Veress J. Neues Instrument sur Ausfuhrung von ... - Dr Philip Thomas

Philip Thomas 

FRANZCOG, FRCS Edinburgh 

BSS Course, May 7-‐8 th 2011 

Sponsored by Karl Storz 

1

Q: Who is it and what did he do that is s/ll 

unique? 

2

A: Sir Jack Brabham-‐ The Fox 

� STILL the only man to 

have won a world 

championship in a car 

of his own design and 

manufacture 

� 1966, BT19 

� Those were the days… 

3

History 

� First described by Pantaleoni in 1869 

� But! Invented by an Irishman, Francis Cruise, in 1865. 

Pantaleoni improved the device’s illumination with the 

addition of a paraffin lamp. 

� This was 10 years pre-‐Hegar, and so laminaria tents 

were used to prepare the cervix 

4

Pantaleoni 

� “…she was placed as near as possible to the 

borders of the bed so that Dr Cruise’s light source 

did not set fire to the curtains…a vivid red 

polypous vegetation was easily discovered in the 

posterior part of the uterine cavity… I employed 

silver nitrate as a caustic and looked again with 

the tube to certify the effect of the cauterisation. I 

was obliged to use the caustic six or seven times” 

5

History (cont) 

� Not used regularly until the 1970’s 

� Fears of spread of carcinomatous cells into the uterine 

cavity…but Roberts, Long and Jonasson demonstrated 

no cells after curettage 

� Was not to replace blind curettage until the 1980’s 

� Now the gold standard for diagnosis…operative 

potential 

6

Equipment 

� Light source 

� Cold light source 

� Tungsten, halogen and 

xenon 

� 175W routine 

hysteroscopy 

� 300W for miniature 

scopes 

7

Equipment (cont) 

� Telescopes 

� 4mm, 3mm, 2mm (usual total OD 5mm) 

� 0, 12 and 30 degree 

� Eyepiece, barrel and lens 

� Fibre-‐optic bundles to convey light 

� Contact/non contact 

8

Telescopes 

9

Equipment (cont) 

� Diagnostic sheath 

� 5mm diameter/ 1mm channel 

� Operative sheaths 

� 7-‐10mm (average 8mm) 

� Common cavity for passage of scope and tools 

� Isolated input and output channels (1980’s) 

� Same 2-‐4mm scope as for diagnostic 

� Resectoscope 

� Double armed mono-‐polar electrode with either loop or roller-‐ 

ball 

� 30 degree telescope/ angled towards the electrode (12mm) 

10

Accessory instruments 

� Alligator grasping forceps, biopsy forceps and scissors. 

Semi-‐rigid 

� Bipolar electrodes 

� Monopolar blade electrodes 

� Flexible hysteroscope (Fujinon, 1980’s) 

� LASER (Argon, Nd, YAG and KTP) 

� Lots of bother and no practical advantage 

� Good coag but poor vapourisation properties 

11

Distension media 

� Uterine distension usually requires at least 

30-‐40mmHg, 70mmHg usually achieves flushing 

through fallopian tubes 

� Never CO2! 

� Office procedures. Micro-‐hysteroflator used 

� Gas embolism. Flattening of endometrium 

12

Distension media-‐ diagnosEc 

� Saline/Hartmann's 

� Safest and easiest 

� Gravity fall 

� 100cm height achieves 70mmHg 

� Iv giving set with hand pump or pressure bag 

� Aim 80-‐100mmHg 

� Hysteromat 

� Pre set flow, input and suction pressure 

� Generally: flow pressure 200ml min, suction 0.25 Bar, outflow 

pressure 75mmHg 

13

DiagnosEc media (cont) 

� Saline and Hartmann’s 

� Electrolytic so not for use with diathermy 

� Mixes easily with blood… clouding unless constant flow 

14

OperaEve hysteroscopy medium 

� Glycine 1.5% 

� Good view, non electrolytic 

� Hypo-‐osmolar 

� Absorption into open blood vessels 

� Hyponatremia… CNS swelling more pronounced in women 

due to progestogen effects on cation pump 

� A function of distension pressure (Mean Art Pres.) 

� Cease if deficit >1000ml or 1 hour 

15

Technique-‐ diagnosEc hysteroscopy (GA) 

� Speak to patient, review notes and scan result, review 

consent, re-‐iterate complications 

� Proliferative phase is best 

� GA/ prep/ drape/ lithotomy 

� Sims speculum, Vulsellum or tenaculum 

� James Marion Sims: born early C19, Alabama. Trials with VVF 

repair on slaves eventually succeeded when a jeweller made 

him silver suture material, due to it’s inert nature 

16

Technique (2) 

� Check equipment 

� Positioning-‐ far enough down table (anteversion) 

� Bladder need not be empty 

� Stack to left/ trolley to right 

� Connections 

� Prime line -‐no air bubbles 

� White balance 

� Focus 

� EUA/ sound/ +/-‐ dilation to 5mm 

� ?over dilate to achieve flow through (tubal ligation?) 

� As far as internal os if necessary 

17

Technique (3) 

� Fluid ‘on’ 

� Approach cervix 

� Cable down (most are anteverted) 

� Let go of vulsellum! 

� Dominant hand on cable, other on camera 

� Stay in centre of lumen. Fluid full on 

� Enter under direct vision 

� ‘steer’ using cable 

� Look left and right 

� Look on the way out 

� Photos 

� curettage 

18

Pathology 

19

Pathology (2) 

20

Pathology (3) 

21

Pathology (4) 

22

Pathology (5) 

23

Pathology (6) 

� AV malf 

� Post D&C 

� DDX , RPOC 

24

Technique-‐ LA/awake 

� Not quite the same procedure! 

� Get practice at GA procedures first 

� An exercise in smooth talking! 

� Limited therapeutic potential 

� Sampling rather than curettage 

� Careful patient selection 

� Previous cone/letz, nulliparas, elderly, obese 

� Misoprostol priming 

� Adjunct to insertion of IUCD's etc 

� Smaller scope somewhat limits view. Light source and cable 

� Buscopan and Non-‐steroidal 

25

Awake hysteroscopy (2) 

� Careful VE-‐ make damned sure AV or RV 

� Develop your ‘patter’ 

� Bivalve speculum 

� Chlorhexidine to cervix and vaginal walls 

� ‘no-‐touch’ technique 

� Consider Ligno w. Adr (dental syringe) 

� Tenaculum 

� Uterine sound 

� Fluid on but limit flow/distension 

� Have a QUICK look! 

� Summarise findings and reassure patient 

26

Technique-‐ resecEon 

� Difficulty and potential for morbidity probably 

underestimated 

� Consent/ and complications including laparoscopy and 

incompleteness 

� Patient preparation 

� First half of cycle 

� Consider Misoprostol 

� Consider analogues 

� Careful control of flow and removal of debris 

� Ease of entry/egress is vital 

27

The Ten Commandments 

for safe hysteroscopic resecEon, according to Phil Thomas 

1. Confirm that it is sub-‐mucosal-‐ a saline infused scan 

is most informative. Don’t accept inexpert scans 

2. Facilitate cervical dilatation-‐ ripen cervix with 

Misoprostol routinely 

3. At least 50% of the fibroid should be in the cavity 

4. Fibroids should be less than 5cm-‐ any more, shrink 

with GnRHa’s first, or another kind of operation 

5. If concerned about distance to serosa, monitor with 

ultrasound intra-‐operatively, or consider laparoscopy 

28

Pathology 

30

Pathology (2) 

31

Pathology (3) 

32

Pathology (4) 

33

Pathology (5) 

34

Pathology (6) 

35

Endometrial ablaEon 

� History 

� Vancaille, 1937: electrical 

� Goldrath, 1981: NdYag laser 

� Procedure more widely accepted 

� Indications 

� Menorrhagia/ DUB 

� Mostly regular cavity 

� Previous hysteroscopy or scan 

� Hyperplasia/ carcinoma excluded 

� Pipelle or curette 

� **What might happen if you inadvertently ablate a 

carcinoma? 

36

AblaEon (2) 

� Contraindications 

� Excessively large or distorted cavity 

� Wish to maintain fertility 

� Not contraceptive 

� Consider concurrent laparoscopy/ tubal ligation 

� Hyperplasia/ carcinoma 

� Other indication for hysterectomy exists 

� Alternatives 

� Hysterectomy 

� Medical 

� Mirena/ other ablations such as Novasure 

37

AblaEon (3) 

� Preparation 

� Consent-‐ failure rate/ 

years of relief 

� Alternatives: Novasure, 

Thermachoice 

� Endometrial thinning 

agents 

� Immediate post-‐menstrual 

phase? 

� Danazol 200 mg tds 6 

weeks 

� GnRHa-‐ ?which 

� Continuous OCP 

� Depo Provera 

38

Technique 

� Roller ball or loop 

� Check equipment 

� 100-‐120W cutting 

� 70-‐80W coag 

� Use pure cut 

� No evidence re comparative effectiveness 

� “ruling up the page” 

� Ostia, then fundus, then pick proximal extent 

� How deep? 

39

AblaEon 

40

Results 

� 10% “failure” 

� Successful reduction in 85-‐90% 

� Normal menses in 5% 

� Similar for laser or diathermy 

� GnRHa’s: possibly less long term pain 

� No clear evidence for one thinning agent over another 

41

ComplicaEons 

� Operator dependent! 

� Diagnostic: 

� Perforation 

� If with sound or scope 

only, no further action 

� antibiotics 

� Cervical laceration 

� Failure to gain entry 

� Gas embolism (CO2) 

� Failure to gain view 

� Menstrual? 

� Perforation? 

� Find ostia 

42

ComplicaEons (2) 

� Operative 

� Fluid overload 

� Avoid >80-‐100mmHg and >30mins 

� Beware deficit >1000ml 

� Myometrial vessles (400-‐500u) intravasation 9ml/min 

� Larger vessels (>1mm) 400ml/min with gravity feed and 

250ml/min with hysteromat 

43

ComplicaEons (3) 

� Perforation 

� Loss of cavity 

� simultaneous laparoscopy mandatory 

� Life-‐threatening due to delays.. Denial, failure to act 

� Polyp forceps/ Rampley’s 

� Last thing to go into the uterus is the scope! 

� Bleeding… Foley balloon catheter 15-‐20ml for 6-‐8 hours 

� Sepsis 

�

Returns to casualty 

� Most morbidity and mortality due to denial and delay 

� Let the surgeon know 

� Full set of bloods 

� Erect and supine abdo films 

� If these normal, do CT scan 

� Iv fluids 

� antibiotics 

45

QuesEons? 

46

Janos Veress 

� 1903-‐1979 

� This is how you spell it(!!) 

� Hungarian respiratory physician 

� Used for draining pleural effusions 

� Died AMI 27/1/1979 

� Veress J. Neues Instrument sur Ausfuhrung von Brustoder 

Bauchpunktionen und Pneumothorax behandlung. Dt Med Wshr 

1938;64:1480-‐81 

47

Veress J. Neues Instrument sur Ausfuhrung von ... - Dr Philip Thomas

Create successful ePaper yourself

Delete template?

Save as template?