Presented by:
Mariah Colussi
Affiliations:
The Ottawa Hospital
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What Is Surgical Tips for the Management of Intrauterine Adhesions?
Hysteroscopic management of intrauterine adhesions, also known as hysteroscopic adhesiolysis, is a minimally invasive procedure used to divide scar tissue within the uterine cavity. These adhesions can develop after intrauterine procedures, infection, or pregnancy-related surgery and may contribute to abnormal or absent menstrual periods, infertility, or recurrent pregnancy loss. Here’s what it involves:
- Diagnosis and Classification: Hysteroscopy and imaging are used to determine the location, extent, and severity of adhesions before and during treatment.
- Vaginoscopic Entry: The uterine cavity may be approached without routine cervical instrumentation, allowing careful assessment while minimizing additional trauma.
- Adhesion Incision: Scar tissue is carefully divided rather than extensively excised to restore the uterine cavity while preserving healthy endometrium.
- Saline Distension: Saline is used to distend the cavity, improve visualization, and help separate tissue planes during adhesiolysis.
- Ultrasound Guidance: In more complex cases, ultrasound can help establish orientation and guide dissection when normal uterine landmarks are difficult to identify.
- Identification of Endometrium: Healthy endometrial tissue is carefully identified and preserved whenever possible to support healing and future reproductive function.
- Controlled Dissection: The angle and direction of dissection are continuously assessed, with deeper dissection stopped when the myometrium is reached.
- Final Cavity Assessment: The uterine cavity is inspected after adhesiolysis to confirm restoration of anatomy and determine whether additional treatment or follow-up is required.
The goal of hysteroscopic adhesiolysis is to safely restore the shape and function of the uterine cavity while minimizing additional injury to the endometrium.
What are the risks of Surgical Tips for the Management of Intrauterine Adhesions?
Hysteroscopic adhesiolysis is generally minimally invasive, but severe adhesions can make normal anatomical landmarks difficult to identify and increase the complexity of surgery.
- Uterine Perforation: Dense adhesions can obscure the boundary between the uterine cavity and myometrium, increasing the risk of creating a perforation during dissection.
- Bleeding: Injury to the myometrium or uterine blood vessels can cause bleeding during or after the procedure.
- Reformation of Adhesions: Intrauterine adhesions can recur following treatment, particularly when the original adhesions are extensive or severe.
- Endometrial Injury: Excessive removal or damage to healthy endometrium may impair healing and potentially affect menstruation or fertility.
- Incomplete Adhesiolysis: Severe or extensive scar tissue may not be safely treatable in a single procedure and can require staged or repeat hysteroscopy.
- Infection: Endometritis or other uterine infection can occur following hysteroscopic surgery.
- Fluid-Related Complications: Absorption of hysteroscopic distension fluid can rarely cause fluid overload or electrolyte abnormalities.
- Future Pregnancy Complications: Patients with significant intrauterine scarring may remain at increased risk for infertility, pregnancy loss, or abnormal placentation, even after successful treatment.
Careful identification of healthy endometrium, controlled incision of adhesions, ultrasound guidance when needed, and avoiding dissection beyond the endometrium into the myometrium can help reduce complications while restoring the uterine cavity.