Hysteroscopic surgery is an operative procedure in which a slender tube (known as ‘hysteroscopy’) is inserted through the cervical canal to view the inside of the uterus (womb) and conduct operations. The hysteroscope is a fiber-optic tube that allows observation of the inner aspects of the cervical canal and the uterus for diagnostic and surgical purposes. It consists of telescopes (that have lenses placed at an angle). For uterine operations, ‘continuous flow hysteroscope’ is utilized, which have a wider diameter outer sheath (7mm).
The instrument has a separate channel to insert surgical instruments such as scissors, suction devices, laser fibers, and biopsy forceps. Channels are also available to flush and draw out fluids so as to maintain a clear field during an operation. Low-viscosity fluids such as saline, % dextrose, 1. 5% glycine and sorbitol may be utilized during the operation. The fluid is usually delivered by automatic devices (such as hysteromat) that control the pressure and flow. Hysteroscopic surgery can be performed to degenerate the endometrium (known as ‘endometrial ablation’), so as to prevent the need for hysterectomy (removal of the uterus).
Some of the conditions endometrial ablation is required include small sub-mucous fibroids, benign endometrial disorders, intrauterine adhesions, heavy uterine bleeding, etc. Endometrial ablation cannot be performed in uterine cancers, unusual hyperplasia of the uterus and excessively large or multiple sub-mucous fibroids. The endometrium has a good chance of regenerating following treatment. However, surgeries performed should make sure that the basal layer of the epithelium is thoroughly degenerated.
Several other methods have been used to degenerate the endometrium such as cryotherapy, heat, curettage, Nd-YAG Lasers, silicone rubber, quinacrine methylcyanocacrylate, oxalic acid, etc. Following this treatment, the endometrium degenerates and scarring develops. Laser devices can also be utilized in endometrial ablation (known as ‘laser ablation’). Laser rays can penetrate the tissues up to a depth of 4 to 5 mm. The success rate following laser treatment is about 97% (Garry et al, 1991), and only a few required a second operation (8%). Goldrath (1989) and Ehrain (1994) also reported similar success rates .
Studies also showed that more than 50% of the women developed amenorrhea after laser ablation . Endometrial ablation can also be performed using a roller-ball ablation (developed by Vancaille, 1989) . A tiny roller ball that freely rotates is used to apply electrical energy to the endometrium, causing a zone of coagulative degeneration. The technique is similar to that of laser ablation. Studies conducted show that more than 80% women who had undergone this procedure were satisfied with the outcome (Daniel et al, 1992) . The tissues were degenerated to a depth of 3. 3 to 3.7 mm.
Besides, radio-waves can also be utilized to cause degeneration of the endometrium (Phipps et al, 1990) . A newly developed technique of introducing a balloon that adapts to the shape of the uterus and uses hot fluids to degenerate the uterine lining is already being performed (known as ‘uterine balloon ablation’). Endometrial resection is a procedure in which the endometrium is removed using a specialized instrument known as a ‘cutting loop resectoscope’. It is performed for severe cases of uterine bleeding, in individuals who are contraindicated for hysterectomy.
A continuous flow resectoscope is usually utilized in the procedure. Studies have shown that more than 80% of the individuals who had undergone this procedure were satisfied (Broadbent & Mago, 1994) . Tissues can be cut to a depth of 3 to 4 mm. Studies conducted by Dayer et al (1993) and Pinion et al (1994) showed that the post-operative complications, period of stay in the hospital, time take to resume normal activities, post-operative bleeding and pain, etc, were drastically lesser with hysteroscopic surgery compared to open surgeries .
However, patients were more satisfied with open surgeries than hysteroscopic surgeries, as relapses of the symptoms were higher in hysteroscopic surgeries than opne. Studies conducted by the Royal College of Obstetricians and Gynaecologists demonstrated that failures were higher with Laser ablation and radio-wave ablation, than roller-ball techniques and open surgeries.