HYSTEROSCOPIC RESECTOSCOPY.

Dušan Tóth, MD, PhD.

R. Arnaud, A.R.P Cayol,A.Gravier

Clinique St.Germain, Brive la Gaillarde

www.gynecobrive.fr

Clermont Ferrand 2016

New developments have made office hysteroscopy and transcervical surgery the

first line procedure in case of certain intrauterine pathologies.

It can be performed on a routine base by every trained gynecologist, often only with

minimal anesthesia or analgesia, as a painless procedure.

It is a common work of the whole medical and paramedical team - global patient

management !!!

HS – hospitalisation

HS - out patient

HS – office procedure 95 %

I. pre intervention

II. intervention

III. post intervention

I. pre intervention.

Examinations / adequate surgery indication .

I. Complete and detailed information about the procedure /consider the psychological

status of the patient, information about pain relief and methods of analgesia/anesthesia,

„Intervention timing“ – from 3rd to 5th day of the cycle – better visibility , post

intervention recommendations !!!!

II. age, clinical symptomatology , gynecological examination(anatomical conditions :

deliveries, previous surgical interventions ), laboratory analyses if needed

III. ULTRASONOGRAPHY description of the intrauterine pathology

pre operative evaluation

HS without anesthesia HS with anesthesia

Patient selection and anesthesia choice .

Interventions without

anesthesia:

« see and treat procedures » - minor IU pathologies

polypes (<1-2 cm)

myomas (type 0 ESH, <1-2 cm)

synechias (Igr.ESH)

IU septum

IUD

Essure sterilisation

[IU resection, Thermoablation]

Interventions with anesthesia:

Anxious patients

Anatomical conditions

Type of intervention

(myoma I / II, polype >2cm, synechias II and III)

[IU resection, Thermoablation]

surgeon’ s experience

II. intervention.

Management and logistics of the OR.

Programation of the interventions – morning , first interventions

Technical equipment - choice between single use and reusable / autoclavable devices

Coordination and compliance with anesthesist

Involvement of all the staff of the OR and all departments

Pain management – multimodal anesthesia protocole

1. Analgetics before intervention

NSAID– ibuprofene 400 mg + paracetamol 1gr. H-1 or diclofenac 75 LP – eveneing 1 cp + 1 cp morning with paracetamol 1 gr.

2. Local anesthesia – para cervical block . Naropeine 2 mg en 2-3 portions – at 12H , 4 H et 8 H

3. Intravenous anesthesia

Propofol 0,8-1mg/kg

Local anesthesia – paracervical / intrauterine .

10 - 20 ml divided in 2 or 4 portions – infiltration of the Frankensauser area.

Xylocaine 1%, Naropeine 2mg, Chirocaïne 2,5 mg

Intrauterine anesthesia – infiltration of the uterine fundus.

Valle 1999, Cohen 1994…..

Technical dispositions. - IU pression (50-70mmHg), pre heating 35-36 oC , „continuous flow“ - vaginoscopic access / no speculum – minimal vaginal dilatation and discomfort

-resectoscopic devices - range 5-7-9 mm - bipolar recommended !! -irrigation / fluid management system

Application of high frequency alternating current (AC), creating secondary thermal tissue

effects.

Typical electrosurgical generators work at 500,000 - 3,000,000 hertz (cycles per second)

Frequency range needed to prevent neuromuscular stimulation – the so-called Faradic

effects

Depth of coagulation increases with increasing voltage

“cut” waveform produces the least amount of lateral coagulation

“blend” waveform produces a margin of lateral coagulation

“coag” waveform produces the largest margin of lateral coagulation

But when increasing voltage : more bubbles from hydrogen gas formation, carbonization

and darkening of tissue, adherence, less margin for error near viscera and vessels

Electrosurgery

High density current enters tissue from small active electrode creating secondary thermal events

Current flows through the patient via a myriad of conductive pathways and volume conduction

Current dispersed over a large surface return electrode and returns to isolated ground housed in the electrosurgical generator

Principles of monopolar electrosurgery

Need sufficient voltage to ionize air to sustain an electric arc.

Current is concentrated at specific points

Extremely high current density superheats cellular water > explosive cellular vaporization

ensues cutting/ vaporization

Steam envelope about the tissue facilitates arc formation - minimized by the tissue contact

Non-conductive distention media are effective insulators

Glycine, sorbitol, mannitol

Current density is maintained, electrosurgical effect unaltered

Monopolar electrosurgery in a fluid environment

Maintain low resistance apposition to underlying skin

Select skin areas over tissue with a good blood supply to carry off heat

Avoid areas with hair, hyperkeratosis, scar tissue, or over dense fat deposits or bony prominences

Select sites that are over large muscles and closest to operative site

Place longer edge of return electrode toward operative site

Use return electrode monitoring

Minimizing Risk With Return Electrode Pads

Consolidation of active and return electrodes into single instrument

Current is symmetrically distributed through the tissue between the two electrodes

Patient is not part of essential current pathway

Thermal damage is limited to discrete volume of tissue

Power requirements are reduced with higher electrosurgical efficiency

Principles of bipolar electro surgery

Resection of IU protruded pathology.

If vessels visibles - coagulation

If diameter of the pathology + than diameter of the

resectoscope – never cut the pedicle

If pathology partly intra mural – use ¨hydro

massage¨ (variation of the IU pressure) >expulsion

of the intra mural part into the cavity

Extraction of the chips at the end of the intervention

if possible

Respect the ¨security¨ line in case of partly intra

mural myoma / resection under US control.

Endometrial resection .

If possible – planify the intervention at the

end of the bleeding – better visibility

Start in the fundus and ostias > anterior

wall> lateral walls > posterior wall

Extraction of the chips at the end of the

intervention

Coagulation of the opened vessels.

No cervical / under isthmic resection.

Permanent check the distantion media

loss.

Instruments and procedure:

16 Fr. Gubbini’s resectoscope wth 90 large resection loop / 0

dgr Storz optic

ERBE VIO D300 HF generator

Vaginoscopic approach

No dilatation , no tenaculum and speculum

Minimal IU pressure /50-90 mmHg/, pre heated saline

Toth et al., ESGE 2014

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Multimodal anesthesia 2,08 Local anest. 3,3

VAS and anesthesia mode

Results – anesthesia type :

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General A

Local A

Multimodal A

Toth et al., ESGE 2015

Results.

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Bleeding Cavitydilatation

Neoplasia Essure

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Toth et al, ESGE 2015

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Time

VAS

Uterus L

Relation uterus L /time/VAS

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Time LA

VAS LA

Time AS

VAS AS

Relation Time / VAS/ type anesth.

Results:

Toth et al., ESGE 2014

Prevention and resolution of possible complications.

to prevent complications : RESPECT THE SECURITY

visibility of the operation field

electrode under optical control

experience of the surgeon

minimal power

respect anatomy /cornual areas/

every manipulation must be ¨soft¨, precise and quick

modern technical equipment

in case of surgical or non surgical complication – multidisciplinary care

Do not exceed 20 minutes operation time without anesthesia !

Intraoperative : „fluid overload syndrome“, glycine toxicity, embolia, uterine perforation, bleeding /maximal intravasation in monopolar 1000 ml, in bipolar 3000ml/

Postoperative : infection, thermic necrosis of pelvic organs, bleeding

Secondary : „ Ashermann syndrome “, adenomyosis, uterine rupture

Prevention and resolution of possible complications.

Kuzel, Cs.Gyn.1999

III. after intervention.

After intervention informations.

Recommendations for the hours and days after intervention, and possible complications

Contact to non stop ¨hot line¨ or department with permanent medical help

Postoperative pain management (NSAID, anlagetics )

Cost benefit.

Endometrial ablation Hysterectomy

1. Oper.time 38min. 107

2. Hospit.stay 0,7 day 2,7 days

3. Compl.rate 6,3 % 21,7%

4. Recuperation time 5 days 32 days

5. Total dir.costs 1 1,54 - 2,35

(Hidlebaugh,1998 , Vilos, 1996)

Direct costs

Indirect costs

GHMF SCP Saint Germain

Brive la Gaillarde Correze

www.gynecobrive.fr

SHORTCUT

Minimal anesthesia in transcervical surgery :

how far can we go?

Dušan Tóth, MD, PhD.

R. Arnaud, A.R.P Cayol,A.Gravier GHMF -Clinique St.Germain, Brive la Gaillarde

D.Kuzel,L.Hrazdirova,M.Mara **

**Gynekologicko porodnickà klinika VFN, Prague, Czech Republic .

ESGE – BERLIN - 2013

Main outcomes.

1/ diagnostic procedures – diagnostic hysteroscopy and biopsy :

Small diameters - reduction of diameter (Bettochi2002,2004, Vilos 2005)

No routine cervical priming /misoprostol/ with scopes less 5mm (Cooper

2011)

Minimal uterine distention – 25-70mmHg(Baker 1997)

Vaginoscopic approach, minimal distention pressure, pre heating od DM.

Paracervical block – decrease pain while cervix manipulation and

passage of internal os, but not effect on pain during biopsy

(Cooper2010).

Topical anesthesia and smaller hysteroscopes - decreased risk of

vasovagal syndrome (Cicinelli2003-10,Vilos2005 – versus Cooper ), do

not impact on pain relief during hysteroscopy/biopsy (Cooper2010).

Main outcomes.

2/ see and treat procedures

(concerning 4-5 mm scopes and 5Fr.instruments)

Low diameters – no need dilatation, no need anesthesia if proper patient

selection (DiSpiezio2010,Bettochi2002,2004….)

No differences in pain with 5 mm scope – LA versus any

anesth.(Garutti2008)

LA alone – paracervical block reduce pain during some portions of the

intervention –cervix, internal os – but not have effetc on pain during

implant placement in Essure (Kaneshiro2012)

Size of IU (<2cm) pathology and time (<than 15min) limiting factors in

S&T without anesthesia (Garutti2008,Cicinelli 2010)

Complet polyp/myoma resection – 60-80%cases (Gulumser2010)

Main outcomes.

3/ second generation ablation techniques

end 90ies – outpatient procedure – local anesth./ conscious sedation

Last years – oral analgesia and mowing from outpatient unit to office

(Clark2011,Chapa2010)

Pre-heating phase more painful

Novasure - 80-95 % suitable for office or outpatient in LA

(Kalkat2011,Pennix2009…..)

Microwave ablation - no difference between LA or GA , allocation to type

of anesthesia, parity , cavity depth, POVN and recovery (Wallage2003) –

but shorter stay if LA comparing to GA(Varma2008)

Shorter than TCRE, local anesthesia more used, equipement failure

more likely; less fluid overload,hematometra,perforations; but PONV and

deleyed pain (Lethaby 2010) – prevention !

Main outcomes.

4/ ¨traditional¨ resections

TCRE suitable with local anaesthesia – intracervical block – 278 w – 3

not completed and 9 i.v sedation due to pain (Ferry1994)

Local anesthesia and pre operative NSAID – enhance succes rate - 90%

acceptance (Readman2004).

Spinal block versus short GA /propofol-remifentanyl – better acceptance

of GA-accurate titration of of short acting anesthetics (Danelli2002)

Less glycine absorption in LA/SED than GA , less resorbtion with GA

than PDA (Goledenberg2001)

Perspectives of mini resectoscope in outpatient setting and LA

(Fernandez2011,Papalampros2009,Dealberti2013)

Global ambulatory surgery management. It is a common work of the whole medical and paramedical team !!!

¨Modern day surgery is not simply a shortened hospital stay or an architecturel

stay mode! Rather, it is a complex, multifaceted concept involving institutional,

organizational, medical, economic and qualitative considerations¨(IAAS1995).

Patient

Management of anesthesia/analgesia for

TCS.

1/ Pre emptive analgesia

NSAID do not relieve pain in surgical incision techniques comparing post op administration(animal models,Moiniche2002)

NSAID decrease the postoperative analgetics consumption (Duellman2009).

NSAID not significant effect for pain during anesthesia but significant after procedure versus placebo(Nagele1997)

NSAID+drotaverine synergic effect significant difference during and after the procedure comparing to LA alone or diazepam sedation (Sharma2009).

Oral premedication alone in HTA (NSAID+BD+COD) – 231/1 procedure converted to GA because of pain (Glasser2009)

Coxibs – reduction of gastrointestinal bleeding and platelet function – preferred option ? To be evaluate (Wickerts2011)

NSAID in association with paracetamol – faster and longer effect (O Flynn2010, Merry2010)

Role of long acting NSAID ?

Anxiolytics – hydroxyzine – better anxiolysis than placebo (Boon1996)

Management of anesthesia/analgesia for TCS.

• 2/ Local anesthesia

• Anesthetics :

• quick/short acting -Lignocaine, Lidocaine, Xylocaine

• slow/long acting : Bupivacaine 0,5% (bupivacaine liposome solution –longer action –Dasta 2012)

• levobupivacaine 2,5 mg

• ropivacaine 2mg

• Topical-spray/gel, intracervical, paracervical, intrauterine

Management of anesthesia/analgesia for TCS.

• 3/ i.v short anesthesia

• Benzodiazepines – Midazolam 1-2 mg

• /delayed elimination – obeses, aged patients/

• Propofol – 0,5 – 2 mg / kg /av. 1mg /kg/ - patient controlled sedation – reduction of total dosage

• Not recommended : Thiopenthal (PONV) ? Ketamine /dissociative anesthesia/ ?

• Alfentanyl > sufentanyl > remifentanil

• Corticoides – Dexamethasone – 8mg H-1, reduces NSAID and analgesic consumption

• Prevention of PONV /multimodal approach/

The analgesia / anesthesia solution.

Combination of described techniques

Multimodal anesthesia – synergic effect of minimal doses

(but no consensus or protocol up to day )

NSAID+paracetamol+paracerv.block +/- sedation +(prevention

of POVN) + ¨home¨rescue analgesia

Significant lower pain scores in postop period, less POVN and decrease length of

stay – Efectivness of multimo.pain management protocol in total knee

arthroplasty patients (Lewis2012) –

Minimal invasive LPSK myomectomy - signif. lower VAS scores for postoperative

pain betwen MMA protocol and without MMA.(Xiromeritis2011)

MMA 636 items!!!

Conclusion : minmal anesthesia end transcervical

surgery – how far can we go?

Not the procedure but patient is ambulatory /IAAS 1999/.

Proper surgical indication – selection

Proper instrumentation / reduction of diameter

Autoevaluation – practice and skill- rapidity and gentle manœuvres/manipulation – share of informations.

Minimal dosage and combination of methods – multimodal anesthesia

Pre operative and postoperative care /complete and true information -analgesia – rescue analgesia, complications, follow up /.

large majority of TCS (up to 95%?)