51: Ultrasound-guided hysteroscopy

Abstract

The purpose of this video is to describe the benefit of ultrasound use during complicated hysteroscopy. Hysteroscopy is a common gynecologic surgery that may be technically complex in situations where anatomic landmarks are distorted, including Asherman’s syndrome, Mullerian anomalies, and leiomyoma. We demonstrate how real-time ultrasound can aide the gynecologic surgeon to make key decisions in this case series. The first patient was diagnosed with hematometria secondary to cervical stenosis. The Seldinger technique (commonly used in vascular and cardiac surgery) was employed to perform cervical dilation. Severe intrauterine adhesions distort normal uterine architecture and increase the risk of uterine perforation. Ultrasound can alert the surgeon to the risk of perforation by providing a transabdominal, global view of the uterus, which is demonstrated with the second patient case in our video. The third patient was diagnosed with a complete uterine septum and duplicated cervices. Care needs to be taken to incise the septum in the lower uterine segment cephalad to the cervices to decrease future complications in pregnancy. In addition, ultrasound can be used to notify the physician as to when the septum has been completely incised to the level of the fundus. Similarly, hysteroscopic myomectomy under ultrasound can provide guidance regarding proximity of hysteroscope to the peritoneal cavity and also prevent staged procedures that may be needed to resect the entire fibroid. In our fourth patient case, we demonstrate how ultrasound can visually verify that the surgeon has excised the entire fibroid. Ultrasound-guided hysteroscopy may decrease the risk of uterine perforation in Asherman’s syndrome, assist in identifying anatomical landmarks in uterine septum incision, and ascertain complete fibroid resection, potentially reducing surgical times, fluid deficits, and the need for multiple staged procedures.