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Autori: P. Litta, C. Vasile, F. Merlin, C. Pozzan, G. Sacco, P. Gravila, C. Stelia
Editorial: Proceedings of the European Society of Gynaecologic Endoscopy , Berlin, april, 2002, 2002.
A NEW TECHNIQUE OF HYSTEROSCOPIC MYOMECTOMY: ENUCLEATION “IN TOTO”
P. Litta ,C. Vasile,C. Pozzan, F. Merlin, G. Sacco
P. Gravila*, C. Stelia *
Department of Gynaecology and Obstetrics, University of Padova, Italy
* University of Physics- Western University Timisoara, Romania
Objective: The aim of the study was to determine the safety of a new technique for hysteroscopic resection of uterine submucous myomas with high intramural involvement (G2 type).Hysteroscopic enucleation “in toto” mimicks classic laparotomic myomectomy in resectoscopy. This procedure reduces the risks of intramural hysteroscopic resection as uterine perforation, electric damage and fluid overload by preserving the integrity of adjacent myometrial fibers.
Study design: Prospective study
Setting: University hospital
Patients and Methods: One hundred and sixtysix patients with a mean age of 42,8 years (range 29-54) underwent hysteroscopic myomectomy from 1996 to 2001 in our Endoscopic Center. Sixty eight (40.96%) presented with G0 myomas while 65 (39.16%) with G1 myomas and underwent classic hysteroscopic slicing. Thirty three women (19.88%) had a preoperative diagnosis of myomas with high intramural component. Thirty of these, with a mean age of 42.7 years, underwent hysteroscopic myomectomy using the enucleation “in toto” technique .All patients underwent diagnostic hysteroscopy and transvaginal ultrasounds before resection and were prospectively assigned to enucleation “in toto” when presenting a single submucous myoma with more than 50% of intramural component (G2). Attemps have been done to resect deep intramural myomas by favouring intracavitary protrusion of the intramural component by various tecniques: myoma’s massage through rapid changes of intrauterine pressure (Hamou), two-steps slicing, contraction-stimulating pharmacological agents, laparoscopic control (Mencaglia),combination of electrosurgery and simple mechanical dissection or total “cold-loop” resection (Mazzon).
Technique: ” In toto enucleation” – technique
With a 12° foroblique lens resectoscope and a 90° electrode, an eliptic incision of the endometrial mucosa which covers the myoma, at the level of its reflection on the uterine wall is performed, till reaching the cleavage zone. Then, the connectival bridges between myoma and surrounding myocytes are slowly resected. The effect of this technique is the protrusion of the fibroid in the cavity, facilitating subsequent asportation by slicing. Myoma is pushed into the uterine cavity, enabling the surgeon to work safely and to completely resect the intramural component. It is important to understand the physics and to have a description of the forces that act on the myoma subsequently leading to its expulsion (physical description Gravila-Stelia).
Results: Twenty eight (93.33%)patients had myomas between 2-4 cm in diameter and 2 of them (6.66%) a large myoma (exceeding 4 cm). The mean operating time was 32 minutes (range 16-45min). No intra or postoperatory complications were revealed. All patients were discharged within the day of surgery. All procedures resulted complete as subsequent ultrasound did not reveal residual myomatous tissue in the uterine cavity.
Conclusion : The “enucleation in toto” hysteroscopic technique is efficient, permitting complete resection of submucous myomas with large intramural component (G2) by favouring the intracavitary protrusion of the intramural part; it mimicks laparotomic myomectomy in hysteroscopy.
Cuvinte cheie: miom submucos cu dezvoltare intramurala, miomectomie histeroscopica, tehnica // submucous myomas with intramural involvment, hysteroscopic myomectomy, technique