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    The MIGS approach to fixing failed endometrial ablation


    The procedure

    Patients are asked to arrive in the OR with a full bladder in order to avoid catheterization. Although antibiotic prophylaxis is not generally warranted for hysteroscopic procedures, because of the complexity of these procedures, we administer ampicillin 2 g or clindamycin 300 mg intravenously for prophylaxis. The patient is placed in lithotomy position prior to induction of anesthesia to ensure her comfort. After induction of anesthesia or—for office-based procedures—moderate sedation, a vaginal speculum is inserted and the previously placed laminaria japonica and sponges are removed prior to the vaginal prep.

    A vasopressin solution containing 2.5 units/20 mL saline is injected intracervically at the 3 o’clock and 9 o’clock positions. Aspiration is recommended prior to injection in order to avoid an inadvertent intravascular injection. Mechanical dilation to 8 mm or 10 mm is accomplished under sonographic guidance with Hegar dilators prior to introduction of a 22F or 26F unipolar resectoscope. Glycine 1.5% or saline 0.9% is delivered at sufficient pressure to permit adequate uterine distention and flow. The net fluid absorption is carefully monitored and we are careful to perform all procedures within published fluid management guidelines.13

    Approach to the tubular cavity

    Often the initial hysteroscopy reveals a short tubular cavity with little or no obvious evidence of active endometrium. Often, dense synechiae are present—especially if there has been a long interval since the original EA. Tubular cavities often coexist with areas of cornual or central hematometra that may or may not be evident on U/S guidance. In the absence of sonographically demonstrable hematometra, dissection begins—using a standard resectoscopic electrosurgical loop—on either the anterior or posterior walls (Figure 4), enlarging the cavity and allowing the continuous flow of low-viscosity fluid. As the cavity distends, both hysteroscopic and sonographic visualization are enhanced.

    When a central hematometra lies adjacent to the tubular cavity, dissection is carried out into the hematometra (Figure 5), after which 3 mm–5 mm of tissue is removed beneath the endometrial basalis. If a central hematometra is not identified, the dissection proceeds in a cephalad direction to within 10 mm of the uterine apex and then radially in all directions in order to explore the entire uterus to within 5 mm–10 mm of its serosal surface (Figure 6). In the presence of cornual hematometra we gently explore the cornual regions, if possible, within 2 mm–4 mm of the serosa. Finally, the procedure is completed by coagulating the exposed myometrium with a 2-mm or 3-mm ball-end electrode at 120 watts of coagulation current.

    Lastly, unlike resectoscopic endometrial ablation or resection—for which surgeons often develop their own surgical sequences to accomplish their goals—there is no predetermined order for RHS. The course of each procedure is dictated by the variable hysteroscopic and sonographic findings.



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