Resectoscope and Diathermic Loop [Surgery of submucous fybroid]

Introduction

How about good morning, today I greet you again to tell you about a special case of myomatosis.

Once again we are insisting on this type of pathology because myomatosis is one of the main problems in women of reproductive age, which leads to some alterations in their menstrual cycles, but also to moderate or severe problems such as significant bleeding that leads to anemia remember “Knowledge is power”.

About the patient and the diagnosis.

So, I want to show you, because this patient from her first visit who came is 37 years and 7 months old, she did not come mainly for a fertility problem, if her desire is to get pregnant because she has never been able to get pregnant, but the main problem was bleeding that I was having

She had been bleeding for six months, more or less, and in a study we conducted, she had a hemoglobin of 8.9, that is, she had moderate anemia, which already conditioned her to have problems in her daily life.

She got tired easily even when bathing, changing or doing activities in her house like picking up some things or washing. Many times they ask us that they (the patients) have a fibroid of 2 centimeters or 3 centimeters and their question is when to go to the doctor? Remember one thing, the size is important in some situations for reproduction, but that is also why I want to show you this case, because this was a patient with a relatively small fibroid but she had it in an anatomical situation where it caused her to have significant bleeding During her menstrual cycles, she even had metrorrhagia, which means bleeding between periods.

The size is important but the location is also very important and for reproduction issues the anatomy of the uterus, the location of the fibroids and the number of fibroids depend a lot, because in addition, in this case… As we have always shown the unique fibroids Generally, which are large fibroids, this patient did not have large fibroids, but she did have multiple fibroids. What we colloquially call “myomas in potato sacks”.

When doing an ultrasound we see the cervical canal here, down here on the posterior face of the cervix, if we could say so, but it is inside the abdominal uterine cavity, we have a fibroid and here on the anterior face we have another. I want to show you why I took a large series of photos, here we have another fibroid, this is another fibroid, this is another fibroid… Practically there we have 3 myomites, this fibroid here is a fourth that is on the subserous part, but the most important was this fibroid and this fibroid, although this fibroid is much larger, which we said is on the posterior side of the cervix, this fibroid right here, so with the naked eye, it gave me the suspicion that it was inside the cavity.

The gold test to know a differential diagnosis between a submucosal fibroid and an intramural fibroid is with a tube like this one. We do it in the office, we put a vaginal mirror as if we were going to take a Pap smear, we insert the cannula through the cervical canal, that is, there is no surgical process and here in the office we inject physiological solution. When this liquid passes through the uterine cavity, what it will do is distend the cavity but also make an echo refraction visualizing the tumor.

Here the tumor is perfectly well visualized, which measures more or less 32 millimeters, so it is a fibroid that is relatively very small, but this is important because it was the one that was causing the patient’s bleeding and obviously the moderate anemia, that that also carries some major risks down the road if left unmanaged.

The resectoscopy begins.

As you can see here we are already starting the hysteroscopy, generally we do the hysteroscopy without placing any mirror, or any utensil to separate the vagina, but what we do is with the same hysteroscope tube we enter, see there you can see those fibroids on the side, like this Looking at it from the front, on the left side there is a small fibroid that is practically one centimeter long and the largest fibroid is 3 centimeters. Look at how highly vascular it is, it is called bilobed, that is, it looks like 2 little lemons.

A larger lemon, which is the one on the right side, looking at it from the front, and now you will be able to see how we begin the resection of these fibroids. Generally, the resection of fibroids has to be done with a curved handle that transmits heat and coagulates. On some occasions it already exists to do it with a laser, however, the laser has as always some contraindications, among them, using the laser in large fibroids, no… Sometimes, it is not so viable, why? Because the laser has a smaller cut, and therefore it is more recommended for polyps, adhesions or fibroids smaller than 1 and a half centimeters, this language measures 3 and a half centimeters

So, they are going to be observing how the process is being carried out, what I wanted was for them to visualize how with a hysteroscope you have an accurate diagnosis, but also that surgical shirt allows us to insert; scissors, tweezers, the diathermic loop and being able to perform the resection and extraction of these fibroids without the need to open the uterine cavity.

About the Diathermic Loop.

We are inserting a diathermic loop that is called, that is, it is a curved loop that has heat to be able to cut and coagulate at the same time and then, thus, receive the fibroids that are in the cavity, submucosal, and with forceps which is called “grasper” which is often as if it were a crocodile bite, many times we remove that tissue from the fibroids that are drying out. It is very important to know that this surgery is NOT so “uncomplicated”, you have to have a lot of preparation and above all know.

Because you have to put in a special solution called glycine so that when we are cauterizing the patient she will not have burns outside the uterus, that is, if I do this procedure with a physiological solution when I want to coagulate, I will transmit heat to other tissues and there can be injuries, even quite delicate ones if we don’t realize it. So, it is very important to see that the procedure is a bit laborious, it is for patients who have submucosal fibroids, that is, inside the cavity, but that it be done by a specialist and someone who has expertise in outpatient surgical procedures with hysteroscopy. It is very important, in the video they will be observing how we insert and remove that little forceps, because it is the only way to do it without opening the uterus, without injuring it, but also that I may be resecting small portions of that fibroid.

The process takes from two to three hours, because even if it is a two or three centimeter fibroid, the diathermic loop only measures a millimeter cut, so to remove a two or three centimeter fibroid I have to do practically between 30 or 40 cuts to be doing the resection of that tumor.

Conclusions.

Fortunately the surgery was a success, after I am checking her right now, we are going to see if we can get her pregnant before removing the fibroids that are in the uterus.

Because? Because since she has multiple fibroids, as long as the cavity is free, this patient can get pregnant because they are fibroids that are not large, and she is almost 38 years old, so what we have to do here is to prioritize, first is get her pregnant and then assess whether it is worth doing surgery for fibroids that are intramural and subserous.