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    The MIGS approach to fixing failed endometrial ablation

     

    Patient preparation

    In order to optimize sonographic imaging, women undergoing UGRH should avoid gonadotropin-releasing hormone agonists, although they may be necessary for management of symptoms if a significant operative delay is anticipated. We routinely perform sonographically guided cervical dilation and place a 3- to 4-mm laminaria japonica the day before the scheduled procedure, generally with adjuvant use of minimal sedation. Significant stenosis at the internal os and well beyond it should be anticipated. Patients should be given prescriptions for non-steroidal anti-inflammatory drugs or opiates because cramping following laminaria placement is often significant.

    Equipment and setup

    The equipment and personnel utilized for RHS are identical to what most surgeons already use for routine operative hysteroscopy. Some of my additional preferences include:

    Resectoscopes and reconfigured loops

    Most procedures are performed using a 22F or 26F unipolar resectoscope. We use a 13F pediatric resectoscope for management of the small postmenopausal uterus or when severe cervical stenosis precludes passage of even the smallest dilator. The electrosurgical loops we use vary from 90 degrees to 180 degrees and we often reconfigure them to appropriate shapes to facilitate exploration of the cornua (Figure 2). Bipolar resectoscopes can be used in selected cases where larger fluid deficits may be an issue.13

    Electrosurgical generator

    Our operating room (OR) is equipped with an Autocon II 400, enabling use of both unipolar and bipolar electrosurgery. Unipolar electrosurgery is generally performed at 140 W of C-Cut effect 4, during the resection phase and 120 W of forced coagulation current, effect 4, for the coagulation portion of the procedure. Whenever bipolar electrosurgery is used, a saline C-cut, effect 5, is employed.

    Ultrasound machine and guidance

    We currently use a Siemens Acuson X150 equipped with a variable-frequency abdominal transducer. Our operating room is fitted with 2 side-by-side monitors that facilitate simultaneous sonographic and hysteroscopic views (Figure 3).

    The remainder of the setup is standard for nearly all operative hysteroscopies and includes a video tower, light source, and digital recording system. Careful coordination is necessary so that the sonographer has adequate access to the patient and that monitors are positioned to allow hysteroscopic and ultrasound monitors to be viewed simultaneously.

     

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