Today’s topic is 20 years of hysteroscopy in our country, which is minimally invasive surgery, the idea of minimally invasive surgery was proposed in our country in the seventies, but our modesty makes progress and as a result no progress was made, the name was taken away by the British, hopefully in the future we will come to promote ourselves more, modesty is to some extent. Hysteroscopic surgery is now a model of successful minimally invasive surgery because it has the lowest trauma ratio and the highest efficiency ratio, it avoids hysterectomy and open surgery, so it is one of the mainstream procedures of minimally invasive surgery, and it is irreplaceable, no surgery can replace it, if there is no such technology and no such equipment, you have to open the abdomen, you have to sacrifice your uterus. The founder of hysteroscopy in China is Professor Lin Yuan Ying, who was in the same class of the late Professor Lin Qiaozhi, a well-known professor of obstetrics and gynecology. There were four students in their class, and I have seen their pictures, and some people say that I am the mother of hysteroscopy, and I tell you that we also have a grandfather, and our grandfather is Lin Yuan Ying. Our patriarch, Prof. Cao Zeyi, once said that there is no substitute for the role of hysteroscopy in the diagnosis and treatment of intrauterine diseases, and another patriarch, Academician Lang Jinghe, said that gynecological endoscopy is a necessary skill for obstetricians and gynecologists (note that there is also obstetrical content) in the 21st century, and now that 12 years have passed in the 21st century, we have to ask ourselves whether you are a modern obstetrician and gynecologist and whether you have mastered endoscopic technology. The development of hysteroscopy in our country was made possible by the establishment of the Gynecologic Endoscopy Group under the leadership of the Chinese Medical Association in 2000, and retrospectively by the President of American Laparoscopy, Jordan Phillips, in 1979, and since then our academic activities have been mushrooming. The school is based in Amsterdam, the Netherlands, and its chairman has come to China twice to pass on his experience. This is Prof. Paul Lam, this is Franklin Loffer, the president of the Americas, he is a professor of obstetrics and gynecology at the Northwestern University School of Medicine, he has been doing hysteroscopy since the 1970s, he has published many books and papers, and now he is retired. The patient was an unborn woman who had an IUD placed for family planning, and six years later she wanted to have a baby, and when she came in for the IUD removal ultrasound scan, because there was no hysteroscopic magnification, so the ultrasound report from either hospital thought that her IUD was in the uterine cavity, but the local doctors just couldn’t get it out, and when she came to us, we saw under the hysteroscope We saw that this is a cavity, there is a little endometritis, both sides of the uterine horns, fallopian tubes are very good, behind it there is a cavity, this cavity is also very deep, there is an intrauterine device, indicating that when the device was placed, even the ultrasound scan can not be so clearly distinguished, is placed in a false channel, and this false channel is made very deep, closely connected, and parallel to the uterine cavity This leads to the misunderstanding that the ultrasound scan is inside the uterine cavity, but of course we see it and it is easy to remove it. These six traditional procedures are now classic and recognized. The first one is vaginal endoscopy, which Professor Osama explained to us with pictures, and I will explain it with video today. This is a case of a 12 year old girl with vaginal bleeding for 3 months, without the technique of vaginal endoscopy, an open surgery would have to be done and the vagina would be damaged to some extent. What is a vaginal endoscopy? It’s when we use the hysteroscopic dilatation technique to dilate the vagina to be able to show the anterior and posterior vaginal walls, after that we see the posterior vaginal vault, then we lift the mirror up to see the posterior lip of the cervix, then we lift it up to enter the cervical canal, because there is an occupying lesion, the cervix must have some opening, so we go in with a straight mirror without any difficulty and see an endometrial polyp. The patient has a history of bleeding, so she has petechiae on the mucosal surface. The next step is to see if it is a single or multiple polyp, it is two polyps, and then to see where it is attached, at the base of the uterus in the right corner of the anterior wall, we change to an electrospectroscope, which we have either 7mm, 8mm, 8.5mm, or 9mm, which can be used to easily remove it without damaging the hymen. The lesion can be easily removed without damaging the hymen and then sent for pathological histological examination. This is a 4 year old girl from the northeast who had vaginal bleeding for 2 years without clear diagnosis and treatment, we examined her with vaginal endoscopy. We use Olympus 7mm closed electrode electrosurgery mirror, what is closed type? He said there are too few people using it, there is no sales, in fact, she is very good, especially in doing uterine adhesions, this closed electrode to push forward the uterine cavity can be opened, now we use the ring is also less, the ball is even less, but for this child we are very willing to take out, very precise little by little excision, and finally in the mirror under the conditions of magnification under the visualization of all clean, and then send to do pathology I did a second excision, and after another four months, the patient’s symptoms were gone, and no recurrence of the lesion was found. If we didn’t have such technology, this child would have to undergo open surgery. We have more than 40 cases like this, which is a papillary tumor of the urinary tract, grape sarcoma, rhabdomyosarcoma, and more foreign bodies, children stuffing anything into them, and inflammation of the vagina, all of which can be diagnosed non-invasively with such a method. The hysteroscopic diagnosis of chronic pelvic pain, occupying lesions in the uterine cavity, and adhesions in the uterine cavity will certainly cause pelvic pain, and now about adenomyosis, this morning Professor He Yueming talked about the metastatic zone of the uterus, which is the superficial myometrium, and it is the earliest site of invasion and development of adenomyosis. In this case, we came for hysteroscopy just after menstruation and found that there was no thickened endometrium in the uterine cavity, we could see the opening of the endometrial glands, and after the opening of the glands was blocked, we could see many purple-blue dots, which is very typical. It is interesting to see the tiger skin like structures on the inner side of the entire uterine cavity. This image is used for the early diagnosis of adenomyosis, which must be just after menstruation, which is why I support Osama’s view that he is not contraindicated and we do not have bad consequences for patients with endometriosis. Clinical diagnosis of adenomatous disease of the uterus, which cannot be said to be advanced, at least it is not early. The key operation is a transverse perforation of the uterine cavity, a man-made perforation of the uterus, after which the uterine fundus can be completely cut open, a process that can be done with needle electrodes from left to right or from right to left, which is marked by a deep transverse excision of the inner 1-1.5 cm of the opening of the fallopian tubes bilaterally. This operation took more than 10 minutes, and our doctor was anxious while watching, saying that the hysteroscopic surgery is afraid of perforation of the uterus, and it is not easy to perforate the uterus, but it is not perforated, and finally, it is probably a little thinner here, and we will see that the weak part will be immediately colluded, we are right-handed, to the left Cut some good, this cut in, soon perforated, we see through, the top is no light, but we did not give up, or continue to cut, why can continue to cut? Usually, theoretically, once the uterine cavity is perforated, the media can not gather, it is no field of view, but we have this uterine surgery, perforation after the field of view, why? The pressure of the uterine cavity we can adjust to 100, 120, 130, 150 can, and laparoscopic pressure how much? 15 terrific, so the pressure of the uterine cavity exceeds the pressure of the abdominal cavity, we are still willing to hysteroscopy under direct vision as much as possible to cut, why are you willing to cut under the hysteroscope? Because the folded line at the bottom of the uterus of the hysteroscope is very obvious, cutting up the sign is very clear, but the laparoscopic doctor to a certain extent will beg for mercy, his suction speed will be a large influx into the abdominal cavity, not as fast as our irrigation fluid infusion, he begged for mercy under us to terminate, after termination and then change to the laparoscope to see, change to the laparoscope to see this is the case, see an incision in the abdominal cavity, we see is We opened the plasma membrane and opened this part of the muscle again, and afterwards we cut and sutured it crosswise and longitudinally to form a complete and intact uterus, and then we let the patient use contraception for one year, which seems to be a little long now. The third item of progress is the orthopedic surgery of the T-shaped uterus, which was introduced in the 1940s with the introduction of a synthetic estrogen, which we still have in China, but it’s almost gone, and Prof. Wang Yanguo had it there. In 1970, the U.S. FDA proposed to ban it, but France used it for a few years, and then really could not insist on it, are not used, there is such a malformation, it affects the development of the urethral duct, but also affects the Culler’s duct, but the impact of the Muller’s duct is not so obvious, the development of the urethral duct is affected by what consequences it will appear? The first is the shortening of the uterus from the base of the uterus to the middle and upper part of the uterus, why? This is because there are very thick muscles on both sides of the wall, causing the vertical part of the uterine cavity to come together on both sides, some people say this is a contraction ring or stenosis, very close together, and after it comes together, the upper part of it becomes very narrow from the bottom of the uterus, the whole uterine cavity should be more than 4cm, this part is less than 2cm from here to here, just like this, this is a very typical, like a capital T letter such a letter The literature reports that the correction of T-shaped uterus is the most effective in restoring fertility function in all malformations, with a success rate of 66.7%. Therefore, it can be considered that it is affected by some harmful, biological, physical or chemical factors, resulting in abnormal embryonic development, and this embryonic development is completed from the 4th to the 20th week of gestation, so the process of this violation is relatively long, resulting in such an abnormality, some patients are still able to have children, and if they cannot have children, we can perform orthopedic treatment, and the most sensitive diagnostic method is HSG. The most sensitive method of diagnosis is HSG, HSG we see that its upper segment is shortened, the walls on both sides are narrowed, the middle seems to have a narrow ring, for such patients we performed orthopedic surgery, orthopedic surgery you see Osama is to use a needle electrode to cut both sides, we also use needle electrodes, Dr. Zheng Jie use needle electrodes, I am using ring electrodes to cut, he is cutting, I am excision, you see its upper segment The purpose of this surgery is to expand the volume of the uterine cavity, which should be 90cm3. This surgery is not suitable for beginners, experienced people can master, I have done so many years, from 1990 to do, to do now I still do not feel under my hands, this electricity it is an electrode, not by feeling, is to rely on experience, you just have to psychological number, not feeling is a number, I can not say clearly, can only feel can not say, finally done what look, we see is this look This is the most recent little boy, whose family was overjoyed and wrote such a nice letter of praise. The fourth advancement is Robert’s womb, what is Robert’s womb? The diaphragm of the uterus is not a vaginal diaphragm, and the laparoscopic fundus is not a very typical manifestation of the malformation, because it is generally considered in the literature that the morphology of the fundus or the contour of the fundus is a golden indicator and a marker to understand the type of malformation of the uterus, but for the diaphragm of the uterus it may be an abnormality. In terms of diaphragm it may be abnormal, it may be normal, and the one that is shown to everyone is normal. This patient has an oblique diaphragm on the left side, so the left side of the uterine cavity is not patent. The septum extends downward from the uterine cavity at the base of the uterus, and instead of developing in the direction of the cervical canal, it develops to one side and fuses with the opposite side, indicating that the right side of the uterine cavity is open and the left side of the uterine cavity is atretic. Now, after showing you such an image, we design this surgery to cut the left septum with an electrodes or needle electrode, to remove the septum to the left side, this is the needle electrode to cut in this direction, and then open it, you can see a small hole in the middle after opening, you must imagine that a lot of old blood will accumulate inside, not so, its blood accumulation from puberty is constantly The blood accumulation from the open fallopian tube to the pelvic cavity has been flowing backwards since puberty, which eventually leads to adhesions in the pelvic cavity, chocolate cysts, and many adhesions, so it’s not very nice under laparoscopy. This is a 14-year-old child in adolescence, if she is older to see infertility inside the pelvic cavity is miserable, just open up after, what can we see? We can see some pink mucus-like fluid, and after opening it, the difficulty of the operation is gone. The next progress is the orthopedic unicornuate uterus, unicornuate uterus, you see this is the left unicornuate, right stump angle, or left stump angle, right unicornuate, we have a lot of such images, microscopic look at its cavity foreign reports are shuttle-shaped, we say a little more common is bean-shaped, is crescent-shaped, it is curved, we now see the cavity is narrower, the volume is relatively small, we have to do the surgery is to expand the surgery The surgery we are going to do is a dilation surgery. How is it done? The cavity with the opening of the fallopian tube is definitely not cut, but to its opposite side for excision, because the unicornuate uterus is used to cut to the T-shaped uterus is also willing to cut, cut to the end to see what? There are still some ways to prevent re-adhesion and contracture of the uterus, whether we are talking about a unicornuate uterus or a T-shaped uterus. In this case we have this method to help correct it, and there are reports of deliveries. We have done some single-angle ones for a relatively short period of time, and there were 2 pregnancies, unfortunately 1 miscarriage and 1 ectopic pregnancy, and we are still following up. It’s not. The sixth progress is horn pregnancy. In this meeting, someone mentioned horn pregnancy, one side of the uterine horn will be bulging, we are combining hysteroscopy with traditional aspiration. In fact, this is the left horn of the uterus, but there are still some remnants at the edge that are not necessarily embryos, it is very clean, there are some uneven tissues left, in fact, it may be the mucosa of the uterus or a little bit of myometrial tissue, we can ignore it, in order to pursue perfection, we finally cut it all, cut it cleanly, and finally formed such an image, this is the left horn of the uterus. This is the left side of the uterine horn, and this is the normal uterine cavity, this is the sixth progress. The seventh progress is cystic uterine adenopathy, which was mentioned by Prof. Ayrong Shen yesterday as a lymphatic duct cyst, and in this case there is a 5.6 cm cyst near the bottom of the posterior wall of the right uterus, and these patients are infertile. Under the hysteroscope, there is an inward bulging lesion in the left wall of the lower middle part of the uterus, and under ultrasound guidance, this area is a cyst in its wall. The most vulnerable, easily accessible and easily treatable parts of the myometrium are found in the uterine cavity. This is a case of our Dr. Zheng Jie, Dr. Zheng Jie hysteroscopic surgery is also very good, Dr. Zheng Jie said: not good, the devil training, all day long in doing, he cut a knife, two knives about a dozen knives, in this opened, this is bleeding, in a part of the cut a dozen knives, ultrasound doctor has been monitoring, help him search, help him cut the site is not appropriate, is also quite hairy, sometimes on the What are you afraid of? The patient wants to keep the uterus, you still cut again, you have not found, you cut the wrong place, sometimes it is quite embarrassing, this is cut, and the ultrasound doctor to cooperate closely, our B ultrasound doctor is our own doctor, each of our doctors are B ultrasound doctor, in scanning the pelvic cavity than our center B ultrasound room doctors have more experience, just this little, once some hospitals want to do this kind of surgery The surgeon is very relieved, you say where to cut, I will cut, she says cut this and cut that, finally the surgeon says: no, how to cut the uterine cavity, the ultrasound doctor is still unaware of it, so we must train our own ultrasound doctor, look at this cystic cavity opened, a lot of fluid, old blood out, after this cystic wall is still It is a multifocal disease, we only removed one or not enough, there are some more, so we will soon perform the removal of the ectopic endometrium with its lining, and also open the other small sacs, it takes time. On the first day, OLYBAS showed us a bipolar plasma mushroom head-like cavitation electrode, which we call an iron, and I think it’s great. The eighth progress is the ectopic pregnancy with cesarean incision, which is another type of ectopic pregnancy, which is inside the uterus, but in the cervical area is on the scar, first of all, it is diagnosed by ultrasound, this is microscopic, microscopic localization, microscopic cutting, microscopic rolling ball electrocoagulation to stop the bleeding, and finally ultrasound confirmed that we have a complete removal of the lesion. Now speaking of the latest theory, I cite the literature is still in print in 2012, the year and month of the journal’s magazine is not yet available, to show you. Naming is also not to say that it is named abroad is now being named, there is also a new term called isthmus bulge, isthmocele, cele are the meaning of bulge, isthmus bulge is bulge to the bladder inside, not to the uterus inside, the definition is my translation of the English, but also not necessarily right, is the anterior wall of the uterus isthmus reservoir-like pouch-like defect, what kind of called reservoir-like? This is literally translated, it means localized to be able to gather some fluid, this is a pouch-like defect able to gather some fluid, that is, menstrual blood, located in the scarred area of the previous cesarean section, this is its definition. The symptoms blood accumulates inside the niche and the menstrual blood flow from the cervix may slow down, so there is continuous bleeding, and what I shared with you is that she can cause pelvic pain, which we didn’t pay attention to in the past because it exists fibrotic tissue can cause pelvic pain above the pubic bone, and one more thing, it can cause secondary infertility, continuous bleeding affects the quality of cervical mucus and sperm, hinders the passage of sperm through the cervical canal and interferes with I heard the report yesterday they said there was one case of pregnancy, we sometimes feel that the bleeding is not much, and the effect of surgery is not sure, and to do the combination of the uterus and abdomen, she still has a breast-feeding child, so you just bear to have a second child, the second child when a piece to you to remove to repair, it will also affect infertility, this is surgery, this is orthopedic. There is also a theory that this local inflammation, fibrosis, vascular thickening, our video to see this vascular thickening, many branches are also constantly bleeding, we see this blood is constantly pouring out, this is not our trauma, it is a defect in the anterior wall of a depression, Xu Dabao proposed a valve theory, he is an idea, at least it this is a cause of bleeding, our practice can be in This is a polyp, coexisting polyp we removed, because hysteroscopic surgery it is very simple, if it is not cured we will combine the uterus and abdomen, after that is how to cut, this is also hysteroscopic cutting or get cured, at least it can improve. The last progress is interstitial pregnancy, interstitial pregnancy in this case was transferred from overseas, the diagnosis was right horn pregnancy referred to us, the result of hysteroscopy saw that there is no pregnancy in the right horn, but the right horn is slightly deep, the right tubal opening is a little folded, no peristalsis, the left side is completely normal, such an image, after we how to do it? It is an interstitial pregnancy, and we look at laparoscopy for interstitial pregnancy. The difference between horn pregnancy and interstitial pregnancy is the round ligament attachment, which is on the inside of the round ligament attachment is horn pregnancy and on the outside is interstitial pregnancy. Secondly, because of the high risk of bleeding, we do uterine artery block, which is the root of the uterine artery, the first artery is the uterine artery, which is relatively easy to find the front branch. Because we blocked one side, it is the right side, and we did it on the right side, the right side was already bulging, there is a certain occupancy, making the space on the right side become smaller, very narrow, we also have to separate the uterine artery, but still can be completed, you can see there is not much bleeding, you can see the uterus before the uterine artery blocked there is blood, it is pink, after blocking the color immediately turned into lavender. After the blockade, we use a monopolar hook to make an incision. After the incision, we use a circular forceps to reach to the cheek of the uterus and clip out all the villi as deep as possible. The patient was followed up and the fallopian tube was patent, and this side of the tube was preserved. I hope we can all work together for the prosperous development of hysteroscopy for the benefit of our patients.