- Email: [email protected]
Office operative endoscopy in infertility
International Congress Series 1266 (2004) 381 – 392
www.ics-elsevier.com
Office operative endoscopy in infertility Hugo Christian Verhoeven * Center for Reproductive Medicine and Endocrinology, Voelklinger Strasse 4, Du¨sseldorf 40219, Germany
Abstract. The implementation of ambulatory surgical procedures in endoscopic surgery has been inspired by several coincidental factors. First, there is a necessity to reduce the cost of interventions because of government restrictions on payments, and second, there is a general trend to reduce the invasiveness of endoscopic procedures, thus pushing companies to develop smaller endoscopes without loss of optical quality. At present, however, confusion exists between the concepts of minimal invasive surgery and minimal access surgery. As accuracy of smaller-diameter endoscopes with very high optical quality is comparable with that of larger endoscopes, surgeons were inspired to use lessinvasive surgery and to use smaller instruments. As a result, performing diagnostic procedures and minor interventions under local anaesthesia became possible and was widely accepted. Despite these advances, ambulatory surgery must not diminish the quality of care for patients. In particular, the use of the term ‘office laparoscopy’ can create some confusion in countries outside the US. Many so-called ‘‘office settings’’ in the US have fully equipped operating theaters and, although located outside a hospital setting, they tend to be situated closely to a hospital. For the patient’s benefit and also for medico-legal reasons, full laparoscopies have to be performed in a fully equipped operating theater. Ambulatory surgical procedures must offer patients the requirements of classical surgery in terms of safety and quality. A 1-day clinic setting reduces the costs of hospitalization while, at the same time, minimal invasiveness will result in a low morbidity with a faster resumption of normal professional or home activities. Certainly in reproductive surgery, these are important issues, as we are dealing with healthy patients who dislike frequent interruptions to their daily activities. As such, patients are trying to conceive as soon as possible, a minimal invasive approach with a maximal conservation of their reproductive potential is mandatory. Ambulatory reproductive surgery involves both uterine and tuboovarian interventions. D 2004 Published by Elsevier B.V. Keywords: Office endoscopy; Hysteroscopy; Transvaginal endoscopy; Endometriosis; Ovarian drilling
1. Intrauterine interventions 1.1. Technique In general, the interventions are performed under sedation or general anesthesia with the patient in the normal lithotomy position. After cervical dilatation, if necessary, a 3.5- or * Tel.: +49-211-9019797; fax: +49-211-9019750. E-mail address: [email protected] (H.C. Verhoeven). 0531-5131/ D 2004 Published by Elsevier B.V. doi:10.1016/j.ics.2004.01.111
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5-mm operative hysteroscope is introduced under visual control into the uterine cavity. A continuous flow instrument with separate in- and out-flow channels is used and is connected to a video camera system. This ensures continuous irrigation of the uterine cavity with optimal visualization. As distension medium, Purisole (sorbitol+mannitol) or GlykokolR (glycine 1.5%) are preferred, keeping the distension pressure between 90 and 120 mm Hg. Duration of the procedure should be kept as short as possible, with continuous surveillance of the fluid balance. In case of a negative fluid balance of more than 1200 ml, the procedure should be interrupted and further treatment should be performed at a later stage. 1.2. Complications Operative hysteroscopic procedures are frequently proposed and explained to the patients as minor operative interventions. Nevertheless, some of these operations can cause severe and sometimes life-threatening complications. Knowledge of these complications and how to avoid them is mandatory. Complications are caused by the instrumentation and/or the distension medium, and can occur during or after the operation. The most common complication is uterine perforation, which occurs mainly in the fundal region. In different studies, the rate of uterine perforation varies between 0.8% and 3.0% [1,2]. Significant bleeding is unlikely in this area. On the other hand, if the perforation is lateral in the area of the uterine artery or one of its branches a lifethreatening hemorrhage can occur. Where perforation is due to the use of monopolar current or a laser, a laparoscopy or laparotomy is advisable to exclude intraabdominal damage, and the patient should be monitored carefully for several days to exclude intestinal injury and delayed perforation. Such monitoring includes warning the patient that unexpected and increasing abdominal pain is a cause to return immediately for further evaluation. The concomitant use of abdominal sonography can be helpful in the prevention of uterine perforation. The energy source should only be activated when the position of the working instrument is carefully checked for its safety. Distension medium fluid may enter into the patient’s circulation via the uterine vessels and the lymphatic system. The height of the intrauterine pressure and the duration of the procedure are the determining factors. A status of hypotonic hyperhydration may occur as a consequence. This is known in urologic surgery as the TURP-Syndrome (transurethral resection of the prostate). The frequency of this complication is reported to be between 0.14% and 16% [3]. Careful monitoring of the patient’s fluid and electrolyte balance is mandatory, and, in the case of severe overload, a central venous catheter should be installed and diuresis started. 1.3. Procedures All intrauterine pathology related to reproduction can be treated in a 1-day clinical setting. As mentioned above, utmost care should be taken to avoid any complications. Pathology can be divided into congenital and acquired. In ambulatory pre-IVF diagnostic hysteroscopies, the incidence of abnormal findings is reported as 28.5%, with 13.2% congenital disorders and 15.3% acquired disorders [4]. In the latter, the frequency of intracavitary polyps and myoma is 26%, Asherman 0.1% and intrauterine synechiae
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17.5%. With adequate experience, myomas and polyps can easily be removed using a resectoscope. Although more expensive, the Nd – YAG laser is an alternative tool for treatment. In cases of larger myomata, the preoperative use of gonadotropin-releasing hormone analogues can be considered in an attempt to reduce the size of the myoma and thus facilitate the intervention. The restoration of the normal contours of the uterine cavity becomes more difficult in cases of complete or incomplete Asherman. For subfertility, the incidence in the literature is reported to range from 0.1% to 2% [4– 6]. When the basal layer of the endometrium is destroyed as a result of manipulation of the endometrial cavity following a pregnancy, reformation of adhesions tend to reoccur after treatment and restoration is sometimes only achieved after several procedures. The VersapointR, which vaporizes the cells, probably has a beneficial effect in the prevention of recurrence. Amongst congenital malformations, septate uterus is the most frequent, with a frequency of 63% of the congenital malformations [4]. Diagnosis must be confirmed by laparoscopy to distinguish it from a bicornual uterus. Several instruments can be used for resection of the septum: semi-rigid scissors, Nd – YAG laser or the resectoscope, the latter being the most inexpensive and readily available. Continuous irrigation is applied during the procedure with careful inspection of the right and left tubal ostia. Concurrent application of transabdominal sonography can be helpful to decide where to stop the dissection in order to avoid perforation or, during later pregnancy, uterine rupture. In some cases, a double cervical canal may be present in association with a complete septum. Whereas some authors tend to conserve the double cervical channel to avoid eventual cervical incompetence [7], others advise a resection of the intracervical septum followed by further resection of the total uterine septum. No cervical incompetence has been observed by Donnez and Nisolle [8]. Implantation can also be impaired in the case of a T-shaped uterus. Enlargement of the uterine cavity is obtained by symmetrical incision of the uterine sidewalls using a bipolar cutting needle or the Versapoint. 1.4. Discussion In the hands of experienced hysteroscopists, intrauterine pathology can easily be treated in an ambulatory, same-day clinic setting. Surgeons must be aware of the risks of complications and the necessary precautions must be taken to avoid them. Special care should be given to the fluid balance during the intervention, and the procedure must be interrupted at a negative balance of 1200– 1500 ml. The use of a watery distension medium is preferred over the use of CO2, as the former increases diagnostic accuracy and decreases morbidity. 2. Tubo-ovarian interventions via transvaginal endoscopy 2.1. Introduction For many years, standard laparoscopy was considered the gold standard for the exploration of the female genital tract. With the introduction of mini-endoscopes to decrease patient discomfort, the umbilical approach remains the same, along with the blind
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insertion of a Veress needle and trocar. Complications in major vessels have been described as frequently from the insertion of the Veress needle as from the trocar [9,10]. Initial interest in the transvaginal approach by culdoscopy was abandoned in the 1970s, as laparoscopy provides a more panoramic view and lower risk when performing tubal ligations. However, sepsis in culdoscopy was found to be due to the exteriorization of tubes [11]. Gordts et al. [12] described the technique of transvaginal hydrolaparoscopy (THL) based on a needle puncture technique of the pouch of Douglas. The technique demonstrated in Fig. 1 differs from culdoscopy by the use of the lithotomy position for the patient and warm saline as a distension medium. As the endoscope is in the same axis as the tuboovarian structures, easy access is provided to the fossa ovarica and the anterolateral site of the ovary without the need for extra manipulation (Fig. 2). This creates excellent exposure for ovarian and tubal surgery under direct vision. The use of a saline solution keeps the organs afloat, prevents collapse of microvascularization and filmy adhesions, and is helpful for atraumatic manipulation of the different structures and for a better delineation of the surfaces. Recently, new instruments were developed and manufactured by the Storz and transvaginal hydrolaparoscopy was renamed into transvaginal endoscopy (TVE). 2.2. Technique The access to the pouch of Douglas is performed in the same way described for diagnostic THL [13] and is based on a needle puncture technique of the pouch of Douglas familiar to many as the technique of culdocentesis. For this purpose, initially a specially developed Veress needle was used in which there is progressive dilatation from the diameter of the Veress needle to the outer diameter of the external trocar sheet (5 mm). A rigid mini-endoscope with a 30j optical angle is used and is attached to a video camera
Fig. 1. Technique of TVE.
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Fig. 2. Ampulla during TVE.
system. Once access to the pouch of Douglas is obtained, the Veress needle and the dilating obturator are removed and replaced by the operative endoscope. The operative channel allows the insertion of five French scissors and forceps and a thin bipolar coagulating probe (BicapR, Circon ACMI) or a bipolar coagulating and cutting needle (Storz, Tuettlingen, Germany). Before starting the procedure, about 100-ml warm saline is instilled in the pouch of Douglas to obtain adequate distension (Figs. 3 –5).
Fig. 3. Operative TVE instrumentation.
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Fig. 4. BICAP probe.
As one is working in a saline distension medium, preventive hemostasis is mandatory in order to avoid insufficient or disturbed visualization. All procedures are performed under general anesthesia or conscious sedation. 2.3. Procedures Gordts et al. carried out an operative procedure in 78 patients and included treatment of endometriosis (n=51), ovarian capsula drilling (n=14), adhesiolysis after pelvic inflammatory disease or surgery (n=10), resection of a functional cyst (n=2) and salpingoneostomy (n=1). No conversion to laparoscopy was necessary and no complications occurred. Patients resumed their professional or other activities after 2 days. All patients gave informed consent and they were informed that conversion to laparoscopy could be possible.
Fig. 5. Bipolar needle used during transvaginal endoscopy.
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2.3.1. Endometriosis 2.3.1.1. Selection of patients. Selection of patients was based upon findings at diagnostic TVE or the presence of an endometrioma at transvaginal ultrasound. They were only referred for an operative TVE if vaginal examination revealed absence of any significant induration in the posterior fornix. Patients were classified using the revised American Fertility Society (rAFS) scoring system [14]: rAFS I, n=34; rAFS II, n=11; rAFS III, n=6. It is interesting to note that in a comparative study the presence of subtle ovarian adhesions in patients with minimal or mild endometriosis was observed in 40% of the patients at standard laparoscopy and in 70% at transvaginal endoscopy [15]. 2.3.1.2. Reconstruction of large endometrioma. Similar to standard laparoscopy, treatment of an endometrioma larger than 5 cm is performed in two steps. The technique differs from fenestration and coagulation in the first step [16]. The ovary is carefully dissected and fully mobilized and the site of inversion is identified. The cyst is opened at the site of inversion and rinsed. After aspiration, the site of retraction or inversion is opened widely. Using this technique, there is no collapse of the wall. The absence of high intra-abdominal pressure and the hydroflotation technique maintain the micro-neoangiogenesis and therefore the identification of the implants and keeps the adhesions floating. The fibrotic area at the site of inversion and the visible vascularized endometriotic implants are coagulated (Figs. 6 and 7). The second step is performed 2– 3 months later and includes adhesiolysis, whenever necessary, and the complete coagulation of suspected implants in the involuted pseudocyst. 2.3.1.3. Results. The endometrioma was larger than 5 cm in four patients and the procedure was performed in two steps, reducing the severity of the disease from rAFS III to rAFS II in two patients and to rAFS I in the other two. In the first two patients, the size of the endometrioma was reduced from 7 to 4 cm, with the presence of small adhesions in the fossa ovarica involving about 1 cm of the ovarian surface. In the latter two patients, the endometriomas were reduced from 5 to 1 cm without adhesions. At second intervention,
Fig. 6. An endometrioma is formed by the inversion of the ovarian capsule and is lined by fibroreactive tissue, free endometriotic implants and adhesions.
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Fig. 7. Treatment of endometrioma during TVE. (a) Endometrioma with adhesions. (b) Complete adhesiolysis. (c) Enlargement of the opening of the endometriotic cyst at the site of inversion. (d) Biopsy of endometriotic tissue. (e) Coagulation of vascularised areas. (f) Final view after coagulation.
the invaginating edges of the reduced cyst could easily be identified in all cases and remaining adhesions were easily removed. In this way, the reduced chocolate cyst was widely opened allowing adequate visualization and complete ablation of the remaining endometriotic implants [17]. Thirty-three patients have a follow-up period up to 2 years and no recurrence of endometriosis at ultrasound has been detected. 2.3.1.4. Benefits. The transvaginal approach using the hydroflotation technique provides a remarkable delineation between the ovarian surface and the adhesions. The endometrioma is most frequently adherent to the posterior leaf of the broad ligament, the posterior side of the uterus and the uterosacral ligament. All these structures are directly accessible by the transvaginal route. In contrast with transabdominal access, whether by laparoscopy or laparotomy, a meticulous dissection can be performed and, surprisingly, in this way rupture of the endometriotic cyst can be avoided in most cases. Access to the endometriotic cyst at the site of inversion minimizes ovarian trauma and bleeding. After aspiration and rinsing of the cyst, the pseudocyst is further opened and, on close inspection underwater, the vascularized endometriotic implants and neoangiogenesis are clearly visible and can be selectively cauterized. In contrast to standard laparoscopy, transvaginal endoscopy allows inspection of the ovaries and, particularly, the antero-lateral site and the fossa ovarica without supplementary manipulation. Manipulation of the ovary with standard laparoscopy to expose the posterior leaf of the broad ligament and the antero-lateral site of the ovary frequently
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causes traumatic bleeding, with rupturing of the adhesions and rupture of the endometriotic cyst. 2.3.2. Ovarian capsule drilling Transvaginal endoscopy is quite suitable for drilling of the ovarian capsule in patients with polycystic ovarian syndrome (PCOS) that is resistant to medical therapy. For this purpose, the Versapoint probe and a bipolar needle (Storz, Tuettlingen) can be used (Fig. 8). The arguments against surgical treatment of PCOS are the risk of adhesion formation and morbidity as well as the cost of a standard laparoscopy. At laparoscopy, the exposure to carbon dioxide has been shown to have adverse effects on the peritoneal microcirculation and cell protective systems, such as free radical scavengers, which may be the mechanism involved in adhesion recurrences [18]. Although reduction of adhesion formation occurs after reduced exposure to CO2 [18], further evaluation is needed to prove an eventual reduction of adhesion formation after drilling of the ovarian capsule using warm saline as the distension medium. The data of Fernandez et al. [19] show the feasibility of the transvaginal approach with results comparable with those obtained after standard laparoscopic procedures. As the procedure is easy to perform and permits at the same time, a complete exploration of the female pelvis, with low morbidity, this approach may be preferable to a prolonged low-dose step-up protocol with gonadotropins. It is certainly recommendable before referring patients to an in vitro fertilization (IVF) program. Restoration of monofollicular cycles, reduction of multiple pregnancies and lower rates of miscarriages are factors in favor of surgical treatment of PCOS.
Fig. 8. Ovarian drilling during TVE.
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2.3.3. Sequellae of pelvic inflammatory disease In pelvic inflammatory disease, the patient’s fertility outcome is compromised by the presence and extension of peri-ovarian and particular tubal mucosal adhesions. This interferes with fimbrial capture and transport of the oocyte, but may also impair ovulatory function and oocyte release at the moment of ovulation [20]. The physiological position of the tubo-ovarian structures and the use of saline distension medium during transvaginal endoscopy allow easier performance of a salpingoscopy when required [21]. In hydrosalpinx, the site of occlusion can clearly be recognized. Using the bipolar cutting needle, the hydrosalpinx is opened at this site and staging of the tubal mucosa is performed [22]. Salpingostomy is indicated in stages I and II of the salpingoscopic classification. The salpingoneostomy is performed via transvaginal endoscopy or by a conversion to laparoscopy. In cases of severely damaged tubes (stage III and IV), the patient is referred to an IVF program. 2.4. Discussion This series of operative procedures confirms the feasibility of the transvaginal approach, as was previously reported [13]. In contrast to the transabdominal technique, the transvaginal route offers excellent visualization of the tubo-ovarian structures with direct access and without additional manipulation. During operative TVE procedures, conversion to laparoscopy is seldom required. In comparison to a standard laparoscopy, morbidity after the transvaginal procedures is very low, most of the patients have no sensation of pain afterwards and, at most, complain of a slight tenderness in the lower abdomen. All patients return home the same day and resume their full activity 1 or 2 days later. The 1-day hospitalization and the low morbidity of the procedure make a second-step procedure, when indicated, more acceptable for the patient. The transvaginal approach and hydroflotation technique also allow study of the pathophysiology of endometriosis. The inspection of small endometriomas or early implants in ovaries with in situ endometriomas confirms the inversion origin of most ovarian endometriomas, as suggested by Sampson [23] and Hughesdon [24], and recently restated by Brosens et al. [17], using in situ ovarioscopy and selective biopsies. What initially appears as small brown or black vesicles upon the ovarian surface are, on closer inspection, small invaginated areas of the ovarian cortex, covered by small adhesions and filled with typical endometriotic fluid. At the base of these invaginations, endometriotic implants with their neoangiogenesis can be clearly identified. The use of TVE facilitates a close inspection of lesions, which might be difficult in laparoscopy and impossible at laparotomy. In conclusion, it can be stated that the transvaginal approach for reconstructive tuboovarian endoscopic surgery is feasible. The direct access to the fossa ovarica and the ovaries, the use of hydroflotation and close inspection are of major benefits to achieve reconstructive tubo-ovarian surgery. 3. Conclusions The introduction of small-diameter endoscopes of high optical quality facilitates the success of minimal access surgery in an ambulatory setting. However, the final invasive-
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ness of the procedure is in the hands of the reproductive surgeon. As for microsurgery, a minimal invasive approach is not only a matter of technique, but also and essentially of philosophical and personal attitude. The use of a fluid distension medium is very helpful, not only in intrauterine interventions but also in exploration of the female pelvis and for operative procedures in transvaginal hydrolaparoscopy. It improves accuracy in visualization of small lesions and provides a better distinction between different tissue layers, with a clear delineation between adhesions and organs and conservation of the microvascularization. In contrast to intrauterine and mild pelvic pathology, which can always be treated on an ambulatory basis, severe pelvic pathology necessitates hospitalisation. Because transvaginal endoscopy is still limited due to the absence of the panoramic view of standard laparoscopy, the latter cannot be abandoned as operative procedure. However, for limited interventions, the transvaginal approach diminishes the patient’s morbidity drastically, shortens the hospitalization and reduces the final costs. In this way, standard laparoscopy, with higher morbidity and cost, can be reserved for more severe pathology. References [1] P.G. Brooks, Complications of operative hysteroscopy: how safe is it? Clin. Obstet. Gynecol. 35 (1992) 256. [2] F.D. Loffer, Contraindications and complications of hysteroscopy, Obstet. Gynecol. Clin. North Am. 22 (1995) 445. [3] C.A. Witz, et al., Complications associated with the absorption of hysteroscopic fluid media, Fertil. Steril. 60 (1993) 745. [4] R. Campo, et al., Office mini-hysteroscopy, Hum. Reprod. Updat. 5 (1999) 73 – 81. [5] J. Hucke, R. Campo, Intrauterine synechien, in: J. Keckstein, J. Hucke (Eds.), Die endoskopischen Operationen in der Gynakologie, Urban and Fisher, Munchen, 2000, pp. 394 – 399. [6] J.G. Schenker, E.J. Margalioth, Intrauterine adhesions: an updated appraisal, Fertil. Steril. 37 (1992) 593. [7] J.A. Rock, A.A. Murphy, W.H. Cooper, Resectoscopic technique for the lysis of a class V complete uterine septum, Fertil. Steril. 48 (1987) 495. [8] J. Donnez, M. Nisolle, Operative laser hysteroscopy in Mullerian fusion defects and uterine adhesions, in: J. Donnez (Ed.), Laser Operative Laparoscopy and Hysteroscopy, Nauwelaerts Printing, Leuven, 1994, pp. 295 – 304. [9] C. Chapron, D. Querleu, M.A. Bruhat, Surgical complications of diagnostic and operative gynecological laparoscopy: a series of 29 966 cases, Hum. Reprod. 13 (1998) 867 – 872. [10] F.W. Jansen, K. Kapiteyn, T. Trimbos-Kemper, Complications of laparoscopy: a prospective multicenter observational study, Br. J. Obstet. Gynaecol. 104 (1997) 595 – 600. [11] E. Diamond, Diagnostic culdoscopy in infertility: a study of 4000 outpatient procedures, J. Reprod. Med. 21 (1978) 23 – 28. [12] S. Gordts, et al., Transvaginal hydrolaparoscopy as an outpatient procedure for infertility investigation, Hum. Reprod. 13 (1998) 99 – 103. [13] S. Gordts, R. Campo, I. Brosens, Operative transvaginal hydrolaparoscopy of a large ovarian endometrioma, Gynecol. Endosc. 9 (2000) 227 – 231. [14] The American Fertility Society, Revised American Fertility Society classification of endometriosis, Fertil. Steril. 43 (1985) 351 – 352. [15] I. Brosens, S. Gordts, R. Campo, Transvaginal hydrolaparoscopy but not standard laparoscopy reveals subtle endometriotic adhesions of the ovary, Fertil. Steril. 75 (2001) 1009 – 1012. [16] I.A. Brosens, et al., Reconstruction of the ovary containing large endometriomas by an extraovarian endosurgical technique, Fertil. Steril. 66 (1996) 517 – 521. [17] I.A. Brosens, P.J. Puttemans, J. Deprest, The endoscopic localization of endometrial implants in the ovarian chocolate cyst, Fertil. Steril. 61 (1994) 1034 – 1038.
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[18] O. Taskin, et al., The effects of duration of CO2 insufflation and irrigation on peritoneal microcirculation assessed by free radical scavengers and total glutathione levels during operative laparoscopy, J. Am. Assoc. Gynecol. Laparosc. 5 (1998) 129 – 133. [19] H. Fernandez, et al., Operative transvaginal hydrolaparoscopy for treatment of polycystic ovary syndrome: a new minimally invasive surgery, Fertil. Steril. 75 (2001) 607 – 611. [20] S. Gordts, R. Campo, L. Rombauts, Endoscopic visualisation of the process of fimbrial ovum retrieval in the human, Hum. Reprod. 13 (1998) 1425 – 1428. [21] S. Gordts, et al., Transvaginal salpingoscopy: an office procedure for infertility investigation, Fertil. Steril. 70 (1998) 523 – 526. [22] P.J. Puttemans, I.A. Brosens, P.H. Delattin, Salpingoscopy versus hysterosalpingography in hydrosalpinges, Hum. Reprod. 2 (1987) 535 – 540. [23] J.A. Sampson, Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity, Am. J. Obstet. Gynecol. 14 (1927) 422 – 469. [24] P.E. Hughesdon, The structure of endometrial cysts of the ovary, J. Obstet. Gynaecol. Br. Emp. 44 (1957) 481 – 487.
www.ics-elsevier.com
Office operative endoscopy in infertility Hugo Christian Verhoeven * Center for Reproductive Medicine and Endocrinology, Voelklinger Strasse 4, Du¨sseldorf 40219, Germany
Abstract. The implementation of ambulatory surgical procedures in endoscopic surgery has been inspired by several coincidental factors. First, there is a necessity to reduce the cost of interventions because of government restrictions on payments, and second, there is a general trend to reduce the invasiveness of endoscopic procedures, thus pushing companies to develop smaller endoscopes without loss of optical quality. At present, however, confusion exists between the concepts of minimal invasive surgery and minimal access surgery. As accuracy of smaller-diameter endoscopes with very high optical quality is comparable with that of larger endoscopes, surgeons were inspired to use lessinvasive surgery and to use smaller instruments. As a result, performing diagnostic procedures and minor interventions under local anaesthesia became possible and was widely accepted. Despite these advances, ambulatory surgery must not diminish the quality of care for patients. In particular, the use of the term ‘office laparoscopy’ can create some confusion in countries outside the US. Many so-called ‘‘office settings’’ in the US have fully equipped operating theaters and, although located outside a hospital setting, they tend to be situated closely to a hospital. For the patient’s benefit and also for medico-legal reasons, full laparoscopies have to be performed in a fully equipped operating theater. Ambulatory surgical procedures must offer patients the requirements of classical surgery in terms of safety and quality. A 1-day clinic setting reduces the costs of hospitalization while, at the same time, minimal invasiveness will result in a low morbidity with a faster resumption of normal professional or home activities. Certainly in reproductive surgery, these are important issues, as we are dealing with healthy patients who dislike frequent interruptions to their daily activities. As such, patients are trying to conceive as soon as possible, a minimal invasive approach with a maximal conservation of their reproductive potential is mandatory. Ambulatory reproductive surgery involves both uterine and tuboovarian interventions. D 2004 Published by Elsevier B.V. Keywords: Office endoscopy; Hysteroscopy; Transvaginal endoscopy; Endometriosis; Ovarian drilling
1. Intrauterine interventions 1.1. Technique In general, the interventions are performed under sedation or general anesthesia with the patient in the normal lithotomy position. After cervical dilatation, if necessary, a 3.5- or * Tel.: +49-211-9019797; fax: +49-211-9019750. E-mail address: [email protected] (H.C. Verhoeven). 0531-5131/ D 2004 Published by Elsevier B.V. doi:10.1016/j.ics.2004.01.111
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5-mm operative hysteroscope is introduced under visual control into the uterine cavity. A continuous flow instrument with separate in- and out-flow channels is used and is connected to a video camera system. This ensures continuous irrigation of the uterine cavity with optimal visualization. As distension medium, Purisole (sorbitol+mannitol) or GlykokolR (glycine 1.5%) are preferred, keeping the distension pressure between 90 and 120 mm Hg. Duration of the procedure should be kept as short as possible, with continuous surveillance of the fluid balance. In case of a negative fluid balance of more than 1200 ml, the procedure should be interrupted and further treatment should be performed at a later stage. 1.2. Complications Operative hysteroscopic procedures are frequently proposed and explained to the patients as minor operative interventions. Nevertheless, some of these operations can cause severe and sometimes life-threatening complications. Knowledge of these complications and how to avoid them is mandatory. Complications are caused by the instrumentation and/or the distension medium, and can occur during or after the operation. The most common complication is uterine perforation, which occurs mainly in the fundal region. In different studies, the rate of uterine perforation varies between 0.8% and 3.0% [1,2]. Significant bleeding is unlikely in this area. On the other hand, if the perforation is lateral in the area of the uterine artery or one of its branches a lifethreatening hemorrhage can occur. Where perforation is due to the use of monopolar current or a laser, a laparoscopy or laparotomy is advisable to exclude intraabdominal damage, and the patient should be monitored carefully for several days to exclude intestinal injury and delayed perforation. Such monitoring includes warning the patient that unexpected and increasing abdominal pain is a cause to return immediately for further evaluation. The concomitant use of abdominal sonography can be helpful in the prevention of uterine perforation. The energy source should only be activated when the position of the working instrument is carefully checked for its safety. Distension medium fluid may enter into the patient’s circulation via the uterine vessels and the lymphatic system. The height of the intrauterine pressure and the duration of the procedure are the determining factors. A status of hypotonic hyperhydration may occur as a consequence. This is known in urologic surgery as the TURP-Syndrome (transurethral resection of the prostate). The frequency of this complication is reported to be between 0.14% and 16% [3]. Careful monitoring of the patient’s fluid and electrolyte balance is mandatory, and, in the case of severe overload, a central venous catheter should be installed and diuresis started. 1.3. Procedures All intrauterine pathology related to reproduction can be treated in a 1-day clinical setting. As mentioned above, utmost care should be taken to avoid any complications. Pathology can be divided into congenital and acquired. In ambulatory pre-IVF diagnostic hysteroscopies, the incidence of abnormal findings is reported as 28.5%, with 13.2% congenital disorders and 15.3% acquired disorders [4]. In the latter, the frequency of intracavitary polyps and myoma is 26%, Asherman 0.1% and intrauterine synechiae
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17.5%. With adequate experience, myomas and polyps can easily be removed using a resectoscope. Although more expensive, the Nd – YAG laser is an alternative tool for treatment. In cases of larger myomata, the preoperative use of gonadotropin-releasing hormone analogues can be considered in an attempt to reduce the size of the myoma and thus facilitate the intervention. The restoration of the normal contours of the uterine cavity becomes more difficult in cases of complete or incomplete Asherman. For subfertility, the incidence in the literature is reported to range from 0.1% to 2% [4– 6]. When the basal layer of the endometrium is destroyed as a result of manipulation of the endometrial cavity following a pregnancy, reformation of adhesions tend to reoccur after treatment and restoration is sometimes only achieved after several procedures. The VersapointR, which vaporizes the cells, probably has a beneficial effect in the prevention of recurrence. Amongst congenital malformations, septate uterus is the most frequent, with a frequency of 63% of the congenital malformations [4]. Diagnosis must be confirmed by laparoscopy to distinguish it from a bicornual uterus. Several instruments can be used for resection of the septum: semi-rigid scissors, Nd – YAG laser or the resectoscope, the latter being the most inexpensive and readily available. Continuous irrigation is applied during the procedure with careful inspection of the right and left tubal ostia. Concurrent application of transabdominal sonography can be helpful to decide where to stop the dissection in order to avoid perforation or, during later pregnancy, uterine rupture. In some cases, a double cervical canal may be present in association with a complete septum. Whereas some authors tend to conserve the double cervical channel to avoid eventual cervical incompetence [7], others advise a resection of the intracervical septum followed by further resection of the total uterine septum. No cervical incompetence has been observed by Donnez and Nisolle [8]. Implantation can also be impaired in the case of a T-shaped uterus. Enlargement of the uterine cavity is obtained by symmetrical incision of the uterine sidewalls using a bipolar cutting needle or the Versapoint. 1.4. Discussion In the hands of experienced hysteroscopists, intrauterine pathology can easily be treated in an ambulatory, same-day clinic setting. Surgeons must be aware of the risks of complications and the necessary precautions must be taken to avoid them. Special care should be given to the fluid balance during the intervention, and the procedure must be interrupted at a negative balance of 1200– 1500 ml. The use of a watery distension medium is preferred over the use of CO2, as the former increases diagnostic accuracy and decreases morbidity. 2. Tubo-ovarian interventions via transvaginal endoscopy 2.1. Introduction For many years, standard laparoscopy was considered the gold standard for the exploration of the female genital tract. With the introduction of mini-endoscopes to decrease patient discomfort, the umbilical approach remains the same, along with the blind
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insertion of a Veress needle and trocar. Complications in major vessels have been described as frequently from the insertion of the Veress needle as from the trocar [9,10]. Initial interest in the transvaginal approach by culdoscopy was abandoned in the 1970s, as laparoscopy provides a more panoramic view and lower risk when performing tubal ligations. However, sepsis in culdoscopy was found to be due to the exteriorization of tubes [11]. Gordts et al. [12] described the technique of transvaginal hydrolaparoscopy (THL) based on a needle puncture technique of the pouch of Douglas. The technique demonstrated in Fig. 1 differs from culdoscopy by the use of the lithotomy position for the patient and warm saline as a distension medium. As the endoscope is in the same axis as the tuboovarian structures, easy access is provided to the fossa ovarica and the anterolateral site of the ovary without the need for extra manipulation (Fig. 2). This creates excellent exposure for ovarian and tubal surgery under direct vision. The use of a saline solution keeps the organs afloat, prevents collapse of microvascularization and filmy adhesions, and is helpful for atraumatic manipulation of the different structures and for a better delineation of the surfaces. Recently, new instruments were developed and manufactured by the Storz and transvaginal hydrolaparoscopy was renamed into transvaginal endoscopy (TVE). 2.2. Technique The access to the pouch of Douglas is performed in the same way described for diagnostic THL [13] and is based on a needle puncture technique of the pouch of Douglas familiar to many as the technique of culdocentesis. For this purpose, initially a specially developed Veress needle was used in which there is progressive dilatation from the diameter of the Veress needle to the outer diameter of the external trocar sheet (5 mm). A rigid mini-endoscope with a 30j optical angle is used and is attached to a video camera
Fig. 1. Technique of TVE.
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Fig. 2. Ampulla during TVE.
system. Once access to the pouch of Douglas is obtained, the Veress needle and the dilating obturator are removed and replaced by the operative endoscope. The operative channel allows the insertion of five French scissors and forceps and a thin bipolar coagulating probe (BicapR, Circon ACMI) or a bipolar coagulating and cutting needle (Storz, Tuettlingen, Germany). Before starting the procedure, about 100-ml warm saline is instilled in the pouch of Douglas to obtain adequate distension (Figs. 3 –5).
Fig. 3. Operative TVE instrumentation.
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Fig. 4. BICAP probe.
As one is working in a saline distension medium, preventive hemostasis is mandatory in order to avoid insufficient or disturbed visualization. All procedures are performed under general anesthesia or conscious sedation. 2.3. Procedures Gordts et al. carried out an operative procedure in 78 patients and included treatment of endometriosis (n=51), ovarian capsula drilling (n=14), adhesiolysis after pelvic inflammatory disease or surgery (n=10), resection of a functional cyst (n=2) and salpingoneostomy (n=1). No conversion to laparoscopy was necessary and no complications occurred. Patients resumed their professional or other activities after 2 days. All patients gave informed consent and they were informed that conversion to laparoscopy could be possible.
Fig. 5. Bipolar needle used during transvaginal endoscopy.
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2.3.1. Endometriosis 2.3.1.1. Selection of patients. Selection of patients was based upon findings at diagnostic TVE or the presence of an endometrioma at transvaginal ultrasound. They were only referred for an operative TVE if vaginal examination revealed absence of any significant induration in the posterior fornix. Patients were classified using the revised American Fertility Society (rAFS) scoring system [14]: rAFS I, n=34; rAFS II, n=11; rAFS III, n=6. It is interesting to note that in a comparative study the presence of subtle ovarian adhesions in patients with minimal or mild endometriosis was observed in 40% of the patients at standard laparoscopy and in 70% at transvaginal endoscopy [15]. 2.3.1.2. Reconstruction of large endometrioma. Similar to standard laparoscopy, treatment of an endometrioma larger than 5 cm is performed in two steps. The technique differs from fenestration and coagulation in the first step [16]. The ovary is carefully dissected and fully mobilized and the site of inversion is identified. The cyst is opened at the site of inversion and rinsed. After aspiration, the site of retraction or inversion is opened widely. Using this technique, there is no collapse of the wall. The absence of high intra-abdominal pressure and the hydroflotation technique maintain the micro-neoangiogenesis and therefore the identification of the implants and keeps the adhesions floating. The fibrotic area at the site of inversion and the visible vascularized endometriotic implants are coagulated (Figs. 6 and 7). The second step is performed 2– 3 months later and includes adhesiolysis, whenever necessary, and the complete coagulation of suspected implants in the involuted pseudocyst. 2.3.1.3. Results. The endometrioma was larger than 5 cm in four patients and the procedure was performed in two steps, reducing the severity of the disease from rAFS III to rAFS II in two patients and to rAFS I in the other two. In the first two patients, the size of the endometrioma was reduced from 7 to 4 cm, with the presence of small adhesions in the fossa ovarica involving about 1 cm of the ovarian surface. In the latter two patients, the endometriomas were reduced from 5 to 1 cm without adhesions. At second intervention,
Fig. 6. An endometrioma is formed by the inversion of the ovarian capsule and is lined by fibroreactive tissue, free endometriotic implants and adhesions.
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Fig. 7. Treatment of endometrioma during TVE. (a) Endometrioma with adhesions. (b) Complete adhesiolysis. (c) Enlargement of the opening of the endometriotic cyst at the site of inversion. (d) Biopsy of endometriotic tissue. (e) Coagulation of vascularised areas. (f) Final view after coagulation.
the invaginating edges of the reduced cyst could easily be identified in all cases and remaining adhesions were easily removed. In this way, the reduced chocolate cyst was widely opened allowing adequate visualization and complete ablation of the remaining endometriotic implants [17]. Thirty-three patients have a follow-up period up to 2 years and no recurrence of endometriosis at ultrasound has been detected. 2.3.1.4. Benefits. The transvaginal approach using the hydroflotation technique provides a remarkable delineation between the ovarian surface and the adhesions. The endometrioma is most frequently adherent to the posterior leaf of the broad ligament, the posterior side of the uterus and the uterosacral ligament. All these structures are directly accessible by the transvaginal route. In contrast with transabdominal access, whether by laparoscopy or laparotomy, a meticulous dissection can be performed and, surprisingly, in this way rupture of the endometriotic cyst can be avoided in most cases. Access to the endometriotic cyst at the site of inversion minimizes ovarian trauma and bleeding. After aspiration and rinsing of the cyst, the pseudocyst is further opened and, on close inspection underwater, the vascularized endometriotic implants and neoangiogenesis are clearly visible and can be selectively cauterized. In contrast to standard laparoscopy, transvaginal endoscopy allows inspection of the ovaries and, particularly, the antero-lateral site and the fossa ovarica without supplementary manipulation. Manipulation of the ovary with standard laparoscopy to expose the posterior leaf of the broad ligament and the antero-lateral site of the ovary frequently
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causes traumatic bleeding, with rupturing of the adhesions and rupture of the endometriotic cyst. 2.3.2. Ovarian capsule drilling Transvaginal endoscopy is quite suitable for drilling of the ovarian capsule in patients with polycystic ovarian syndrome (PCOS) that is resistant to medical therapy. For this purpose, the Versapoint probe and a bipolar needle (Storz, Tuettlingen) can be used (Fig. 8). The arguments against surgical treatment of PCOS are the risk of adhesion formation and morbidity as well as the cost of a standard laparoscopy. At laparoscopy, the exposure to carbon dioxide has been shown to have adverse effects on the peritoneal microcirculation and cell protective systems, such as free radical scavengers, which may be the mechanism involved in adhesion recurrences [18]. Although reduction of adhesion formation occurs after reduced exposure to CO2 [18], further evaluation is needed to prove an eventual reduction of adhesion formation after drilling of the ovarian capsule using warm saline as the distension medium. The data of Fernandez et al. [19] show the feasibility of the transvaginal approach with results comparable with those obtained after standard laparoscopic procedures. As the procedure is easy to perform and permits at the same time, a complete exploration of the female pelvis, with low morbidity, this approach may be preferable to a prolonged low-dose step-up protocol with gonadotropins. It is certainly recommendable before referring patients to an in vitro fertilization (IVF) program. Restoration of monofollicular cycles, reduction of multiple pregnancies and lower rates of miscarriages are factors in favor of surgical treatment of PCOS.
Fig. 8. Ovarian drilling during TVE.
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2.3.3. Sequellae of pelvic inflammatory disease In pelvic inflammatory disease, the patient’s fertility outcome is compromised by the presence and extension of peri-ovarian and particular tubal mucosal adhesions. This interferes with fimbrial capture and transport of the oocyte, but may also impair ovulatory function and oocyte release at the moment of ovulation [20]. The physiological position of the tubo-ovarian structures and the use of saline distension medium during transvaginal endoscopy allow easier performance of a salpingoscopy when required [21]. In hydrosalpinx, the site of occlusion can clearly be recognized. Using the bipolar cutting needle, the hydrosalpinx is opened at this site and staging of the tubal mucosa is performed [22]. Salpingostomy is indicated in stages I and II of the salpingoscopic classification. The salpingoneostomy is performed via transvaginal endoscopy or by a conversion to laparoscopy. In cases of severely damaged tubes (stage III and IV), the patient is referred to an IVF program. 2.4. Discussion This series of operative procedures confirms the feasibility of the transvaginal approach, as was previously reported [13]. In contrast to the transabdominal technique, the transvaginal route offers excellent visualization of the tubo-ovarian structures with direct access and without additional manipulation. During operative TVE procedures, conversion to laparoscopy is seldom required. In comparison to a standard laparoscopy, morbidity after the transvaginal procedures is very low, most of the patients have no sensation of pain afterwards and, at most, complain of a slight tenderness in the lower abdomen. All patients return home the same day and resume their full activity 1 or 2 days later. The 1-day hospitalization and the low morbidity of the procedure make a second-step procedure, when indicated, more acceptable for the patient. The transvaginal approach and hydroflotation technique also allow study of the pathophysiology of endometriosis. The inspection of small endometriomas or early implants in ovaries with in situ endometriomas confirms the inversion origin of most ovarian endometriomas, as suggested by Sampson [23] and Hughesdon [24], and recently restated by Brosens et al. [17], using in situ ovarioscopy and selective biopsies. What initially appears as small brown or black vesicles upon the ovarian surface are, on closer inspection, small invaginated areas of the ovarian cortex, covered by small adhesions and filled with typical endometriotic fluid. At the base of these invaginations, endometriotic implants with their neoangiogenesis can be clearly identified. The use of TVE facilitates a close inspection of lesions, which might be difficult in laparoscopy and impossible at laparotomy. In conclusion, it can be stated that the transvaginal approach for reconstructive tuboovarian endoscopic surgery is feasible. The direct access to the fossa ovarica and the ovaries, the use of hydroflotation and close inspection are of major benefits to achieve reconstructive tubo-ovarian surgery. 3. Conclusions The introduction of small-diameter endoscopes of high optical quality facilitates the success of minimal access surgery in an ambulatory setting. However, the final invasive-
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ness of the procedure is in the hands of the reproductive surgeon. As for microsurgery, a minimal invasive approach is not only a matter of technique, but also and essentially of philosophical and personal attitude. The use of a fluid distension medium is very helpful, not only in intrauterine interventions but also in exploration of the female pelvis and for operative procedures in transvaginal hydrolaparoscopy. It improves accuracy in visualization of small lesions and provides a better distinction between different tissue layers, with a clear delineation between adhesions and organs and conservation of the microvascularization. In contrast to intrauterine and mild pelvic pathology, which can always be treated on an ambulatory basis, severe pelvic pathology necessitates hospitalisation. Because transvaginal endoscopy is still limited due to the absence of the panoramic view of standard laparoscopy, the latter cannot be abandoned as operative procedure. However, for limited interventions, the transvaginal approach diminishes the patient’s morbidity drastically, shortens the hospitalization and reduces the final costs. In this way, standard laparoscopy, with higher morbidity and cost, can be reserved for more severe pathology. References [1] P.G. Brooks, Complications of operative hysteroscopy: how safe is it? Clin. Obstet. Gynecol. 35 (1992) 256. [2] F.D. Loffer, Contraindications and complications of hysteroscopy, Obstet. Gynecol. Clin. North Am. 22 (1995) 445. [3] C.A. Witz, et al., Complications associated with the absorption of hysteroscopic fluid media, Fertil. Steril. 60 (1993) 745. [4] R. Campo, et al., Office mini-hysteroscopy, Hum. Reprod. Updat. 5 (1999) 73 – 81. [5] J. Hucke, R. Campo, Intrauterine synechien, in: J. Keckstein, J. Hucke (Eds.), Die endoskopischen Operationen in der Gynakologie, Urban and Fisher, Munchen, 2000, pp. 394 – 399. [6] J.G. Schenker, E.J. Margalioth, Intrauterine adhesions: an updated appraisal, Fertil. Steril. 37 (1992) 593. [7] J.A. Rock, A.A. Murphy, W.H. Cooper, Resectoscopic technique for the lysis of a class V complete uterine septum, Fertil. Steril. 48 (1987) 495. [8] J. Donnez, M. Nisolle, Operative laser hysteroscopy in Mullerian fusion defects and uterine adhesions, in: J. Donnez (Ed.), Laser Operative Laparoscopy and Hysteroscopy, Nauwelaerts Printing, Leuven, 1994, pp. 295 – 304. [9] C. Chapron, D. Querleu, M.A. Bruhat, Surgical complications of diagnostic and operative gynecological laparoscopy: a series of 29 966 cases, Hum. Reprod. 13 (1998) 867 – 872. [10] F.W. Jansen, K. Kapiteyn, T. Trimbos-Kemper, Complications of laparoscopy: a prospective multicenter observational study, Br. J. Obstet. Gynaecol. 104 (1997) 595 – 600. [11] E. Diamond, Diagnostic culdoscopy in infertility: a study of 4000 outpatient procedures, J. Reprod. Med. 21 (1978) 23 – 28. [12] S. Gordts, et al., Transvaginal hydrolaparoscopy as an outpatient procedure for infertility investigation, Hum. Reprod. 13 (1998) 99 – 103. [13] S. Gordts, R. Campo, I. Brosens, Operative transvaginal hydrolaparoscopy of a large ovarian endometrioma, Gynecol. Endosc. 9 (2000) 227 – 231. [14] The American Fertility Society, Revised American Fertility Society classification of endometriosis, Fertil. Steril. 43 (1985) 351 – 352. [15] I. Brosens, S. Gordts, R. Campo, Transvaginal hydrolaparoscopy but not standard laparoscopy reveals subtle endometriotic adhesions of the ovary, Fertil. Steril. 75 (2001) 1009 – 1012. [16] I.A. Brosens, et al., Reconstruction of the ovary containing large endometriomas by an extraovarian endosurgical technique, Fertil. Steril. 66 (1996) 517 – 521. [17] I.A. Brosens, P.J. Puttemans, J. Deprest, The endoscopic localization of endometrial implants in the ovarian chocolate cyst, Fertil. Steril. 61 (1994) 1034 – 1038.
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[18] O. Taskin, et al., The effects of duration of CO2 insufflation and irrigation on peritoneal microcirculation assessed by free radical scavengers and total glutathione levels during operative laparoscopy, J. Am. Assoc. Gynecol. Laparosc. 5 (1998) 129 – 133. [19] H. Fernandez, et al., Operative transvaginal hydrolaparoscopy for treatment of polycystic ovary syndrome: a new minimally invasive surgery, Fertil. Steril. 75 (2001) 607 – 611. [20] S. Gordts, R. Campo, L. Rombauts, Endoscopic visualisation of the process of fimbrial ovum retrieval in the human, Hum. Reprod. 13 (1998) 1425 – 1428. [21] S. Gordts, et al., Transvaginal salpingoscopy: an office procedure for infertility investigation, Fertil. Steril. 70 (1998) 523 – 526. [22] P.J. Puttemans, I.A. Brosens, P.H. Delattin, Salpingoscopy versus hysterosalpingography in hydrosalpinges, Hum. Reprod. 2 (1987) 535 – 540. [23] J.A. Sampson, Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity, Am. J. Obstet. Gynecol. 14 (1927) 422 – 469. [24] P.E. Hughesdon, The structure of endometrial cysts of the ovary, J. Obstet. Gynaecol. Br. Emp. 44 (1957) 481 – 487.