Transcript Septum Resection

Mounir M. Fawzy El-Hao
Prof. in Ob/Gyn
Ain Shams University
Cairo - Egypt
Incidence of Mullerian
Abnormalities

General population Unknown0.1 1.5%
(Rudigozand Dorgent, 1985)

HSG in infertility
1-3%
(Ludmir et al., 1990)

Women with reproductive difficulties1-12%
(Rock and Schlaff, 1985)
Incidence:
15 – 25% of spontaneous abortions are caused by
Mullerian fusion defects
1986)
(Portuonodo et al.,
Simple classification of Mullerian
anomalies:
1.
Agenesis (R-K.H-Syndrome)
2.
Problems of vertical fusion
Obstructive
 Non-obstructive

3.
Problems of lateral fusion
Obstructive
 Non-obstructive

Agenesis (RKH syndrome)
Surgically corrected for sexual function

Mc indoe’s

William’s

Modified vicchietti
Remember …
Problems with vertical fusion represent a fault in
the function between the down-growing
Mullerian ducts (tubercle) and the up-growing
derivative from the urogenital sinus
Remember …
Problems of lateral fusion of the two Mullerian
ducts are especially note worthy in that obstructive
lesions seem to have been observed clinically only
when the obstruction was unilateral (absent
kidney) i.e. (if bilateral = nonviable)
Remember …
Attention to obstructive lesions is often urgently
necessary to prevent deterioration of reproductive
capacity from retained mucous or menstrual blood
Classification of LFD.
Septum Resction
Pregnancy rate
 Topkins laparotomy procedure is 71.4%
 Hysteroscopic resection of septum is 84%
(Fayez, 1986)
Vaginal delivery
 Topkins laparotomy 80%
 Hysteroscopic metroplasty 76%
(Fayez, 1986)
Hysteroscopic resection of the
uterine septum was first described by
Edstrom in 1974
DIAGNOSIS.
 HSG.
 LAPAROSCOPY.
 HYSTEROSCOPY.
 MRI.
 3DIMENSION US.
Diagnosis:
Difference between the data obtained by HSG and
those by hysteroscopy as regards the length of the
septum, was due to dispersion of the dye around
the septum on both sides, which faded the septum
that disappears especially in the lower part
(Kesler and Lancet, 1986)
LAPAROSCOPY.
 VISUALISES THE OUTSIDE OF THE UTERUS.
HYSTEROSCOPY
 VISUALISES THE INSIDE OF THE UTERUS.
 THREE DIMENSION US VISUALISES THE INSIDE
OF THE UTERUS,THE CAVITY AND THE
OUUTSIDE..
Septate uterus.
MRI septate uterus ?
Laparoscopy broad fundus.
SEPTATE BY 3D.
LARGE BASE SEPTUM
DISTORTED SEPTATE ? TB.
Septate with two cervicies.
Told unicornuate.
Told unicornuate.
WRONG DIAGNOSIS BY HSG(end
on x ray)
(Portuonod(Portuonodo
et al., 1986)
o et al., 1986)
Unicornuate uterus by HSG.
Laparoscopy unicornuate uterus.
Unicornuate uterus.
URINARY
BLADDER.
HAEMATOMETREIA
Abnormal uterus by three D US.
 Endometrium of each uterus shows triangular
cavity.
Unequal double uterus.
Remember …
Primary infertility in a patient with a
symmetrical double uterus (bicornuate or
septate) is sometimes observed, but the
etiological relationship between the infertility
and the anomaly is an unresolved problem
(Howard Jones, 1983)
Remember …
It is seldom that a bicornuate uterus needs
surgical reconstruction. It follows that almost
invariably if a double uterus gives reproductive
problems which require surgical correction, it is
the septate uterus which will be involved
(Howard Jones, 1983)
Recurrent pregnancy loss in
septate uterus
 Poor blood supply
 Poorly developed endometrium
 Inability to expand
 Abnormal uterine contraction
(De Cherney et al., 1986)
Timing
Follicular phase, when pregnancy is
unlikely and the endometrium is
thin, tubal ostea are well apparent
Technique
 Down up or side to side?
 Knife or loop?
 Diathermy or scissor
 One or two sittings?
Technique
Medium used:
 Gas: smoke and bubbles and thermal effect
 Glycine: no electric conduction, cooling effect of
electric current
Technique
Because the resectoscopic electrode also
provides coagulation while the septum is
incised, vessels at the fundal region may not
bleed upon division, depriving the
hysteroscopist of their landmark when the
myometrium is reached
SEPTUM RESECTION.
Complications
Perforation
3 cases
Hemorrhage
None
Infection
None
IUS
Minor (7 cases)
Major (None)
Complications
 Cervical laceration and uterine perforation during
introduction of the scope
 Distention media complications
 Deep dissection problems (bleeding, IUS)
Incidence of different complaints in patients
with uterine septum
Main Complaint
No of
patients
%

Repeated abortions*
63
66.3

Unexplained infertility
24
25.2

Dysmenorrhea
5
5.3

Irregular uterine bleeding
3
3.2
Total
*repeated abortions=2 or
more spontaneous
miscarriages.
100
95
Correlation between
hysteroscopy and HSG in women
with uterine septae
Degree of the septum
HSG
Hysteroscopy
Complete
36
41
2/3
40
38
1/3
19
16
Total
95
95
Correlation of number of repeated
abortions and number of patients (63
cases)
No of abortions
No of patients
%
2
38
60.3
3
19
30.2
>4
6
9.5
Total
63
100
Operative details of 95 cases of
uterine septae resection with
resectoscope
Operative details
 Operating time
 Average amount of distention
media
 Deficit of medium
 Intra-uterine Foley’s catheter


None intra-uterine
Postoperative antibiotics
Mean data
15 ± 4 (min)
1275 ± 56 (ml)
210 ± 550 (ml)
19 cases
76 cases
87cases
Obstetric performance
(follow up 24 months)
Defaulters
23 cases
24.2%
Spontaneous
abortion
6 cases
6.3%
7 cases
7.4%



Preterm labor

Term labor
48 cases
50.5%

No pregnancy
11 cases
11.6%
95 cases
100%
Total
Remember …
The main reason for performing hysteroscopic
metroplasty is for poor pregnancy outcome, recurrent
pregnancy loss and infertility
Why hysteroscopic?
Outpatient basis
 No abdominal or uterine scar
 Minimal postoperative morbidity
 No reduction in uterine volume
 Pregnancy attempted soon after the operation
(Fayez, 1986 – Daly, 1983)
 THANK
YOU FOR YOUR ATTENT