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Intraoperative ultrasound guidance for intrauterine endoscopic surgery*
Techniques and instrumentation Vol. 62, No.3, September 1994
FERTILITY AND STERILITY
Printed on acid-free paper in U. S. A
Copyright© 1994 The American Fertility Society
Intraoperative ultrasound guidance for intrauterine endoscopic surgery*
Gerard S. Letterie, M.D. t:j: Dawna J. Kramer, M.D.§ Virginia Mason Medical Center, Seattle, Washington
Recent advances in endoscopic equipment have enabled increasingly complicated procedures for a variety of clinical entities previously requiring laparotomy to be performed by endoscopic techniques. Because of their complexity, intrauterine endoscopic procedures are frequently performed under direct laparoscopic guidance to avoid the possibility of inadvertent uterine perforation. Intraoperative use of sophisticated ultrasound (US) equipment has provided a sensitive means to monitor a variety of surgical procedures and may have potential application to endoscopic gynecologic procedures (1). Prior data describe the use of US guidance for dilatation and evacuations, intraoperative guidance for intrauterine tandem placement, and retrieval of impacted foreign bodies (2-4). The purpose of the present study was to determine the role of intraoperative US guidance for intrauterine endoscopic procedures.
MATERIALS AND METHODS
Fifteen patients were studied. Nine underwent resectoscopic myomectomy only and 6 underwent
Received February 4, 1994; revised and accepted April 18, 1994. * Presented at the 49th Annual Meeting of The American Fertility Society, Montreal, Canada, October 11 to 14, 1993. t Reproductive Endocrinology Service, Department of Obstetrics and Gynecology. :j: Reprint requests Gerard S. Letterie, M.D., Reproductive Endocrinology Service, Department of Obstetrics and Gynecology, Virginia Mason Medical Center, PO Box 900 (X8-0B), Seattle, Washington 98111 (FAX: 206-625-7274). §Department of Radiology. 654
Letterie and Kramer
Techniques and instrumentation
both resectoscopic myomectomy and endometrial resection. Patients were referred for evaluation of abnormal uterine bleeding unresponsive to medical management. All patients underwent preoperative transabdominal and transvaginal pelvic US examination to assess uterine anatomy and to determine size, location, and number of fibroids. Patients were treated preoperatively with depot leuprolide acetate 3.75 mg IM (Depo-Lupron; TAP Pharmaceuticals, Inc., North Chicago, IL) monthly for an 8week course of ovarian suppression. A second US was performed to re-evaluate uterine and fibroid dimensions at completion of medical therapy. Intraoperative US guidance was performed transabdominally, using a 3.5-MHz sector transducer (Acuson 128, Mountview, CA). Resectoscopic myomectomy and endometrial resections were performed under transabdominal US scanning of the uterine cavity. The bladder was filled with 200 to 300 of mL of saline through a Foley catheter until an optimal window for US imaging was achieved. Continuous pelvic US monitoring was performed in both the sagittal and transverse planes. Submucous myomectomy and endometrial resection were performed with an Olympus gynecologic resectoscope (Olympus, Lake Success, NY) and a unipolar wire loop. Power settings varied between 50 and 100 W and were determined by tissue response and ease of movement of the loop through the tissues. Fibroid and endometrial fragments were retrieved using polyp forceps and/or an 8-mm suction curette. Glycine 1.5% was used as a distending medium and was gravity fed to pressures adequate for complete visualization of the endometrial cavity. Endoscopic procedures were performed using a video monitor. All procedures were performed with resident or preFertility and Sterility
ship of the operative loop to the anterior and poste rior uterine walls and fundus. No complications were observed.
DISCUSSION
Figure 1 Intraoperative longitudinal US examination showing uterine distention, anterior uterine wall (large arrow head), submucosal fundal fibroid (arrow), and resectoscopic tip and loop at the inferior aspect of the fibroid before dissection (small arrow heads).
ceptor assistance as part of residency training in gynecologic surgery or a preceptorship in endoscopic surgery. RESULTS
The intraoperative use of US imaging provided information regarding the location of the resectoscope, guidance of the cutting loop, and definition of anterior and posterior uterine walls (Figs. 1 and 2). Visualization was enhanced by the intrauterine distending media, which provided an ideal environment for US imaging. In all cases, detailed information was available regarding the relationship of the cutting loop to the fibroid(s), endometrium, myometrium, and outer uterine walls. Anterior fibroids were imaged with greater precision than posterior fibroids. During the myomectomy, the location and dimensions of the fibroid could be determined accurately and the depth and adequacy of dissection through the uterine wall assessed with intraoperative real time scanning. These images were most useful in determining the endpoint of the intramural component of the fibroid(s). Microbubbles were evident within the uterine cavity or uterine wall during scanning after application of the cutting current and occasionally compromised the US images. These images cleared with passage of the bubbles from the operative field. In two patients, microbubbles were entrapped between a partially dissected fibroid and the myometrium, partially compromising but not obscuring the US image. During endometrial resections, US guidance provided an excellent means of assessing the relationVol. 62, No.3, September 1994
The availability of sensitive and easily transported US equipment has made possible intraoperative US imaging. Real-time imaging has been useful in various general surgical procedures, including intraoperative needle placement for fluid aspiration, resection of organs, and extraction of stones and foreign bodies (4). Operative hysteroscopy and intraoperative US guidance may provide an accurate and precise method to guide intrauterine surgery for a variety of gynecologic procedures. Data of the present study suggest that this modality may be used to enhance the performance of resectoscopic myomectomy(ies) and endometrial re section. The uterine distention and intrauterine fluid pocket facilitated visualization of the endoscope, fibroid, endometrium, and uterine walls. Sufficient details of the relationship of the endoscope to the fibroid and uterine walls to prevent uterine perforation and gauge of depth were rendered for each case. These US scans were easily done, and the US equipment fit neatly into the operating room. This combination also provided an excellent teaching aid for both residents and preceptors and enhanced appreciation of their move ments with the resectoscope. Trainees were able to visualize the endometrial cavity directly on the video monitor and the myometrial thickness and depth of dissection on the scan. Recommendations have been made for direct
Figure 2 Intraoperative longitudinal US examination of anterior uterine wall (large arrow head), submucosal posterior fibroid (arrow), and resectoscope tip (small arrow heads) . Letterie and Kramer
Techniques and instrumentation
655
visualization of the uterus by laparoscopy when contemplating complicated intrauterine procedures, such as the resection of multiple myomas or during resident training. Laparoscopy provides details only of the relationship of the instrument to the uterine wall, often at times just before perforation. The intraoperative use of US guidance adds a second dimension beyond that of laparoscopy and improves the intramural portion of dissection during myomectomy, increasing the likelihood of complete resection. This combination may be especially useful for the removal of intramural fibroids where adequacy of resection may be related to both recurrence of symptoms and need for additional procedures (5). Real-time imaging may also represent a savings and decreased morbidity when compared with laparoscopy.
cavity and uterine wall. A combination of intrauterine endoscopic procedures and intraoperative US guidance provides an accurate method to guide resectoscopic myomectomies and endometrial resection and to prevent inadvertent uterine perforation. Intraoperative imaging may have an application for other intrauterine endoscopic procedures and may preclude the need for simultaneous laparoscopy. Key Words: Intraoperative ultrasound, endoscopy. REFERENCES 1. Machi J, Sage! B, Kurohiji T, Zaren HA, Sarieg HA. Opera-
2.
3.
SUMMARY 4.
Intraoperative US guidance for intrauterine endoscopic procedures appears to offer a noninvasive means of assessing the precision and adequacy of resectoscopic myomectomy and to provide the exact location of the instruments within the uterine
656
Letterie and Kramer
Techniques and instrumentation
5.
tive ultrasound guidance for various surgical procedures. Ultrasound Med Biol1990;10:37-42. Granai CO, Allee P, Doherty F, Bal HG, Madoc-Jones H, Curry SL. Intraoperative real time ultrasonography during intrauterine tandem placement. Obstet Gynecol 1986; 67:112-4. Tamour RK, Sabagha RE. Intraoperative ultrasound for gynecologic procedures. Obstet Gynecol 1985;66:440-3. Letterie GS, Case KJ. Intraoperative ultrasound guidance for hysteroscopic retrieval of intrauterine foreign bodies. Surg Enclose 1993;7:182-4. W amsteker K, Emanuel MH, deKruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol 1993;82:736-40.
Fertility and Sterility
FERTILITY AND STERILITY
Printed on acid-free paper in U. S. A
Copyright© 1994 The American Fertility Society
Intraoperative ultrasound guidance for intrauterine endoscopic surgery*
Gerard S. Letterie, M.D. t:j: Dawna J. Kramer, M.D.§ Virginia Mason Medical Center, Seattle, Washington
Recent advances in endoscopic equipment have enabled increasingly complicated procedures for a variety of clinical entities previously requiring laparotomy to be performed by endoscopic techniques. Because of their complexity, intrauterine endoscopic procedures are frequently performed under direct laparoscopic guidance to avoid the possibility of inadvertent uterine perforation. Intraoperative use of sophisticated ultrasound (US) equipment has provided a sensitive means to monitor a variety of surgical procedures and may have potential application to endoscopic gynecologic procedures (1). Prior data describe the use of US guidance for dilatation and evacuations, intraoperative guidance for intrauterine tandem placement, and retrieval of impacted foreign bodies (2-4). The purpose of the present study was to determine the role of intraoperative US guidance for intrauterine endoscopic procedures.
MATERIALS AND METHODS
Fifteen patients were studied. Nine underwent resectoscopic myomectomy only and 6 underwent
Received February 4, 1994; revised and accepted April 18, 1994. * Presented at the 49th Annual Meeting of The American Fertility Society, Montreal, Canada, October 11 to 14, 1993. t Reproductive Endocrinology Service, Department of Obstetrics and Gynecology. :j: Reprint requests Gerard S. Letterie, M.D., Reproductive Endocrinology Service, Department of Obstetrics and Gynecology, Virginia Mason Medical Center, PO Box 900 (X8-0B), Seattle, Washington 98111 (FAX: 206-625-7274). §Department of Radiology. 654
Letterie and Kramer
Techniques and instrumentation
both resectoscopic myomectomy and endometrial resection. Patients were referred for evaluation of abnormal uterine bleeding unresponsive to medical management. All patients underwent preoperative transabdominal and transvaginal pelvic US examination to assess uterine anatomy and to determine size, location, and number of fibroids. Patients were treated preoperatively with depot leuprolide acetate 3.75 mg IM (Depo-Lupron; TAP Pharmaceuticals, Inc., North Chicago, IL) monthly for an 8week course of ovarian suppression. A second US was performed to re-evaluate uterine and fibroid dimensions at completion of medical therapy. Intraoperative US guidance was performed transabdominally, using a 3.5-MHz sector transducer (Acuson 128, Mountview, CA). Resectoscopic myomectomy and endometrial resections were performed under transabdominal US scanning of the uterine cavity. The bladder was filled with 200 to 300 of mL of saline through a Foley catheter until an optimal window for US imaging was achieved. Continuous pelvic US monitoring was performed in both the sagittal and transverse planes. Submucous myomectomy and endometrial resection were performed with an Olympus gynecologic resectoscope (Olympus, Lake Success, NY) and a unipolar wire loop. Power settings varied between 50 and 100 W and were determined by tissue response and ease of movement of the loop through the tissues. Fibroid and endometrial fragments were retrieved using polyp forceps and/or an 8-mm suction curette. Glycine 1.5% was used as a distending medium and was gravity fed to pressures adequate for complete visualization of the endometrial cavity. Endoscopic procedures were performed using a video monitor. All procedures were performed with resident or preFertility and Sterility
ship of the operative loop to the anterior and poste rior uterine walls and fundus. No complications were observed.
DISCUSSION
Figure 1 Intraoperative longitudinal US examination showing uterine distention, anterior uterine wall (large arrow head), submucosal fundal fibroid (arrow), and resectoscopic tip and loop at the inferior aspect of the fibroid before dissection (small arrow heads).
ceptor assistance as part of residency training in gynecologic surgery or a preceptorship in endoscopic surgery. RESULTS
The intraoperative use of US imaging provided information regarding the location of the resectoscope, guidance of the cutting loop, and definition of anterior and posterior uterine walls (Figs. 1 and 2). Visualization was enhanced by the intrauterine distending media, which provided an ideal environment for US imaging. In all cases, detailed information was available regarding the relationship of the cutting loop to the fibroid(s), endometrium, myometrium, and outer uterine walls. Anterior fibroids were imaged with greater precision than posterior fibroids. During the myomectomy, the location and dimensions of the fibroid could be determined accurately and the depth and adequacy of dissection through the uterine wall assessed with intraoperative real time scanning. These images were most useful in determining the endpoint of the intramural component of the fibroid(s). Microbubbles were evident within the uterine cavity or uterine wall during scanning after application of the cutting current and occasionally compromised the US images. These images cleared with passage of the bubbles from the operative field. In two patients, microbubbles were entrapped between a partially dissected fibroid and the myometrium, partially compromising but not obscuring the US image. During endometrial resections, US guidance provided an excellent means of assessing the relationVol. 62, No.3, September 1994
The availability of sensitive and easily transported US equipment has made possible intraoperative US imaging. Real-time imaging has been useful in various general surgical procedures, including intraoperative needle placement for fluid aspiration, resection of organs, and extraction of stones and foreign bodies (4). Operative hysteroscopy and intraoperative US guidance may provide an accurate and precise method to guide intrauterine surgery for a variety of gynecologic procedures. Data of the present study suggest that this modality may be used to enhance the performance of resectoscopic myomectomy(ies) and endometrial re section. The uterine distention and intrauterine fluid pocket facilitated visualization of the endoscope, fibroid, endometrium, and uterine walls. Sufficient details of the relationship of the endoscope to the fibroid and uterine walls to prevent uterine perforation and gauge of depth were rendered for each case. These US scans were easily done, and the US equipment fit neatly into the operating room. This combination also provided an excellent teaching aid for both residents and preceptors and enhanced appreciation of their move ments with the resectoscope. Trainees were able to visualize the endometrial cavity directly on the video monitor and the myometrial thickness and depth of dissection on the scan. Recommendations have been made for direct
Figure 2 Intraoperative longitudinal US examination of anterior uterine wall (large arrow head), submucosal posterior fibroid (arrow), and resectoscope tip (small arrow heads) . Letterie and Kramer
Techniques and instrumentation
655
visualization of the uterus by laparoscopy when contemplating complicated intrauterine procedures, such as the resection of multiple myomas or during resident training. Laparoscopy provides details only of the relationship of the instrument to the uterine wall, often at times just before perforation. The intraoperative use of US guidance adds a second dimension beyond that of laparoscopy and improves the intramural portion of dissection during myomectomy, increasing the likelihood of complete resection. This combination may be especially useful for the removal of intramural fibroids where adequacy of resection may be related to both recurrence of symptoms and need for additional procedures (5). Real-time imaging may also represent a savings and decreased morbidity when compared with laparoscopy.
cavity and uterine wall. A combination of intrauterine endoscopic procedures and intraoperative US guidance provides an accurate method to guide resectoscopic myomectomies and endometrial resection and to prevent inadvertent uterine perforation. Intraoperative imaging may have an application for other intrauterine endoscopic procedures and may preclude the need for simultaneous laparoscopy. Key Words: Intraoperative ultrasound, endoscopy. REFERENCES 1. Machi J, Sage! B, Kurohiji T, Zaren HA, Sarieg HA. Opera-
2.
3.
SUMMARY 4.
Intraoperative US guidance for intrauterine endoscopic procedures appears to offer a noninvasive means of assessing the precision and adequacy of resectoscopic myomectomy and to provide the exact location of the instruments within the uterine
656
Letterie and Kramer
Techniques and instrumentation
5.
tive ultrasound guidance for various surgical procedures. Ultrasound Med Biol1990;10:37-42. Granai CO, Allee P, Doherty F, Bal HG, Madoc-Jones H, Curry SL. Intraoperative real time ultrasonography during intrauterine tandem placement. Obstet Gynecol 1986; 67:112-4. Tamour RK, Sabagha RE. Intraoperative ultrasound for gynecologic procedures. Obstet Gynecol 1985;66:440-3. Letterie GS, Case KJ. Intraoperative ultrasound guidance for hysteroscopic retrieval of intrauterine foreign bodies. Surg Enclose 1993;7:182-4. W amsteker K, Emanuel MH, deKruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol 1993;82:736-40.
Fertility and Sterility