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WJOLS

Reproductive Outcome following Hysteroscopic Adhesiolysis in Patients with Asherman’s Syndrome

vaporization system could provide effective and precise it has the advantage of detecting the perforation
cutting as well as good hemostasis, but there is a theoretical immediately, preventing any further trauma to pelvic
possibility of further endometrial damage. Electrosurgery organs. Laparoscopy also provides an opportunity to
systems, such as a monopolar cutting needle, Versapoint inspect the pelvis, to diagnose and treat any concurrent
bipolar have been used in treatment of intrauterine adhesions. pathology, such as endometriosis or adhesions.
Thermal damage of endometrium may be limited by using Fluoroscopic control: This technique provides an
an electrode needle rather than a cutting loop because of intraoperative fluoroscopic view of pockets of endometrium
the reduced exposure to the current. Several studies have behind an otherwise blind-ending endocervical canal in
reported successful outcomes of adhesiolysis by using women with severe Asherman’s syndrome. 47
electrosurgery, which suggests that with proper application Gynecoradiologic uterine resection (GUR): Karande
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significant damage is unlikely. 43 et al reported the use of a special catheter inserted into the
Hysteroscopic surgery using laser vaporization, including uterine cavity through the cervix with a balloon attached to
Nd-YAG laser and KTP laser, have been reported by its tip. Radiopaque dye was injected through a side channel
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Newton et al and Chapman and Chapman. The depth of of the catheter to delineate the uterine cavity with its
necrosis in the latter modality has been described as minimal, adhesions, and hysteroscopic scissors were introduced
at about 1 to 2 mm. through a central channel of the catheter to divide the
In Cochrane database review of pain relief for outpatient adhesions. The study, however, had a small sample size
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hysteroscopy, meta-analysis demonstrates a significant and needs further evaluation. The main disadvantage of this
reduction in the mean pain score with the use of local procedure relates to radiation exposure.
anesthetic in comparison to placebo or no treatment during Transabdominal ultrasound guidance: Transabdominal
and within 30 minutes after hysteroscopy. However, the ultrasound guidance has been increasingly used to replace
clinical signicance of the results is limited as the reduction laparoscopic guidance during hysteroscopic division of
in mean pain scores is small. Subgroup analysis has intrauterine adhesions, especially in women with severe
demonstrated a further reduction in mean pain scores during intrauterine adhesions. When there are severe adhesions in
and within 30 minutes after hysteroscopy in postmenopausal the uterine cavity, it may be very difficult to identify the
women. cavity without ultrasound. Our opinion is that transabdominal
ultrasonography provides efficient monitoring of the
Methods of Guidance hysteroscopic procedure and guiding the scope towards
the uterine cavity even when the adhesions may have
Hysteroscopic division of intrauterine adhesions may be
technically difficult, especially if the adhesions are dense. It completely or almost completely obliterated the uterine
carries a significant risk of perforation of uterus, especially cavity. It can significantly decrease the risk of perforation
during the dilatation of the cervical channel and introduction of uterus, especially during the procedure of dilatation of
of the hysteroscope. The introduction of the dilator and cervical channel. Moreover, it is a nontraumatic, readily
hysteroscope must be guided carefully by one of the available technique. Several newer innovative surgical
methods described here to avoid perforation because procedures have been described for women with severe
perforation at this early stage would preclude satisfactory intrauterine adhesions albeit need large studies to evaluate
completion of the hysteroscopy. The efficiency and safety them better. They include: 49
of hysteroscopic surgery for Asherman’s syndrome may 1. Transcervical adhesiolysis after use of laminaria tent.
be improved if the procedure is guided by one of the 2. Conversion of blind hysteroscopic procedure to a
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following methods: septum division. 51
Laparoscopy: Laparoscopy is a common method used 3. Myometrial scoring technique. 52
to monitor hysteroscopic adhesiolysis. Some investigators 4. Pressure lavage under guidance; a novel technique
have performed hysteroscopic surgery under concomitant which may be good for women with mild intrauterine
laparoscopic control to prevent perforation of the uterus. 43 adhesions.
This is of particular importance if the adhesions are dense.
Lateral perforation of the uterus may cause significant Complications During Hysteroscopic
bleeding, compared with central perforations. When the Adhesiolysis Procedures
uterine wall becomes unduly thin, it will permit Complications during the adhesiolysis procedure include
transmission of light across the uterine wall, and there uterine perforation, hemorrhage and pelvic infection. Uterine
will be a bulge over the remaining serosal layer, which perforation occurred in about 2% of all cases reported.
signifies that further hysteroscopic surgery must However, the rate was up to 9% in those with severe
immediately stop. However, with laparoscopic guidance, adhesions. The incidence of perforation can be reduced by
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it is often too late to prevent the perforation. Nevertheless, ultrasound guidance. Hemorrhage is less commonly
World Journal of Laparoscopic Surgery, January-April 2011;4(1):31-39 35