
tissue damage is also a primary concern.
Once the case has been completed, the instruments are removed from
the abdomen allowing for the efflux of CO2 gas. I usually take an additional
5 or so minutes to move the abdominal wall and contents about with only
one remaining trocar sleeve in place to try to allow any trapped gas
to escape. Incisions are closed with subcuticular stitches so as to
avoid cosmetically unpleasant "railroad" type skin scars.
The fascia is closed on any incision in the fascia greater than 5 mm.
In the immediate postoperative recovery time period, common problems
include
- nausea and vomiting, most likely related to the CO2 gas or the narcotic
pain medications used perioperatively. Zofran is often the most effective
anti emetic agent for post laparoscopic vomiting. The nausea and vomiting
does not typically persist for more than 12 hours postop.
- shoulder pain due to retained CO2 gas, which if trapped under the
diaphragm (at base of the lungs) causes irritation of the phrenic
nerve to cause the sensation of shoulder pain. Lying on one's abdomen
with a pillow under the hips and lower abdomen (or the knee chest
position) may allow the CO2 gas to recollect in the pelvis rather
than under the lungs and reduce this discomfort.
- subcutaneous crepitance (crackling) under the skin over the abdomen
and extending superiorly to the chest and neck or inferiorly to the
buttocks and thighs is typically a minor complication due to escape
of the gas into the abdominal wall. A rare patient develop a very
low blood pressure (not related to blood loss) and usually responds
immediately to a bolus of IV solution.
- incisional pain is usually mild but the internal (visceral) pain
after surgery can be intense and may require narcotics or anti inflammatory
agents. Reportedly a heating pad applied to the abdomen may also be
helpful.
- if a large volume of fluid is left in the abdomen at the conclusion
of the case (I rarely leave this fluid here but some surgeons do this
as a routine) then leakage through the incision sites is common for
up to 2 days.
- the surgeon should be called if there is a fever (greater than 100
degrees) or chills, heavy or prolonged vaginal bleeding, heat or swelling
of the incision sites, frequency or burning on urination, severe pelvic
pain, persistent nausea or vomiting, faintness or dizziness, inability
to spontaneously urinate.
- postoperative urinary retention occurs more often in cases that
last longer than 2 hours. If the patient is not able to void within
4-5 hours postop (and after removal of the foley catheter) then she
should be straight catheterized for the residual volume of urine and
she should try to void spontaneously once again. I do not allow my
patients to go home until either they can void spontaneously or they
have an indwelling foley catheter placed (for about 1 day).
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