Because hysteroscopic surgery differs greatly from conventional gynecological open surgery, there are certain operational skills in how to cut, stop bleeding and deal with some specific lesion tissues, which are briefly described below.
1.Step of cutting tissue
(1) place the electric cutting ring on the distal side of the tissue to be excised, the surface of the tissue to be excised, when moving the electric cutting ring to start cutting, the first step is to start the foot switch and feel the cutting effect in your hand, then move the handle or spring of the cutter, the electric cutting ring cut into the tissue according to the excision requirements, and the tissue will be cut down according to the depth of the tissue to be excised, the moving speed is generally 1cm / sec. remember that in a fixed It is important to remember that the time spent at a fixed site should not exceed 1 second, otherwise the electrical heat radiation will lead to perforation of the uterus.
(2) At the end of each excision, tissue should be seen to be cut off from the trauma, but it is only possible to cut off the tissue completely when the electric cutting ring is moved into the mirror sheath and then the foot switch is released.
(3) The cut tissue is generally in the shape of a strip, slightly thin at both ends and thicker in the center, like a small boat. The thickness of the tissue slice is proportional to the depth of placement of the electrosurgical ring, and its length is determined by the distance of movement of the ring and the mirror sheath.
(4) The thickness of the cut tissue is adjusted with the endocervical opening as the fulcrum.
(5) When the tissue to be cut is thick, the head of the electrosurgical sheath should be slightly tilted forward so that the electrosurgical ring can cut into the tissue, and then the electrosurgical ring should be moved slightly deeper in an arc until the end of cutting, and then the sheath should be slightly raised so that the tissue can be cut smoothly.
2.Cutting method
(1) posterior pull method: is the most commonly used knife method using passive cutter. That is, after looking at the distal lesion, pull back the trigger, the cutting ring is extended forward to reach the destination, such as the destination for polyps will be polyps into the ring, release the trigger, the trigger back when the cutting ring from the distal end to the proximal end of the movement, that is, backward pull, at this time the operator according to the depth to be cut, the endocervical as a fulcrum, downward pressure or upward lift the cutter, the cutting ring through the tissue will be cut and separated, the cutting ring after pulling to the sheath mouth, that is The tissue block is cut off and the basal cut surface is yellowish white due to electrocoagulation.
(2) Forward pushing method: The target object to be excised is directed toward the front of the endoscope, the trigger is pulled back, and the cutting ring extending forward cuts into the target object.
(3) Transverse sweep method: It is suitable for resection of lesioned tissues at the base of the uterus, placing the cutter on the side of the target, with the cutting ring facing the target, pulling back the trigger to make the cutting ring reach the target, holding the trigger without releasing it, moving the cutter laterally, cutting the lesion down transversely, and this method is used for resection of adhesions in the official cavity and the uterine septum.
(4) Side cutting method: cutting with the lateral edge of the cutting ring can prevent cutting too deep.
3, the uterine cavity is not clear and its treatment, the uterine cavity is not clear, generally seen in the following two cases
(1) the uterine cavity is white like a cloud, this is because the uterine cavity is too little filled with water, the uterus can not be fully expanded, can be seen in: ① endometrial hypertrophy, edema, protruding to the uterine cavity, can not be fully expanded and unfolded. ②The water injection pressure of the perfusion fluid is lower than the required pressure of 13.3kPa (100mmHg), resulting in inadequate expansion of the official cavity. (3) Outflow suction pressure is greater than the required pressure of 13.3kPa (100mmHg), outflow suction pressure can deflate the lower tube and empty the uterine cavity of fluid.
(2) A piece of blood red in the uterine cavity can be seen in the following cases: ① the small blood vessels in the inner wall of the uterine cavity extensively seep blood, at this time the endoscope should be removed several times to flush out the blood; ② the clot or cervical mucus in the uterine cavity is sucked, blocking the downstream hole of the outer sheath, resulting in the blood cannot be discharged; ③ the front end of the hysteroscope is hung with a clot or tissue block; ④ the front end of the hysteroscope is against the bottom or side wall of the uterus.
4. Special requirements for removal of various lesions
(1) Submucosal fibroid: because of the narrow field of view under the microscope, the whole myoma cannot be seen and it is difficult to grasp the direction, so more ultrasound screen should be seen to understand the cutting range and direction to prevent cutting into the uterine wall.
(2) Endometrial resection
①Sometimes the vision is not clear deep in the uterine cavity, it can also be cut from the lower part of the uterus first, when the uterine cavity is larger, the infusion of irrigation fluid increases, the vision will gradually be clear, and it will not be difficult to cut the upper part of the uterus and the bottom.
② it is best to cut deep enough: if the cut is too shallow, the basal layer of the endometrium still exists, later regeneration, still bleeding, and regardless of the depth, as long as the cut is once, the base is yellowish white, it is difficult to grasp the site and depth of the second cut.
③ Because the uterine cavity is inverted triangle, the lower part of the uterus sometimes protrudes inward, and the contraction of the uterus caused by electrodesection makes the protrusion here more obvious, so when the lesion above it needs to be cut, the lower part of the uterine wall that is higher than the upper part of the lesion can be cut away first, and then the upper part can be cut without difficulty.
④ if the uterine fundus is wider than the lower uterine segment, and if the uterine cavity is cone-shaped or the fundus is biased to one side after cutting, the opposite side should be searched for uncut uterine horns.
⑤ if the cut fundus is hairy, it is endometrial tissue that has been electrocauterized and has not been cut to the myometrium.
(6) The uterus is contracted by the stimulation of electrocutting, resulting in the front and back walls of both sides being stuck together, and after the endometrium is cut, we should wait for a while and see the striped endometrium on both sides of the wall when the uterus is relaxed.
(7) The uterine horn wall is thin and easily perforated, so special attention should be paid when cutting the endometrium. It is best if the operation can be performed under ultrasound guidance. The endometrium of the horn of the uterus can only be removed with the backward pulling knife method, do not push forward; in some cases, the horn of the uterus is deep and the cutting ring is too large to enter, so the endometrium can be cauterized by sending the electrocoagulation roller ball instead.
For beginners in hysteroscopic surgery, hemostasis is a basic operation, which may be more difficult than familiarity with cutting, but must be mastered gradually. The degree of bleeding during electrosurgery varies greatly depending on the condition and the experience of the operator, ranging from spot bleeding in mild cases to the need for blood transfusion in severe cases. Therefore, rapid and accurate hemostasis during surgery is the key to prevent excessive blood loss.
How to reduce intraoperative bleeding and stop bleeding completely? The following points should be noted.
(1) Try to make the endometrium as thin as possible to facilitate resection, such as preoperative drug treatment or intraoperative scraping first followed by endometrial resection.
(2) Ensure sufficient flow rate of irrigation fluid to keep the surgical field clear.
(3) The depth of endometrial resection should be 2 to 3 mm below the endometrium. The vascular layer of the uterine wall is located 5-6 mm below the endometrium, so if the excision is too deep, the damage to the vascular layer may cause massive bleeding, and it is not easy to control.
(4) The excisional wound should be smooth and flat, so that the blood vessels can be seen clearly. For bleeding points that are not easily seen behind or between tissues, blind electrocoagulation to stop bleeding is often not ideal, and the raised tissues should be excised to reveal the bleeding points clearly before stopping bleeding.
(5) Sequential cutting, each excision of one part to be perfect hemostasis, and then cut the next part. Avoid too large trauma and excessive bleeding. Multiple bleeding can easily cause blurring of the surgical field and affect the operation.
(6) For bleeding from larger arteries or bleeding directly sprayed to the receiving lens, withdraw the electrodesiccoscope slightly backward to avoid the bleeding artery while observing carefully, and then extend the electrodesiccation ring or electric roller ball to compress the trauma in time after seeing the bleeding point, which helps to see the bleeding point clearly. Some small arteries bleed with great pressure, spraying to the lateral wall of the uterus and then bouncing back, making the real bleeding point not easy to be found, and it is necessary to rotate the electrosurgery mirror 180 degrees to find the bleeding point on the opposite side. Sometimes the bleeding point happens to be behind the uncut tissue, and the bleeding point can be seen after the bulging tissue is removed at this time.
(7) In case of bleeding below the blood clot, the bleeding point can be seen only after the blood clot is scraped off with the electrosurgical ring.
(8) If the blood vessels deep in the myometrium are cut and electrocoagulation is difficult to stop bleeding, a Foley catheter can be placed with the front end cut off leaving only the balloon, which is filled with water. The volume of the normal uterine cavity is 5-10 ml, for severe bleeding in a larger uterus 15-30 ml can be injected. 30-60 ml is needed for patients with uterine fibroids. because the balloon expands and comes into close contact with the uterine wall, the uterine wall is evenly stressed and compression to stop bleeding is mostly effective. Generally the balloon can be placed for 12-24 hours to stop the bleeding adequately. Note that antibiotics should be given at the same time to prevent infection.
(9) General cervical bleeding point is not easy to stop bleeding, because of poor cervical contraction, cervical bleeding can be filled with gauze dipped in posterior pituitary pressor dilution (20U posterior pituitary pressor + 30ml saline) to stop bleeding, which also has the effect of stimulating uterine contraction, and removed 8 to 12 hours after surgery.
(10) The cervical injection of 20 ml of posterior pituitary hormone injection with a concentration of 0.05 U/ml can promote local vasoconstriction. This drug has an excitatory effect on the non-pregnant uterus, but has a weaker effect on the pregnant uterus. There is no significant difference in the contractile effect on the uterine body or the cervix.
(11) If various methods of hemostasis are ineffective after hysteroscopic surgery, emergency uterine vascular block or hysterectomy is feasible. Uterine vascular blockade mainly includes uterine artery embolization, transvaginal or laparoscopic uterine artery ligation.
(12) If all methods of hemostasis are ineffective, hysterectomy is considered.