Name: improved hysteroscopic resection of endometrial polyps using 6-fr micro-scissors and forceps
Uploaded: 2024-08-02T14:45:00.000+00:00
Duration: 3 min 1 s
Description: Endometrial polyps commonly contribute to female infertility, and hysteroscopic resection is the established surgical approach for their treatment. ...

We express our gratitude to the patients, surgeons, anesthesiologists, scrub nurses, and technicians who actively participated in this study. Without their cooperation, this research would not have been possible.

This prospective observational study, involving outpatient hysteroscopy surgery patients, was conducted from March to December 2023. It was approved by the hospital&#39;s ethics committee of Shanghai JiAi Genetics &#38; IVF Institute (ethics file number: JIAI E2020-09). All participants provided informed consent prior to inclusion in the study.
1. Patient selection and preparation
<ol>
	<li>Patient eligibility
	<ol>
		<li>Inclusion criteria: include patients with primary or secondary infertility, aged 18-45, with at least one transvaginal ultrasound suggesting uneven endometrial thickening or suspicion of endometrial polyps.</li>
		<li>Exclusion criteria: exclude individuals aged below 18 or above 45 years, those with severe internal medical comorbidities, unstable hemodynamics, acute pelvic inflammatory diseases, untreated infections, body temperature exceeding 37.5 &#176;C on the day of surgery, pregnant women, individuals with suspected endometrial or cervical cancer, uncontrolled hyperthyroidism, uterine enlargement with uterine cavity exceeding 12 cm, and those unwilling to provide informed consent.</li>
	</ol>
	</li>
	<li>Preoperative patient preparation
	<ol>
		<li>Perform a thorough assessment covering tests for hepatitis B, hepatitis C, human immunodeficiency virus (HIV), and syphilis, alongside evaluations such as an electrocardiogram, liver and kidney function tests, blood coagulation function analysis, complete blood count, vaginal discharge examination, and preoperative transvaginal ultrasound.</li>
		<li>Schedule surgery within 10 days following the cessation of menstrual bleeding. Prepare the following surgical instruments: a speculum, Hegar dilators, sponge holder, cervical forceps, sterilized gauze, probes, and curettes, as illustrated in Figure 1A.</li>
	</ol>
	</li>
</ol>
2. Surgical preparation
<ol>
	<li>Pre-operative preparation
	<ol>
		<li>Gather comprehensive medical history records encompassing the patient&#39;s age, obstetric and menstrual history, underlying medical conditions, history of uterine and abdominal procedures, and pertinent clinical symptoms such as irregular vaginal bleeding. Additionally, document uterine size, position (anteverted or retroverted), endometrial thickness, endometrial echo, and the presence of other uterine diseases such as uterine fibroids or adenomyosis through transvaginal ultrasound examinations during the follicular phase preceding the surgery.</li>
		<li>Determine the surgical risks to the patient and obtain their signed informed consent. Furthermore, prior to the surgical procedure, evaluate the patient&#39;s anesthesia risks, obtain their signed informed consent, and allow the patient to choose between local anesthesia and no anesthesia based on their individual condition.</li>
	</ol>
	</li>
	<li>Operation field
	<ol>
		<li>Ask the surgical team to be positioned as follows: the surgeon is situated at the foot of the patient, the first assistant stands to the right of the surgeon, the anesthesiologist is located on the left side at the head end of the patient, and the scrub nurse is positioned on the left side of the patient (refer to Figure 1B).</li>
		<li>Position the endoscopic equipment on the right side at the foot of the patient, place the anesthesia equipment on the right side at the head end of the patient, and situate the monitoring equipment at the head end of the patient. Place the patient in the lithotomy position, with the lower legs secured by bandages on both sides to ensure immobilization during the procedure.</li>
	</ol>
	</li>
	<li>Disinfection
	<ol>
		<li>Perform disinfection according to the principle of disinfecting from top to bottom and inside to outside. Use iodine gauze to disinfect the external genitalia, labia, perineum, inner thighs, and perianal skin three times. Perform iodine gauze disinfection of the vagina 3 times. Complete the surgical draping with sterile surgical drapes.</li>
	</ol>
	</li>
</ol>
3. Surgical procedure
<ol>
	<li>Perform the following tasks as per the personnel&#39;s specialization: the anesthesiologist establishes peripheral venous access; the primary surgical assistant is responsible for assembling the hysteroscope lens, cleaning the lens, adjusting focus, and setting the white balance. 
	NOTE: All surgeries are performed using a 5.2-mm-diameter hysteroscope by the same experienced hysteroscopic surgeon.</li>
	<li>Set the hysteroscope pressure at 100 mmHg, with a flow rate of 300 mL/min. Use 0.9% saline solution as the distension media. Evacuate gas from the uterine cavity using the hysteroscope. Use cervical forceps to grasp the lower right lip of the cervix and carry out iodine disinfection again for the vagina, fornix, and cervix.</li>
	<li>Introduce the hysteroscope into the uterine cavity through the cervical canal. In case of encountering difficulties, retract the hysteroscope and use a measuring probe with a scale to evaluate the uterine cavity&#39;s positioning and depth. Then, pull the cervical clamp to flatten the overly curved uterus to facilitate the hysteroscope to enter the uterine cavity.</li>
	<li>Perform cervical dilation using Hegar dilators ranging from No. 3.5 to No. 5.5. Administer Phloroglucinol (80 mg intravenous injection) to relax the cervical smooth muscle if required.</li>
	<li>Keep detailed records during hysteroscopy surgeries upon introducing the hysteroscope into the uterine cavity, documenting the presence or absence of endometrial polyps, along with their location, size, morphology (pedunculated or broad-based), and any other notable endometrial conditions.</li>
	<li>Polyp removal
	<ol>
		<li>For patients with a single uterine polyp, perform the following steps.
		<ol>
			<li>Carry out individual removal using micro-forceps. Use the blunt end of the micro-forceps to pinpoint the basal layer of the endometrium (refer to Figure 2A). An anatomical gap exists between the endometrial polyp and the basal layer (as illustrated in Figure 2B); place the forceps here to grasp the basal portion of the endometrial polyp.</li>
			<li>Swiftly withdraw the micro-forceps to ensure complete separation of the polyp base from the endometrial base (as depicted in Figure 2C). Carry out the procedure incrementally until the polyp is entirely excised. Collect the excised polyp tissue for pathological examination. The typical pre- and post-operative images are shown in Figure 3A, B.</li>
		</ol>
		</li>
		<li>For patients with multiple endometrial polyps, perform the following steps.
		<ol>
			<li>In patients presenting with multiple endometrial polyps causing obstructive effects during surgery, employ micro-scissors initially to excise most of the polyps (refer to Figure 2D). This strategy is intended to increase the surgical space and enhance visibility within the operative field. Following this, remove any remaining polyp bases utilizing step 3.6.1. 
			NOTE: Special caution should be exercised when using micro-scissors to avoid cutting too deeply during the procedure to prevent injury to the basal layer of the endometrium.</li>
			<li>Start the sequence for polyp excision with the posterior uterine wall, followed by the uterine lateral wall and corners, and then the anterior uterine wall. This surgical order is designed to optimize the clarity of the surgical field.</li>
			<li>Once the complete excision of all polyp bases is confirmed, withdraw the hysteroscope and use a small curette or sponge forceps to ensure complete removal of the polyp tissue. The typical pre- and post-operative images are shown in Figure 3C-E. 
			NOTE: To minimize the heightened risk of infection associated with repeated hysteroscope insertions, it is generally advisable not to conduct further hysteroscopic exploration after the tissue removal.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Following the retrieval of all surgical instruments, clean the cervix and vagina by iodine disinfection.</li>
</ol>
4. Postoperative procedures
<ol>
	<li>Following the surgical procedure, thoroughly document all observations and surgical interventions performed. After this, submit the specimens for pathological evaluation.</li>
	<li>Carry out postoperative monitoring for 1 h to assess the patient&#39;s condition. In the absence of any complications, discharge patients without the need for additional medication. 
	NOTE: The surgery process does not require any electronic devices and only requires the use of micro-scissors and micro-forceps. If electronic devices are used during surgery, it will be documented as a failure of the surgical procedure. All surgical complications should be documented, and postoperative pathological reports should also be recorded.</li>
</ol>
5. Statistical analysis
<ol>
	<li>For quantitative data, use descriptive statistics such as mean, standard deviation, median, and confidence interval; for qualitative data, use frequency and percentage for description.</li>
</ol>

Hysteroscopic Technique with Micro-Scissors and Forceps for Polyp Removal

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The authors declare no competing interests.

Our research presents a novel surgical technique for removing endometrial polyps without cutting or causing electrical damage to the uterine endometrium, which is especially beneficial for women with fertility concerns. Sharon et al. introduced a similar technique using a non-electric loop for polyp excision11, demonstrating its efficacy and safety. However, the traditional resectoscope has a larger diameter12, necessitating cervical dilation and potentially increasing the ...

Endometrial polyps are abnormal tissue growths in the uterine lining with significant implications for fertility and reproductive health1. The estimated incidence rate of endometrial polyps is approximately 35% among patients with infertility2, though this figure may vary. These polyps can disrupt embryo implantation by inducing structural deformities in the uterine cavity and impacting the endometrium&#39;s ability to support implantation3,4,5,6. While hysteroscopic surgery is a common procedure for removing endometrial polyps, it is not without risks, with uterine perforation being the primary complication, particularly during the removal of multiple polyps7. Hysteroscopy with resectoscopes and classic mechanical resection with scissors and/or graspers remain standard for evaluating and treating the pathology of the cervical canal and endometrial cavity8. The application of electric energy during the procedure can result in endometrial damage, especially in cases involving anatomical variations such as a unicornuate uterus9. Mechanical technology such as morcellators and scissors are less painful than electrical devices when eliminating structural lesions in the office10.
In response to these challenges, a novel approach is proposed involving the combined use of micro-scissors and forceps during hysteroscopy. This technique aims to minimize the risk of injury to the endometrium, particularly the basal layer while ensuring the complete excision of polyps to enhance fertility outcomes for women. The technique is easy to learn and requires two doctors to perform the operation. Doctors with experience in hysteroscopy are capable of executing this procedure. It is a new and unique technique that eliminates thermal damage in a very common gynecologic indication.
Overall, this innovative approach presents a safer and more precise method for eliminating endometrial polyps, particularly in women with fertility concerns, offering a valuable alternative to traditional hysteroscopic procedures and potentially enhancing outcomes for patients requiring treatment for endometrial polyps.

<table><tbody><tr><td>Grasping Forceps</td><td>ShenDa</td><td>X5164B</td><td></td></tr><tr><td>Hysteroscope Lens</td><td>ShenDa</td><td>J0122A</td><td></td></tr><tr><td>Hysteroscopic Infusion Set</td><td>ShenDa</td><td>T7511&amp;nbsp;</td><td></td></tr><tr><td>IMAGE 1 S CONNECT</td><td>KARL STORZ</td><td>TC200</td><td></td></tr><tr><td>IMAGE1 HD</td><td>KARL STORZ</td><td>H3-Z</td><td></td></tr><tr><td>IMAGE1 S H3-LINK</td><td>KARL STORZ</td><td>TC300</td><td></td></tr><tr><td>Monitor</td><td>NDS surgical imaging, LLC</td><td>N-90X0568-G</td><td></td></tr><tr><td>Optical Cable</td><td>ShenDa</td><td>U8724</td><td></td></tr><tr><td>Scissors</td><td>ShenDa</td><td>X5261A&amp;nbsp;</td><td></td></tr><tr><td>Sealing Cap</td><td>ShenDa</td><td>T7303</td><td></td></tr><tr><td>Uterine Balloon Dilator</td><td>ShenDa</td><td>U9522 DG-1</td><td></td></tr><tr><td>XENON NOVA 300</td><td>KARL STORZ</td><td>201340 20</td><td></td></tr></tbody></table>

improved hysteroscopic resection of endometrial polyps using 6-fr micro-scissors and forceps

Endometrial polyps commonly contribute to female infertility, and hysteroscopic resection is the established surgical approach for their treatment. Numerous resection methods are available, with the most used and cost-effective options being cold resection employing micro-scissors or hot resection using an electric loop. However, both methods involve sharp resection, posing a challenge in achieving complete polyp removal while avoiding damage to the uterine endometrium. To address this issue, this study proposes an innovative approach: the combined use of the 6 Fr micro-scissors and forceps under hysteroscopy. The method entails utilizing 6 Fr micro-scissors to initially remove large polyps, followed by using 6 Fr micro-forceps to extract the remaining polyp tissue expeditiously and bluntly near the basal layer of the endometrium. This approach not only prevents surgical damage to the basal layer of the endometrium but also mitigates the risk of residual polyps resulting from incomplete resection. This method is particularly suitable for women with fertility requirements, offering additional considerations for the selection of treatment options for endometrial polyp resection.

A total of 114 patients suspected of having endometrial polyps based on transvaginal ultrasound findings participated in this study (Figure 4). All patients underwent hysteroscopy, with 15 patients diagnosed without endometrial polyps. The remaining 99 patients underwent endometrial polyp resection using the hysteroscopy technique. Among these 99 patients, aged between 26 and 44 years (Table 1), the average parity was 0.54 &#177; 0.78, and the median diameter of endometrial ...

Author Spotlight: A Reproductive Hysteroscopy Approach for Complete Endometrial Polyp Removal and Enhanced Endometrial Receptivity

The novel technique presented here employs a combination of 6-Fr micro-scissors and forceps for hysteroscopic treatment of endometrial polyps, demonstrating encouraging outcomes for infertile patients afflicted with this condition.

Improved Hysteroscopic Resection of Endometrial Polyps Using 6-Fr Micro-Scissors and Forceps

Endometrial polyps commonly contribute to female infertility, and hysteroscopic resection is the established surgical approach for their treatment. ...

improved-hysteroscopic-resection-endometrial-polyps-using-6-fr-micro

Research

JoVE Journal

Medicine

550 Views.  Shanghai Geriatrics Medical Center. The novel technique presented here employs a combination of 6-Fr micro-scissors and forceps for hysteroscopic treatment of endometrial polyps, demonstrating encouraging outcomes for infertile patients afflicted with this condition.

Video: Author Spotlight: A Reproductive Hysteroscopy Approach for Complete Endometrial Polyp Removal and Enhanced Endometrial Receptivity

Intraoperative Detection of Subtle Endometriosis: A Novel Paradigm for Detection and Treatment of Pelvic Pain Associated with the Loss of Peritoneal Integrity

Endometriosis is a common disease affecting 40 to 70% of reproductive-aged women with chronic pelvic pain (CPP) and/or infertility. The purpose of this study was to demonstrate the use of a blue dye (methylene blue) to stain peritoneal surfaces during laparoscopy (L/S) to detect the loss of peritoneal integrity in patients with pelvic pain and suspected endometriosis. Forty women with CPP and 5 women without pain were evaluated in this pilot study. During L/S, concentrated dye was sprayed onto peritoneal surfaces, then aspirated and rinsed with Lactated Ringers solution. Areas of localized dye uptake were evaluated for the presence of visible endometriotic lesions. Areas of intense peritoneal staining were resected and some fixed in 2.5% buffered gluteraldehyde and examined by scanning (SEM) electron microscopy. Blue dye uptake was more common in women with endometriosis and chronic pelvic pain than controls (85% vs. 40%). Resection of the blue stained areas revealed endometriosis by SEM and loss of peritoneal cell-cell contact compared to normal, non-staining peritoneum. Affected peritoneum was associated with visible endometriotic implants in most but not all patients. Subjective pain relief was reported in 80% of subjects. Based on scanning electron microscopy, we conclude that endometrial cells extend well beyond visible implants of endometriosis and appear to disrupt the underlying mesothelium. Subtle lesions of endometriosis could therefore cause pelvic pain by disruption of peritoneal integrity, allowing menstrual or ovulatory blood and associated pain factors access to underlying sensory nerves. Complete resection of affected peritoneum may provide a better long-term treatment for endometriosis and CPP. This simple technique appears to improve detection of subtle or near invisible endometriosis in women with CPP and minimal visual findings at L/S and may serve to elevate diagnostic accuracy for endometriosis at laparoscopy.

Loss of peritoneal integrity provides a new paradigm to understand and treat chronic pelvic pain in women with mild forms of endometriosis and can be easily detected using intraoperative instillation of dye at the time of laparoscopy.

Endometriosis is a  common disease affecting 40 to 70% of reproductive-aged women with chronic  pelvic pain (CPP) and/or infertility. The purpose of this ...

Two Methods for Establishing Primary Human Endometrial Stromal Cells from Hysterectomy Specimens

Many efforts have been devoted to establish in vitro cell culture systems. These systems are designed to model a vast number of in vivo processes. Cell culture systems arising from human endometrial samples are no exception. Applications range from normal cyclic physiological processes to endometrial pathologies such as gynecological cancers, infectious diseases, and reproductive deficiencies. Here, we provide two methods for establishing primary endometrial stromal cells from surgically resected endometrial hysterectomy specimens. The first method is referred to as &#8220;the scraping method&#8221; and incorporates mechanical scraping using surgical or razor blades whereas the second method is termed &#8220;the trypsin method.&#8221; This latter method uses the enzymatic activity of trypsin to promote the separation of cells and primary cell outgrowth. We illustrate step-by-step methodology through digital images and microscopy. We also provide examples for validating endometrial stromal cell lines via quantitative real time polymerase chain reactions (qPCR) and immunofluorescence (IF).

Establishing primary endometrial stromal cell culture systems from hysterectomy specimens is a valuable biological technique and a crucial step prior to pursuing a vast array of research aims. Here, we describe two methods used to establish stromal cultures from surgically resected endometrial tissues of human patients.&#160;

Many efforts have been devoted to establish in vitro cell culture systems. These systems are designed to model a vast number of in vivo processes. Cell ...

Murine Ileocolic Bowel Resection with Primary Anastomosis

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer being two common examples. Despite the frequency of these procedures, a significant knowledge gap remains in describing the inherent effects of intestinal resection on host physiology and disease pathophysiology. This article provides detailed instructions for an ileocolic resection with primary end-to-end anastomosis in mice, as well as essential aspects of peri-operative care to maximize post-operative success. When followed closely, this procedure yields a 95% long-term survival rate, no failure to thrive, and minimizes post-operative complications of bowel obstruction and anastomotic leak. The technical challenges of performing the procedure in mice are a barrier to its wide spread use in research. The skills described in this article can be acquired without previous surgical experience. Once mastered, the murine ileocolic resection procedure will provide a reproducible tool for studying the effects of intestinal resection in models of human disease.

Ileocolic resection is commonly performed in several human diseases; however, little is known regarding the impact of intestinal resection on surgical illnesses. This article provides instruction on executing the procedure in mice with high success, providing a means to study the effects of ileocolic resection in models of disease.

Intestinal resections are frequently required for treatment of diseases involving the gastrointestinal tract, with Crohn&#8217;s disease and colon cancer ...

Calibrated Forceps Model of Spinal Cord Compression Injury

Compression injuries of the murine spinal cord are valuable animal models for the study of spinal cord injury (SCI) and spinal regenerative therapy. The calibrated forceps model of compression injury is a convenient, low cost, and very reproducible animal model for SCI. We used a pair of modified forceps in accordance with the method published by Plemel et al. (2008) to laterally compress the spinal cord to a distance of 0.35 mm. In this video, we will demonstrate a dorsal laminectomy to expose the spinal cord, followed by compression of the spinal cord with the modified forceps. In the video, we will also address issues related to the care of paraplegic laboratory animals. This injury model produces mice that exhibit impairment in sensation, as well as impaired hindlimb locomotor function. Furthermore, this method of injury produces consistent aberrations in the pathology of the SCI, as determined by immunohistochemical methods. After watching this video, viewers should be able to determine the necessary supplies and methods for producing SCI of various severities in the mouse for studies on SCI and/or treatments designed to mitigate impairment after injury.

Spinal cord injury models should be highly reproducible. We demonstrate that the calibrated forceps compression model of spinal cord injury is an easy to use surgical method for generating reproducible injuries to the murine spinal cord.

Compression injuries of the murine spinal cord are valuable animal models for the study of spinal cord injury (SCI) and spinal regenerative therapy. The ...

The Influence of Liver Resection on Intrahepatic Tumor Growth

The high incidence of tumor recurrence after resection of metastatic liver lesions remains an unsolved problem. Small tumor cell deposits, which are not detectable by routine clinical imaging, may be stimulated by hepatic regeneration factors after liver resection. It is not entirely clear, however, which factors are crucial for tumor recurrence.
The presented mouse model may be useful to explore the mechanisms that play a role in the development of recurrent malignant lesions after liver resection. The model combines the easy-to-perform and reproducible techniques of defined amounts of liver tissue removal and tumor induction (by injection) in mice. The animals were treated with either a single laparotomy, a 30% liver resection, or a 70% liver resection. All animals subsequently received a tumor cell injection into the remaining liver tissue. After two weeks of observation, the livers and tumors were evaluated for size and weight and examined by immunohistochemistry.
After a 70% liver resection, the tumor volume and weight were significantly increased compared to a laparotomy alone (p &#60;0.05). In addition, immunohistochemistry (Ki67) showed an increased tumor proliferation rate in the resection group (p &#60;0.05).
These findings demonstrate the influence of hepatic regeneration mechanisms on intrahepatic tumor growth. Combined with methods like histological workup or RNA analysis, the described mouse model could serve as foundation for a close examination of different factors involved in tumor growth and metastatic disease recurrence within the liver. A considerable number of variables like the length of postoperative observation, the cell line used for injection or the timing of injection and liver resection offer multiple angles when exploring a specific question in the context of post-hepatectomy metastases. The limitations of this procedure are the authorization to perform the procedure on animals, access to an appropriate animal testing facility and acquisition of certain equipment.

A high incidence of tumor recurrence after resection of liver metastases remains an unsolved problem. The illustrated mouse model may be useful to investigate the reasons for such recurrences. It combines a liver resection model with intrahepatic tumor cell injection for the first time.

The high incidence of tumor recurrence after resection of metastatic liver lesions remains an unsolved problem. Small tumor cell deposits, which are not ...

Introduction of Intracapsular Rotary-cut Procedures (IRCP): A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For patients desiring pregnancy, laparoscopic intracapsular myomectomy (LM) is an alternative surgery option. Although LM is widely accepted to treat fibroids, it is technically demanding with risk of excessive bleeding and difficult suturing, especially in cases with large fibroids or tumors in unusual locations. Therefore, we developed an intracapsular rotary-cut procedure (IRCP) as a modification of laparoscopic intracapsular myomectomy, with the intention to minimize risks of LM and help uterine healing. A summary of the improvements to the IRCP is described: 1) making an incision at the site of the fibroid with a length of one-third to one-half of the fibroid&#39;s diameter at a depth reaching the fibroid&#39;s surface; 2) holding the fibroid stably and making rotary cuts on the fibroid at a depth of 0.5&#8211;1 cm within its pseudo-capsule while pulling it outward slightly, making sure not to cut off any pieces of the fibroid; and 3) repeating the cutting-and-pulling until the longest dimension of the fibroid is outside the incision. The multiple cuts are to minimize the diameter and extend the length of the fibroid. When the multiple cuts cause half of the fibroid body to &#34;shrink&#34;, the fibroid is squeezed out by contraction of the surrounding myometrium. Evaluation of the outcomes of IRCP showed that the time of enucleation and suturing, intraoperative bleeding, and decline of hemoglobin were significantly lower in the IRCP group than the LM group. As for reproductive outcomes, the full-term live birth rate of the IRCP group was significantly higher than that of LM group. However, there was no difference in delivery modes between the two groups. In conclusion, IRCP significantly benefits fertility preservation by minimizing damage to the uterus, protecting myofibers of the pseudo-capsule, and resulting in a shallower residual cavity, which eases stitching and causes less bleeding. It is worthwhile to adopt IRCP in younger patients who desire preservation of their fertility.

Introduction of Intracapsular Rotary-cut Procedures IRCP: A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Here, we present a protocol for performing an intracapsular rotary-cut procedure (IRCP), a modified laparoscopic intracapsular myomectomy that promotes fertility preservation.

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For ...

Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. Historical treatments were invasive and had adverse effects on the endometrium. Hysteroscopically guided laser therapy is easy and effective for endometrial cysts resection, with no deleterious effects for the endometrium.
A 110 cm long and 1.0 cm wide endoscope is sterilely introduced in the uterus through the open cervix of an estrous mare after vulvar cleaning. The uterus is slowly infused with less than 1 L of physiologic solution and the laser fiber is inserted in the biopsy canal of the endoscope. Cysts are then cauterized with the 980 nm diode laser with a contact fiber set at 20&#8210;2 5W in continuous mode. Each cyst is punctured&#160;until complete voiding of the cyst and shrinking of the cyst wall around the fiber. Uterine lavages with sterile saline solution are performed directly after the surgery and for one or two days as non-inflammatory fluid can be observed.
This procedure is easy and quickly performed, with no obvious deleterious effects. Cysts resection makes ultrasound pregnancy diagnosis easier and, in some cases, could restore proper embryo migration in the uterine horns between day 6.5 and 17. However, this treatment does not improve the underlying histological lesions related to endometriosis. These considerations should be clearly expressed to the breeder before this procedure.

The aim of this report is to describe the photoablation of endometrial cysts in the mare using an endoscopic laser device, and to discuss the interest and limitations of this new approach to deal with low fertility issues.

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated with a potential reduction in the ovarian reserve due to the inadvertent removal and thermal damage of healthy ovarian tissue. New ablative techniques with reduced tissue penetration depth and less thermal spread to the surrounding parenchyma may represent a viable alternative to cystectomy. For these reasons, the aim of this manuscript is to demonstrate the ablation of the endometrioma capsule using a CO2 fiber laser technique and discuss the clinical outcomes. Once the cyst has been drained and washed, a biopsy is taken. After cyst eversion, vaporization of the inner surface of the cyst is performed using a CO2 fiber laser. The technique is simple and reproducible as even young surgeons without any surgical experience were more confident in performing laser CO2 vaporization instead of cystectomy. The positive effects of CO2 technology are reported in a randomized controlled trial, where the postoperative changes in the antral follicular count (AFC) and antimullerian hormone (AMH) levels were compared between patients who had their endometrioma excised (cystectomy) and those who had undergone endometrioma vaporization with CO2 laser. The patients treated with CO2 laser showed significantly increased AFC without a reduction in serum AMH levels as compared to the cystectomy group, in which both parameters were significantly reduced. The postoperative pregnancy rate was also assessed, and comparable pregnancy rates were found after both treatments. On the contrary, patients treated with the CO2 fiber laser technique had more favorable in-vitro fertilization (IVF) outcomes compared to cystectomy.
In conclusion, the CO2 fiber laser technique may represent a viable alternative to cystectomy in the surgical treatment of endometrioma in terms of ovarian preservation, pregnancy rates, and IVF outcomes. Moreover, it has the advantage of being independent of the surgeon's skills and personal experience.

In this protocol, CO2 fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated ...

Transumbilical Endoscopic Resection of Intra-abdominal Mesenchymal Tumor

Gastrointestinal stromal tumors (GISTs) typically occur in the stomach and proximal small intestine but can also be found in any other part of the digestive tract, including the abdominal cavity, albeit rarely. In the present case, the tumor was resected endoscopically through the anterior gastric wall. Computed tomography (CT) scan and gastroscopy of a 60-year-old woman revealed submucosal lesions in the gastric body. The possibility of a stromal tumor was considered more likely. The endoscopic surgery was performed under endotracheal anesthesia. After a solution had been injected at the lesion site in the stomach, the entire gastric wall was dissected to expose the tumor. As the lesion was in the abdominal cavity and its base was attached to the abdominal wall, it was accessed using a sterilized PCF colonoscope. A sodium chloride injection was administered at the base. The tumor was then peeled along its boundaries using the hooking and excision knife combined with the precutting knife. Subsequently, the tumor was pulled into the stomach through the incision made in the stomach and then extracted externally through the upper digestive tract using the ERCP spiral mesh basket. After confirming the absence of bleeding at the incision site, the endoscope was returned to the stomach, and the stomach opening was closed using purse-string sutures. The patient recovered satisfactorily following the surgery and was discharged on day 4. Histological examination revealed a low-risk stromal tumor (spindle cell type, &lt;5 mitosis/50 high-power fields [HPF]). Immunohistochemistry revealed positive staining for CD34 and CD117, negative staining for SMA, positive staining for DOG1, and negative staining for S100. Additionally, the expression of ki67 was 3%.

The article introduces the surgical method, endoscopic submucosal dissection (ESD) for the complete removal of intra-abdominal tumors using natural orifice transluminal endoscopic surgery (NOTES). The procedure reaches the stomach by using gastrointestinal endoscopy, creating a controlled perforation for tumor removal, followed by stitching the gastric incision.