Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Resection of the Complete Uterine Septum?
- What are the Risks of Resection of the Complete Uterine Septum?
- Video Transcript
Video Description
The surgical correction of a complete uterine and cervical septum.
1. Overview of the background, clinical presentation and relevant pre-operative planning.
2. An illustration and instruction for surgical correction.
3. Discussion of the post-operative care and long-term outcomes.
Presented By
Affiliations
University of Toronto
Watch on YouTube
Click here to watch this video on YouTube.
What is Resection of the Complete Uterine Septum?
Resection of the complete uterine septum is a surgical procedure designed to correct a congenital anomaly known as a septate uterus, where a fibrous or muscular septum divides the uterine cavity into two distinct chambers. This condition is associated with increased risks of miscarriage, infertility, and complications during pregnancy.
- The procedure is typically performed using a minimally invasive technique called hysteroscopy. During hysteroscopy, a small camera and surgical instruments are inserted through the cervix into the uterus, allowing the surgeon to see and remove the septum without the need for abdominal incisions. The septum is carefully cut away, often with scissors or a laser, to restore the uterine cavity to a more normal, single chamber that can better support a pregnancy.
- By removing the septum, the procedure aims to decrease the risk of miscarriage and improve overall fertility outcomes. Post-surgery, the uterus generally has a more typical shape and functionality, potentially leading to fewer complications in future pregnancies. Patients are usually monitored with follow-up imaging to ensure the septum was completely removed and that the uterus heals properly.
What are the Risks of Resection of the Complete Uterine Septum?
Resection of the complete uterine septum, while generally safe and effective in improving reproductive outcomes, carries certain risks and potential complications, similar to other surgical interventions. Here are the key risks associated with this procedure:
- Perforation of the Uterine Wall: One of the primary risks during the resection is the accidental perforation of the uterine wall with surgical instruments. This can occur if excessive force is applied or if the septum is deeply embedded in the uterine muscle. Uterine perforation may require additional surgical intervention to repair and can lead to complications like infection or bleeding.
- Creation of Intrauterine Scarring: Any surgical intervention on the uterus can lead to the formation of scar tissue. In the case of septum resection, there is a risk that scar tissue (adhesions) may develop in the uterine cavity, potentially leading to issues similar to those caused by the septum itself, such as impaired fertility or increased risk of miscarriage.
- Incomplete Removal of the Septum: There is a possibility that not all of the septal tissue is removed during the procedure, which might not fully correct the anomaly and could necessitate additional surgeries.
- Infection: As with any surgical procedure, there is a risk of infection. Infections following hysteroscopic surgery can be serious and require prompt treatment with antibiotics.
- Bleeding: Although significant bleeding is rare in hysteroscopic procedures due to the use of instruments that can seal blood vessels, there is still a risk of bleeding during or after the surgery.
- Anesthesia-related Complications: General anesthesia is sometimes used for this procedure, carrying its own set of risks, including allergic reactions or respiratory issues.
- Impact on Future Pregnancies: Although the goal of the procedure is to improve pregnancy outcomes, any surgical alteration of the uterus can potentially affect future pregnancies. This might include abnormal placentation or changes in how the uterus expands during pregnancy.
Patients considering this procedure should discuss these risks thoroughly with their healthcare provider to understand how the benefits outweigh the potential complications, and to plan for careful monitoring and management of any postoperative issues.
Video Transcript: Resection of the Complete Uterine Septum
Resection of a complete uterine and cervical septum.
A complete uterine septum occurs due to failed resorption of the fibromuscular septum following the fusion of the paired Müllerian ducts. Longitudinal uterine septums may extend to the external cervical os, giving the impression of cervical duplication or a septate cervix. These findings often present with a complete or partial vaginal septum. Importantly, the external contour of the uterus is typically normal or with minimal indentation.
Uterine and cervical septums are typically asymptomatic. They are often diagnosed during a cavity assessment for infertility or for recurrent pregnancy losses. When a vaginal septum is present, the diagnosis may be earlier, at menarche or coitarche. Trauma to the septum can present with significant postcoital bleeding.
Poor pregnancy outcomes are indications for surgery, but after careful counselling, surgery may be offered without any prior obstetrical complications in the presence of a complete uterine septum.
Preoperative evaluation is completed in two steps. One, a speculum exam and vaginal exam to focus on the presence and location of any vaginal septums and the appearance of the cervix. Two, gold standard imaging should be able to characterise the internal anatomy as well as the external contour of the uterus. Optimal tests are MRI or saline-infused 3D transvaginal ultrasound. It is important to exclude associated congenital urological abnormalities.
There are four main surgical steps. Step one, resect the vaginal septum. The vaginal septum is resected to the level of the external cervical os. In this case, we see a midline anteroposterior partial septum in the upper third of the vagina. The posterior edge of the septum is resected first so that any unexpected bleeding will not obscure the surgical field.
This resection is done where the rugae appear less prominent in order to avoid damaging normal vaginal mucosa. The mucosa is reapproximated with interrupted absorbable sutures. After the resection of the vaginal septum, the septate cervix is easily visible.
Step two, confirm the anatomy. Hysteroscopic and laparoscopic visualisation are used to confirm the internal and external contours of the uterus. Laparoscopically, a single uterus is seen with a broad and regular external contour, which excludes a didelphys or bicornuate uterus.
Hysteroscopically, there is a narrow uterine cavity on the left side, with the cervical and uterine component of the septum seen medially. Similarly, from the right cavity, the septum is seen separating the two narrow uterine cavities.
Step three, insert the uterine Foley. To define the uterine septum clearly and allow for safe incision of the anteroposterior midpoint of the septum, an adult Foley catheter is advanced into the contralateral uterine cavity and inflated. As it fills, the cavity distends, displacing the septum laterally.
Here, a Foley catheter is threaded into the left uterine cavity, alongside a Hegar dilator seen in the right cervix. Laparoscopically, a subtle bulge in the uterus can be seen where the Foley catheter is inflated. The balloon creates a bulge in the uterine septum, allowing for better visualisation.
Step four, resect the uterine septum. The uterine septum is incised, and the incision is extended superiorly to the fundal myometrium and inferiorly to the internal cervical os.
Using the monopolar hysteroscopic knife, the septum is incised midway between the anterior and posterior uterine walls. The initial incision should be done immediately superior to the internal cervical os, as the lower aspect of the uterine septum will be fibrous and at its thinnest. The incision is extended cephalad and caudad, until the contralateral cavity can be clearly visualised. The Foley catheter balloon can be seen in the contralateral cavity.
The balloon is then deflated, clamped and withdrawn but left within the cervix to maintain the distension of the cavity. The incision is further extended caudad to the level of the internal cervical os. To avoid future mechanical cervical insufficiency, it is important to ensure that the cervical portion of the septum is left and not resected.
Superiorly, the septum is incised to the level of the fundus. Gradual resection avoids perforation. The monopolar knife can be used as a depth gauge to ensure the fundal contour is even. This is continued until the level of the two tubal ostia. If significant bleeding or vessels are evident, resection should cease, as this reflects myometrium.
When the resection is complete, the shape of the cavity is restored, and the cervical portion of the septum remains. The uterus is transilluminated, using the hysteroscopic light. Even lighting of the uterine wall suggests even thickness of the myometrium.
Technical tips include, use a 13-gauge or larger Foley catheter, as smaller catheters do not distend the contralateral cavity sufficiently to visualise the bulge. To help maintain cavity distension, avoid over-dilation of either cervical os. Clamp and do not fully withdraw the Foley catheter from the cervix. Transillumination of the uterus allows for better visualisation of the even myometrial thickness of the uterus, suggesting a complete resection of the septum.
To review the steps of the procedure, step one, resect the vaginal septum to the level of the external cervical os. Step two, confirm the anatomy using hysteroscopy and laparoscopy. Step three, insert a silicon Foley catheter into the contralateral uterine cavity. Step four, incise the uterine septum cephalad to the fundal myometrium and caudad to the internal cervical os.
There is a 10% risk of adhesion formation postoperatively. There is currently insufficient evidence for or against the use of a Foley balloon to hold the uterine walls apart or for postoperative hormonal or antibiotic treatment. Evidence suggests the endometrium and the uterine cavity will be fully healed eight weeks after surgery is completed.
Although there are no randomised, controlled studies, observational studies have shown a significant decrease in miscarriage rate, an increase in both natural and IVF pregnancy rates and an increased live-birth rate.