Departments of Obstetrics and Gynecology (Drs. A.V. Kulkarni, Alahabade, Ruikar, Mahajan, T. Kulkarni, Giri, and Nandana).
Department of Urology (Dr. V.M. Kulkarni), Mamta Hospital, Latur, Maharashtra, India.
J Minim Invasive Gynecol. 2024 Apr;31(4):271-272. doi: 10.1016/j.jmig.2024.01.010. Epub 2024 Feb 1.
To demonstrate the safety, efficacy, and ease of hysteroscopic metroplasty using holmium:YAG (Ho:YAG) laser for treatment of septate uterus.
Stepwise demonstration of surgical technique with narrated video footage.
Septate uterus is the most common type of uterine anomaly. The incidence of uterine septum in women presenting with infertility and recurrent abortions is 15.4% [1,2]. Hysteroscopic septal incision is associated with improvement in live-birth rate in these women [3]. Hysteroscopic metroplasty for septate uterus can be done with the use of scissors and energy sources such as monopolar and bipolar electrosurgery and lasers. Ho:YAG laser is commonly used by urologists for various surgeries because of its "Swiss Army Knife" action of cutting, coagulation, and vaporization [4]. Ho:YAG laser is known for its precision. It causes lesser depth of tissue injury and necrosis and minimal collateral thermal damage compared with the electrosurgical devices and other lasers used for hysteroscopic surgery [5-8]. This is advantageous in hysteroscopic metroplasty given that it reduces the risk of uterine perforation during surgery and hence uterine rupture in the subsequent pregnancy. Reduced collateral damage to the surrounding endometrium helps promote early endometrial healing and prevent postoperative intrauterine adhesions. A 28-year-old patient with history of 2 spontaneous abortions came to our hospital for investigations. 3D transvaginal sonography of the patient showed presence of partial septate uterus with a fundal indentation of 1.5 cm (Supplemental video 1).
Diagnostic hysteroscopy followed by septal incision using Ho: YAG laser was planned. We used a 2.9 mm BETTOCCHI Hysteroscope (Karl Storz SE & Co.) with a 5 mm operative sheath. Normal saline was used as the distending medium and the intrauterine pressure was maintained at 80 to 100 mm Hg. The procedure was done under total intravenous anesthesia using propofol injection. Vaginoscopic entry into the uterus (without any cervical dilatation) showed evidence of a partial uterine septum with tubal ostia on either side of the septum. A 400 micron quartz fiber was passed through a laser guide into the 5-Fr working channel of the operative hysteroscope. Ho:YAG laser (Auriga XL 50-Watt, Boston Scientific) with power settings of 15 watts (1500 mJ energy at 10 Hz) was used. Incision of the septum was started at the apex of the septum in the midline and continued in a horizontal manner from side to side toward the base (Supplemental video 2). Incision of the septum is continued till the tip of the hysteroscope can move freely from one ostium to the other (Supplemental video 3). The operative time was 12 minutes. There were no intra- or postoperative complications. Postoperative estrogen therapy was given for 2 months in the form of estradiol valerate 2 mg (tablet, Progynova, Zydus Cadila) 12 hourly orally for 25 days and medroxyprogesterone acetate 10 mg (tablet, Meprate, Serum Institute of India, Ltd) 12 hourly orally added in the last 5 days [9]. 3D transvaginal ultrasound was done on day 8 of menses. It showed a triangular uterine cavity with a very small fundal indentation of 0.37 cm. A second look hysteroscopy that was done on day 9 of menses showed an uterine cavity of good shape and size [10]. Few fundal adhesions were seen and they were incised using Ho:YAG laser. The patient conceived 5 months after the primary surgery and delivered by cesarean section at 38 weeks, giving birth to a healthy baby of 2860 grams. There were no complications during her pregnancy and delivery. A comparative study is essential to prove its advantages over other energy sources for this surgery.
Hysteroscopic metroplasty using Ho:YAG laser for treatment of septate uterus is a simple, precise, safe, and effective procedure. VIDEO ABSTRACT.
展示使用钬：YAG（Ho：YAG）激光进行宫腔镜子宫整形术治疗纵隔子宫的安全性、有效性和简易性。
分步演示手术技术，并配有解说视频。
纵隔子宫是最常见的子宫畸形类型。在不孕和反复流产的女性中，子宫隔的发生率为 15.4%[1,2]。宫腔镜子宫隔切开术可提高这些女性的活产率[3]。宫腔镜子宫整形术可使用剪刀和单极、双极电外科以及激光等能源进行。由于具有切割、凝固和汽化的“瑞士军刀”作用，钬：YAG 激光通常被泌尿科医生用于各种手术[4]。与用于宫腔镜手术的电外科设备和其他激光相比，钬：YAG 激光以其精确性而闻名。它可导致组织损伤和坏死的深度较浅，对周围子宫内膜的热损伤最小[5-8]。在宫腔镜子宫整形术中，这是有利的，因为它降低了手术过程中子宫穿孔和随后妊娠中子宫破裂的风险。减少对周围子宫内膜的损伤有助于促进子宫内膜的早期愈合，并防止术后宫腔粘连。
一位有 2 次自然流产史的 28 岁患者来我院就诊。患者的 3D 经阴道超声显示存在部分纵隔子宫，宫底凹陷 1.5 厘米（补充视频 1）。
计划采用 Ho：YAG 激光进行诊断性宫腔镜检查和子宫隔切开术。我们使用了 2.9 毫米 BETTOCCHI 宫腔镜（Karl Storz SE & Co.）和 5 毫米手术鞘。生理盐水用作扩张介质，将宫腔内压力维持在 80 至 100 毫米汞柱。手术在丙泊酚注射全身静脉麻醉下进行。阴道镜进入子宫（无需宫颈扩张）显示部分子宫隔，隔的两侧有输卵管口。一根 400 微米的石英纤维通过激光导丝穿过手术宫腔镜的 5Fr 工作通道。使用功率设置为 15 瓦（10 Hz 时 1500 mJ 能量）的 Ho：YAG 激光（Auriga XL 50 瓦，波士顿科学公司）。从隔的顶点在中线开始切开隔，然后从一侧到另一侧水平向底部切开（补充视频 2）。继续切开隔，直到宫腔镜的尖端可以从一个输卵管口自由移动到另一个输卵管口（补充视频 3）。手术时间为 12 分钟。无术中或术后并发症。术后给予雌激素治疗 2 个月，形式为戊酸雌二醇 2 毫克（片剂，普罗雌烯，Zydus Cadila），每日 12 小时口服 25 天，加用醋酸甲羟孕酮 10 毫克（片剂，美普他酚，印度血清研究所，有限公司），每日 12 小时口服，在最后 5 天[9]。月经第 8 天行 3D 经阴道超声检查。显示三角形子宫腔，宫底凹陷非常小，仅 0.37 厘米。月经第 9 天行第二次宫腔镜检查显示子宫腔形状和大小良好[10]。可见少量宫底粘连，使用 Ho：YAG 激光切开。患者在初次手术后 5 个月怀孕，并在 38 周时行剖宫产分娩，产下一名体重为 2860 克的健康婴儿。妊娠和分娩过程中无并发症。有必要进行对照研究，以证明其在该手术中优于其他能源的优势。
使用钬：YAG 激光进行宫腔镜子宫整形术治疗纵隔子宫是一种简单、精确、安全、有效的手术方法。
