BOTROS RIZK: Good morning, ladies and gentlemen, and welcome to this telesurgery session for operative hysteroscopy for the American Association of Gynecological Laparoscopies. We are very delighted to share with you our operative experience this morning that has been sponsored by Hologic. We would like to acknowledge their tremendous efforts in setting it up and in arranging that is necessary for it, particularly Brandy Weatherly from Alabama and Jeffrey Smith from Georgia. We'll also like to introduce my friend and colleague, Dr. Dan Herrera, who's been a great surgeon and has been the greatest force behind driving the operative procedures here at Springhill. And our OR team, we'd like to acknowledge them one by one because their daily efforts has been incredible. The OR team here has done a phenomenal job to keep every day process going very smoothly.
With this being said, I would welcome you this morning. I know it's a couple of hours behind us in Vancouver this morning, so I hope you're getting some good coffee. This case this morning that we have will be a case of operative hysteroscopy with a possible resection of submucosa fibroids.
Can I have the first slide, please? The procedure will be performed by operative hysteroscopy using the MyoSure tissue removal by Dr. Herrera and myself.
And this morning-- can I have the next slide, please? We will have a case of small submucosa fibroid. As you can see clearly, submucosa fibroids could be nice, pedunculated, totally intracavitary like the one with the large arrow, a type one submucosa fibroid with half of the myoma itself in the wall of the uterus. Once you remove those fibroids, you can see more and more. Let me see the next slide, please.
So in this case that you're seeing, we removed the first fibroid on the right side, and we found four additional fibroids about it. So be always prepared that there might be additional fibroids, even if you have done ultrasound, and you have done office hysteroscopy for those patients, because office hysteroscopy does not lend itself to that amount of distention of fluid that you can do. Next slide, please.
The typical submucosa fibroids that we see are either totally in the cavity, which we call type zero-- type one being half of them or less in the wall, and type two would be more than half in the wall of the uterus.
Not all cases are suitable. You can see on the right hand picture that there are three kinds of fibroids that, in this case, Dr. Herrera and I did by open laparotomy and myomectomy. She had about 42 fibroids, some intramural, some subserous, and some submucosa. The submucosa it could be one of the three that I have mentioned. Next slide, please.
This being said, comixture of pathologies is always expected, so on the left side, you see a large single myoma, but within the myoma, there are bluish nodules. Those bluish nodules are adenomyotic nodules, and the patient had the typical features of abnormal bleeding, of pain, and so forth. On the right side, you see-- what you think is the uterus is not uterus. This is a single myoma. And this, indeed, has a patient with about, again, 30, 40 fibers that we removed that day.
Some of the fibroids that you see are typical endocavity, some of them are in the wall, and some of them are on the outside. So I wanted to show you in the next few slides one of the fibroids in the wall of the uterus itself. The fibroid extends from the endometrium-- can I have the next slide, please? The lower left corner, the fibroid, it extends from the endometrium all the way to the outside. So do not be over enthusiastic, do not be too ambitious and try to remove that from within the cavity, because it will keep going and going and going to the outside. So at some point, you have to define where you're going to do laparoscopy, and this is a case for combined laparoscopic procedure or even laparotomy if you wish to do so.
The picture on the right shows you multiple fibroids on the uterus. The surface of the fibroids is always very vascular. And that is on the surface from the side seen laparoscopically, as well as from the base. And this is where techniques to seal those vessels before removing of the fibroids is very essential. Next slide, please.
So comes the question, how do you evaluate fibers? How do you evaluate somebody with abnormal bleeding? Simply, the office evaluation is more than perfect. You have 2D and 3D ultrasound. 3D ultrasound is invaluable. As I will show you in a few minutes, you can tell whether the fibroid is in the cavity or in the wall. You cannot do that by simply doing a 2D ultrasound. It will just show you the fibroid.
Once you've done your 2D and 3D ultrasound, you can move in with saline infusion sonohistogram. The saline infusion like in the picture you're seeing shows you that the fibroid is totally in the wall. You might want to see that the fibroid is in the cavity as well as in the wall, as I will show you in a minute.
And that office hysteroscopy is very valuable. We use both flexible and rigid office hysteroscopies. This is typically showing you a fibroid that is projecting in the cavity using office hysteroscopy. Next slide, please.
When we go to the ultrasound evaluation itself, this is a typical myoma. The myoma is seen here. The densities within the myoma are very different from the densities within the uterus. It's also circumscribed, which is not always the case, and always casts some shadows below it. And this fibroid is a typical intramural fibroid that you're seeing on the right hand of this patient. Next slide, please.
In contrast, here is a subserous fibroid. So the fibroid there is projecting from the cavity of the uterus. For many times, you do not have to remove those fibroids, but sometimes you do have to remove them, of course, if you're doing combined multiple myomectomy, as well. Next slide, please.
Fibroid is in the back of the uterus. Here, you can see the edge of the calcified fibroid. The calcified fibroid is seen very clearly. And then because of the calcification, you might not see clearly behind it, but still, with the calcification, you can see the lower edge of the fibroid, so you can get an accurate estimate of the size of the fibroid. Next slide, please.
And in this case, you have a submucosa fibroid. The submucosa fibroid, the central part of it has degenerated, so giving the appearance of a central cystic lesion. Indeed, this degenerated area looks as if you're doing a solo hysterogram or a saline infusion sonohistoriography, but it's not. It is simply fluid inside the cavity of the fibroids as a result of degeneration. Next slide, please.
I love this picture because it demonstrates many things for you. This picture shows you the sagittal view of the uterus. At the lower part, you see the posterior wall. In the middle, you see the endometrium. The endometrium is that shining white line that you can see there. Anterior to that endometrium, you see the fibroid. So it looks like 100% amenable to cavity procedures, like hysteroscopy. But when you look carefully, it goes out and out and out, almost all the way to the outside of the uterus.
So this is a five-by-four centimeter fibroid. If this was totally intracavitary, it would be great. If this was in, the majority of it, intracavitary, it would be fine. But the case like that should be done by combined laparoscopic hysteroscopic procedure. Next slide, please.
Same patient, but giving you a 3D. So on the top left, you see a sagittal view. On the top right, you see a horizontal view. In the lower left, you see a coronal view, and then in the lower right, you see a rendered coronal view, where you can see the fibroid pressing on the endometrial cavity. The top of the fibroid, you really can't see it in the picture, because it is large enough to extend to the outside of the limit of the picture. But it demonstrates the concept that this is a fibroid extending to the outside, so you do not want to attack that only by hysteroscopic procedures. Again, a combined hysteroscopy laparoscopy is ideal. Next slide, please.
For the evaluations, saline infusion is invaluable. This is a patient who's also in her early 40s, complaining of abnormal uterine bleeding, severe periods lasting two weeks and then starting again within a few days. So on saline infusion, you can see that the fibroid is going into the cavity, about two centimeters in the cavity.
But when you look carefully, you find that it also goes to the outside. This is a right cornual fibroid. That fibroid will be very difficult to remove hysteroscopically. We're doing that case later today after our first case that we do together.
Here is our case for this morning. This is a sagittal view of her uterus, showing you the longitudinal diameter and transverse. The uterus is not particularly enlarged. So you'd wonder, why would somebody like that, whose uterus is not as big as the few pictures that I have shown you before, cause so much bleeding, heavy bleeding to the point that she requested three blood transfusions over the last seven years?
This is really the puzzle or is the area in which technology has helped. In the past, when people had big fibroids, they underwent hysterectomy. But here it is, and I'm demonstrating that to you to show you that the uterine length is about 10, 11 centimeters. The width is about five centimeters. So by no means that this is a uterus that is extensively enlarged. 10.6 centimeters is enlarged, but marginally enlarged. Nothing compared to the pictures I've shown you earlier this morning from myomectomies or hysterectomies. Next slide, please.
When you look carefully in front of the endometrium or ahead of the endometrium, but not anterior posterior, there is an area that appears there that measures less than two centimeters or two centimeter area. That area that is there could be one of two things. Could be an adenomyotic nodule, could be a fibroid, could be a polyp. You really, really could be sure after you have pathology. But at least when you look at the ultrasound, and you find this area, you have to move with the second line of evaluation, which is basically performing hysteroscopy. So I'll show in the next slide her hysteroscopic appearance. Next slide, please.
So this is office hysteroscopy performed on her by a rigid hysteroscope, three millimeter hysteroscope. And you can see the fundus is this yellow line at the top. Anterior to the fundus, there is a small bulging area that could be fibroid, and this is our case for this morning is removing that fibroid. Anterior to that is the endometrium. The endometrium has been evaluated before, has being negative. But one of our advantages in keeping all the tissues that we remove today is that we have a very extensive pathology performed. So that will check to the endometrium, and if I may show you the next slide, please.
We're pulling back the hysteroscope a little bit on the same patient this morning in the office, and you can see here the endometrium is wavy and so on. Again, pathology was negative. Fibroid is bulging inside to the anterior wall of the uterus. And all that specimen will be sent for pathology. Because that fibroid is anterior, then you have to keep in mind when performing the MyoSure tissue removal movement that your lens and camera is posterior. And I'll show you that in two seconds.
So you use the opposite direction of where your lesion is or where your pathology is. So if you look here carefully, you can see the fundus by this yellow line. And before you reach the fundus, there is a smaller fibroid there, and this is our target for today. We will try and go for it straight rather than go for the endometrium. The reason for going for it straight is that if we go for the endometrium, there will always be some minimum oozing or bleeding. Once this happens, the picture will not be clear for the fibroid. So we start with our target, and then at the end, we will attempt to clear that area of the endometrium to get it all for pathology.
As I will show you later this morning, there are several other indications and uses that we will use, but for this purpose in particular, we will focus on the fibroid. May I have the next slide?
So if you look at the two scopes on the right side of the picture here, there is the Standard and the Excel. We always use Excel for our fibroids, almost unanimously for them, because they give you better tissue removal and better visibility for fibroids. When you have polyps and so on, you can use either, or. The end of the device has an operating channel and has a rod lens. The operating channel is opposite in direction to where your lens is outside. So you see the end of the lens where the camera will be attached. It is the opposite of the operating channel.
So where was our fibroid this morning? It was in the anterior wall. So the lens that we have will have to be going down or towards the posterior wall, and vice versa if the fibroid was on the posterior wall. Similarly, the plastic ridge on the device itself should go opposite of your lesion because of all the-- the operating channel would be the opposite direction. So keep that in mind.
Without further ado, our patient is here in the operating room, and we are delighted to start the case together for removal of her fibroid. Thank you.
So of course, the first thing, we examine the patient, and we did her ultrasounds before and after. As I mentioned, this patient needed three blood transfusions in the entire time. Visualization of the cervix is mandatory. We give them Cytotec when we're planning to do an operative procedure because Cytotec assists a lot in making the entry to the cervix much easier. And then after that, we sound the uterus. So what I'm doing now is basically putting a single tooth tenaculum on the anterior lip of the cervix and sounded uterus. The uterus sounded to nine centimeters, which is close to what we had in ultrasound. The total length on ultrasound, if you remember a minute ago, was 10.6 centimeters.
We're checking the cavity to see if we can get the MyoSure Excel. Occasionally with the Cytotec, you do not have to do any dilatation. It's my preference not to do any dilatation. But sometimes you have to. So we're dilating the cervix.
Great. We think we have enough for insertion. If not, we will actually re-dilate again. The hystoscopy has been primed. There's two channels. There is an in and out channel. If I could show you those, the blue that is connected here, that is the in. The yellow, that is out. What I was talking about earlier, this is the lens, and the camera is here, is opposite in direction to where the operating channel. So the operating channel that you have is anterior. So if I have an anterior wall fibroid, I want to keep the lens pointing posteriorally. That is irrelevant to the camera.
If it is the other way, if it's the posterior fibroid, so you turn it all the way around, and then you get the lens pointing anteriorally. Means that the operating channel is pointing posteriorally. Keep that in mind.
One of the advantages of having the MyoSure in the case is being able to smooth our way inside the cervix itself. Sometimes you go into the cervix, and it's impossible to go through the cervix. Today, it's easier than many times. So when you go through the cervix and you cannot, then you can stop, and then use the MyoSure to ease your way through the cervix there.
We are inside her cavity. We flush the cavity several times to make sure that we have good visibility. We're adjusting the focus. That is the posterior wall itself. That's the marker from there. Some little fluffy endometrium. This is our lesion for this morning. And this is a beautiful lesion. This is her left cornu of the uterus. You can see the left cornu here. The lesion is there. That is our target for today. And then this is the right cornu of the uterus. You can see maybe a slightly arcuate uterus. Maybe not. But of course, this is of not much relevance-- or even the septum. You can see the right cornu here.
And normally, I would say that if you pick a point from the right cornu to the left cornu and do a line in between them, that line should be at least straight. If not, it should be cathedral looking ceiling. It should not be a chandelier ceiling. By that, I mean it should not be jutting down.
So this is our main target for today. We will try and attempt and remove that first before-- we would like to remove everything in between so that we have easy access. So I'm pulling back to show you that the clearer the endometrium, the better visibility you have. Because if these fluffs get in your way, you will not be seeing as comfortably as you would like to see.
So if I may have the table slightly up, please, that would be great. And then if we can please have the MyoSure device.
DAN HERRERA: The Aquilex system that we are using with the MyoSure helps keep the cavity distended and gives you a very good view. We've come a long way from having to hang a bag and use the pressure cuff on the bag.
BOTROS RIZK: Can we increase the pressure? Dr. Herrera is making a very, very good point, that before we had the Aquilex system, we used to be struggling, sometimes, with visibility. But now, certainly, visibility is better. You'll see also that the visibility changes as the distention changes. So you can see a beautiful, clear image. This is another advantage of using the MyoSure tissue removal is that the hysteroscopic image is crisp and clear. When you use your regular hysteroscopes, unless you have a team that makes sure that your hysteroscopes are well maintained.
You see the black mark on the device here. The black mark is the same direction as the green ridge, the plastic ridge on the outside of the device. And this is the opposite of the operating channel.
So this is my fibroid, where I'm touching it with the tip. These, I think, are just endometrium. OK. So we go there, and this will start our procedure. So we're starting the tissue removal part of the procedure here, basically applying it to the fibroid. As it is on the surface, it keeps swiping across it. But as I took some of that endometrium off, you can see the fibroid itself now.
DAN HERRERA: You may want to show them the blades so they see where the blade is, which would be opposite to the black line.
BOTROS RIZK: Can I have a little bit more pressure inside?
DAN HERRERA: You see, the MyoSure sucks the tissue in so it keeps the area very clean and clear for the procedure.
BOTROS RIZK: So here is our lesion that we are targeting. And once it bites, you have a good bite in it, the rest comes much easier. If you stay on the surface, it keeps slopping across the surface. So you see the surface was-- the endometrium was slightly thickened. Not much. But you see here, now, you can start seeing the inside of the fibroid. I think you can see that. Before that, you only saw this surface. I'm trying to turn it to 45 degrees so when it is at 45 degrees, you can see very nicely that it is taking the fibroid.
Once we finish the fibroid, we'll attend to the rest of the endometrium. The rest of the endometrium is very good for making sure pathology. So in the past, all of us did only D&Cs for those patients for pathology. But you and I agree that D&C might not pick all the lesions that are inside the cavity, so removal of most of the tissues could be helpful for that.
Fibroid is two by two centimeters by ultrasound. Could vary a little bit, and, of course, you can have some endometrium above it and so on. I'll let it clear for a second. And because the lens is down, sometimes the water trickles on it, and it gets a little bit fuzzy from the humidity.
DAN HERRERA: So that part looks like it's more fibrous than the--
BOTROS RIZK: Right.
DAN HERRERA: And it makes it a little harder. But if you keep the blade there steady, it'll eventually--
BOTROS RIZK: Yeah. And like Dr. Herrera is saying, also, you see that's how that fiber is. So that's not endometrium, for sure. Because at the beginning, even with office hysteroscopy, we pondered for a minute or two, is this polypoidal? But this looks definitely fibrous tissue, and the fibrous tissue protrudes more to the cavity if we drop the pressure down, but we are keeping the pressure up so that we can see better.
This fibroid has been there for a long time, like I mentioned of her history of bleeding, and she was transfused in 2007 and 2009. So it is not unusual to have calcification of that fibroid. I'm pushing the scope more down so that the device is in the same line as the scope. If I don't, you hear this noise that we call torquing.
You just maintain the pressure on it. If this was only intracavitary, this would have basically disappeared in front of your eye in one minute. But part of that, as you see here, is in the wall itself. And you can see this is the endometrium here, from here to there. That is the portion that is in the wall.
DAN HERRERA: We welcome questions from the audience at any time. Send your questions by fill out the Ask a Question section.
BOTROS RIZK: Dr. Herrera will be addressing all your questions about the procedure or other procedures that you may wish to ask. If you have anything, please go ahead and prepare it.
DAN HERRERA: If you can see throughout the procedure, the field is very clear, very clean.
BOTROS RIZK: On the ultrasound, when you saw, do you see that the fibroid was [INAUDIBLE] of the endometrium? And this, again, like I said, could either be classic fibroid, or it could be adenomyotic nodule. But this doesn't look to me adenomyosis at this point, at least. Looks a classic fibroid with more fibromuscular tissue, more fibrous tissue.
And once you get, like I said, your teeth into it, it starts biting more. So you can see here nicely.
DAN HERRERA: And Dr. Rizk is doing an excellent job of keeping the contact with the fibroid, which helps with decreasing the amount of tissue as it's being sucked.
BOTROS RIZK: So as you see, the end of the device is blunt, so the part that removes the tissue is more approximate to that by a few millimeters. So of course, this is the active part of the device that removes the tissue.
And I think you can see it very, very nicely here. Again, the edge of the fibroid is down there. And we're applying it on it. Or maybe even we should come closer so that you can see well.
DAN HERRERA: And when you're doing this procedure, if you have other tissue that gets in the way of your view, you can readily remove it as you're doing the procedure. Like those little areas there.
BOTROS RIZK: We usually try to take them out. The only thing, they ooze a little bit, so we'll definitely clear that. So for demonstration, if we have those, you can see they almost disappear in front of your eye as we're coming back. This is here almost the endocervical canal and the lower segment of the uterus.
So here, I'm going to the right side of the remaining portion. Half the fibroid has been removed, but still part of it is here. You can see that is still above the level of the fundus, so I'm going here, literally pushing it a bit into the fundus. And do not be concerned or afraid that-- and this is what Dr. Herrera is referring to, that we have those polypoidal areas in the way. So I'm taking them out, not because they're necessary now to be removed, but because they get in the way when we look.
The more you're inside, the better the seal we have, so we're not leaking fluid outside. And, again, we give her Cytotec that might make her leak some.
DAN HERRERA: We've got a question that says, why is there no bleeding? And I think part of it has to do with the fact that the Aquilex system maintains pressure inside the uterine cavity, and that helps to keep a clear vision.
Any comments about that, Peter?
BOTROS RIZK: Exactly. Exactly. If we drop the pressure-- I mean, two things. If you increase the pressure, you minimize bleeding. So for example, when I stop here, you're seeing much better than what I'm doing, right? Because we have maintained pressure, and there is no suction. Once I put the foot on the pedal, and the suction continues, then you immediately start seeing the bleeding.
If you have any bleeding-- and we thank god this goes nicely-- but if you have any bleeding, your first option is to increase the pressure. Second option is to decrease the suction.
Let me show you, for example, this area, you want to go into it. And this is most important for every gynecologist, not just reproductive endocrinology. You have a lesion, you want to go on the lesion and remove it. So you see that? Gone. And look, for example, that polypoidal tissue there, you go on top of it, and it is gone.
That, of course, is a ridge from the path itself of the scope as we're going. But of course, when you do many of those, you see that slight pinkish oozing there from here. So that's why we leave those until the end if we can. So the pressure maintains the beautiful visibility. You do not have bleeding.
If you have even bleeding from another procedure, and you want to do it with even another tool or another instrument, you can use still Aquilex system to maintain your pressure, even though you could be using something else, another device totally, and so on. I'm not advocating that, but it certainly has helped me many times before.
DAN HERRERA: And we did not use vessel pressing in this case. And I don't believe we've used vessel pressing in any of the cases that we've had. What do you think, Peter?
BOTROS RIZK: Right, absolutely. We do not use vessel pressing usually. Or, actually, we have never used vessel pressing at all. We rely on-- by modifying the pressure and the suction as the main way to minimize the oozing altogether.
DAN HERRERA: Peter, when do you administer the Cytotec?
BOTROS RIZK: We give it usually the morning of surgery, but in her case-- I mean, she is 45 and so on-- so we give her last night and then two this morning. How many Cytotecs and so on, depending on your evaluation of her cervix before. If you think that the cervix was tight, you can use more Cytotec. Like, for example, you can use anywhere from 200 milligrams the night before and 200 milligrams the morning of the surgery. It will help a great deal in opening the cervix. We almost did not use any dilatation this morning. But, again, it makes the cervix looser, so you can get some leakage of fluid from the cervix. So it is a balance between the two.
In office hysteroscopy, we not use any Cytotec. Particularly, it was the flexible hysteroscope.
We'll pause a minute to change the fluid. And we're working on many things to advance that, to modify the amount of time that we use for fluid change.
DAN HERRERA: The question is, when do you stop resecting the fibroid? And I think you get to when you're flush with the uterine wall.
BOTROS RIZK: Right. And this is exactly-- you see, Dr. Herrera's point is, when do you stop? Like this fibroid here, when we looked at the beginning, it bulged inside. And to remind you, I'll show you at the end how much we bulged inside.
We removed the intracavitary portion. There is a portion still of that fibroid right there. That's the anterior wall. That is the posterior wall. So that's anterior wall here. You see is it still. But that part is not really protruding in the cavity. This is just simply the endometrium. I even, I think, have gone inside the endometrium. Look at that carefully. This is a beautiful view. This is the endometrium here, which is pink. This is the fibroid here. So I have gone below the level of the endometrium.
Remember, the cornu that I told you at the beginning, I told you that if you draw a line between the right and the left, you should never have that line sagging down towards you. You want that line above you. So I think this has been done enough to get us a cavity. And we'll clear the cavity in two seconds.
One thing that I'd mentioned to you theoretically at the beginning is turning the scope 180 degrees. So if you want something on the posterior wall, turn it 180 degrees so that your lens is anterior. And here we are keeping the camera in the same position, but if you look carefully here, the black mark-- you see that black mark? The black mark is opposite of your operating channel. So we want to get that endometrium. Look at that. Done.
And this is again and again and again, if you have a lesion, do hysteroscopy, and remove your lesion. There is no reason in 2014 to do it blind.
Look at this part here, a divide. This is not anything that is pathologic. But you want to remove it. Look, I apply it to the right, and it would be gone in two seconds. And of course, this is not a big polyp, but it demonstrates to you the principle of the point. Look at the right hole here. The right hole is gone. And all I'm doing is moving my hand clockwise in this situation.
To get it posterior, you keep the lens anterior, and vice versa. Did I do a reasonable job or not? How can you judge? By judging-- this was the fibroid area, this is the bed-- how much was it was going inside? So I think we are flush with there. There is still a very small area here. This is just in our way, so I'm taking that out so that we see better. There's no need, again, to remove it, but it's like your camera at home. If an object comes in front of your camera, the object becomes the focus.
At all times, we check how much fluid we know we have missed and so on. Our fluid limit is 2,500 for the procedures. If you think it is going faster than you do, of course, keep cap of how much fluid. And we know that we're leaking some from the cervix-- not much, but leaking some-- you can always give diuretic before it reaches a point where you would be concerned in any degree. So generally, if we reach-- unless there is a contraindication for a diuretic-- if we reach 2,500, we do.
And I think we're almost done with there. I'm focusing very much here. This is our fundus here. This was the fibroid that was projecting two centimeters inside the cavity. It was not a big fibroid. It was a small fibroid. But for sure, it was symptomatic fibroid. Like I mentioned, this woman required three times in her life to have blood transfusions following heavy period. She would have a period, like, 14, 15 days and after that, get admitted to one of the places, one of the emergency rooms or hospitals, for heavy bleeding.
DAN HERRERA: For this size fibroid, we'll use just one tissue trap.
