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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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Differential Diagnosis
Arcuate/subseptate uterus: Defined as having a fundal indentation of <1 cm.
Bicornuate uterus: Distinguished from a septate uterus by indentation of the outer fundus >1 cm. Can commonly have a
coexisting septate component.
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IMAGING AND OTHER DIAGNOSTICS
Three-dimensional ultrasound with or without saline infusion show equivalent diagnostic accuracy and lower cost compared to
MRI or laparoscopy/hysteroscopy. Three-dimensional ultrasound imaging should be considered first-line in the evaluation of a
uterine septum. Hysteroscopy alone or a hysterosalpingogram (HSG) are inadequate due to the lack of external uterine
contour evaluation.
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PREOPERATIVE PLANNING
Imaging should be used to attempt to determine the extent of the uterine septum and to define the outer contour of the
uterus.
Intraoperative abdominal ultrasound scanning through a full bladder can be helpful in guiding the extent of the septum
resection and may reduce the incidence of a residual septum.
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Surgery should be planned in the early proliferative phase or after endometrial preparation. Endometrial preparation can
improve visualization during the procedure. This can be accomplished with the use of combined oral contraceptive pills or a
progestin (norethindrone acetate 2.5 to 5 mg daily) taken for 14 to 21 days prior to the procedure.
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SURGICAL MANAGEMENT
If preoperative diagnostic procedures are unclear in determining the external uterine contour, a diagnostic laparoscopy can
be considered at the same time as the hysteroscopy to verify outer uterine contour. Laparoscopy can also allow for the
diagnosis and treatment of coexistent endometriosis that is found with a higher incidence in women with a septate uterus.
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Resection of the septum can be achieved with the hysteroscopic scissors, a monopolar resectoscope loop, or bipolar
electrocautery such as the Gynecare Versapoint™ (Ethicon, Somerville, NJ).
With all methods, the septum generally only needs to be incised to allow retraction into the anterior and posterior uterine
walls. In cases with a thicker septum, excision may be necessary.
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Positioning
The patient is placed in the standard dorsal lithotomy position.
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Distention Media
Normal saline is used for procedures using nonelectrical instruments or with bipolar instruments. Monopolar instruments
require hypotonic solutions such as 3% sorbitol, 5% mannitol, or 1.5% glycine. Fluid deficits should be limited to 2,500 mL of
normal saline or 1,000 mL of hypotonic solutions due to concerns of hyponatremia with hypotonic solutions. Hypertonic
solutions such as 32% Dextran-70 in 10% glucose (Hyskon
®
, CooperSurgical Inc., Trumbull, CT) should be avoided due to
side effects of pulmonary edema and anaphylaxis.
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Keeping intrauterine pressure below the patient’s mean arterial pressure can decrease distention fluid absorption.
Intracervical injection of a very dilute vasopressin solution (8 mL of 0.05 U/mL vasopressin) can also decrease absorption.
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Concentrations of vasopressin should not exceed 0.4 U/mL.
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Procedures and Techniques
Performance of diagnostic laparoscopy
If preoperative diagnostic procedures are unclear in determining the external uterine contour, a diagnostic laparoscopy can
be considered prior to the hysteroscopy to verify outer uterine contour. In cases with an indented outer fundus, the septum
resection may not achieve a fully normal triangular cavity due to a partial bicornuate configuration.
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Initial hysteroscopy and planning
In cases of an incomplete septum, the hysteroscopy should be performed utilizing the least amount of cervical dilation
necessary to allow passage of the operative hysteroscope. Excessive dilation will lead to leakage of the distention fluid. If
distention fluid leakage occurs, placement of an additional single tooth tenaculum on the cervix near external cervical os can
create a tight seal against the hysteroscope sheath.
Inspect the septum and plan the septal incision in the midportion of the septum, taking care to prevent dissection into the
anterior or posterior walls of the uterus (Te ch Fig. 3.3.1).
A 12-degree scope is ideal for instrument usage. A 0-degree scope view will be limited by blockage from the instruments.
With a 30-degree scope, the instrument may be out of the visual field due to the orientation of the instrument and the lens of
the hysteroscope.
See details below for steps regarding a complete uterine septum.
Te ch Fig ure 3.3.1. Initial view of an incomplet e uterine sept um.
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Septum i nci sion with scissors
Incise the septum horizontally, staying in the middle of the septum vertically (Te ch Fig. 3.3.2). Maintain proper orientation
by keeping the fallopian tube ostia visualized. The incision should be in a plane that would connect the two ostia. As the
septum is incised, the septum will usually retract into the anterior and posterior uterine walls (Tech Fig. 3.3.3).
Te ch Fig ure 3.3.2. Start of incision in midport ion of septum.
Te ch Fig ure 3.3.3. Retract ion of sept um anteriorly and posteriorly.
The incision continues, keeping in the transverse plane that would connect the fallopian tube ostia (Tech Fig. 3.3.4).
As the fundus is approached and the septum thickens, an incision slightly anterior and posterior to the midplane may be
necessary to fully remove the septum.
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The procedure is completed when a normal triangular cavity is recreated, or when myometrial tissue is reached in the
midline. The myometrial tissue appears more red and vascular compared to the typical white appearance of the septum.
The presence of bleeding usually indicates having reached the myometrium (Tech Fig. 3.3.5).
Te ch Fig ure 3.3.4. Upper thicker sept um seen.
Te ch Fig ure 3.3.5. Unified uterine cavity.
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