JOURNAL OF GYNECOLOGIC SURGERYMary Ann Liebert, Inc., Publishers

A Modification of Technique for Hysteroscopic Lysis ofSevere Uterine Adhesions

JOHN A. ROCK, M.D.,1 MANVINDER SINGH, M.D.,2 and ANA A. MURPHY, M.D.3

ABSTRACT

A useful technique to assist the surgeon in the treatment of Asherman's syndrome isdescribed. This technique, using méthylène blue to distend the uterine fundus, allows thesurgeon to identify the plane of dissection easily. It is particularly useful to avoid dissection inthe wrong plane and to lessen the risk of uterine perforation. (J GYNECOL SURG 9:191,1993)

INTRODUCTION

Asherman's syndrome most frequently is caused by curettage and infection in an antecedentpregnancy.1 The use of operative hysteroscopy with or without laparoscopic guidance has been the

mainstay of treatment for uterine synechiae. Uterine synechiae in their most severe form may obliterate thelower uterine segment and lower fundal cavity. The hysterogram may reveal only the lower portion of theendocervical canal. This report describes a modification of a technique to allow the surgeon to safely identifythe plane of dissection and minimize the risks of uterine perforation.

MATERIALS AND METHODS

Three patients were referred to our office for secondary amenorrhea related to complications in an

antecedent pregnancy. Two patients had suffered postpartum hemorrhage requiring D & C and uterinepacking. One patient developed a severe postoperative endometritis. This patient received a curettage on two

separate occasions. On referral, all patients were amenorrheic, and a hysterosalpingogram had revealed no

uterine cavity. Only a small portion of the endocervical canal filled with contrast material. One patientreceived magnetic resonance imaging (MRI). Focal areas of fluid collection were noted in the uterine cavity.Each patient received a complete evaluation for secondary amenorrhea, which included normal TSH, FSH,LH, and prolactin. A biphasic basal body temperature chart was documented in two patients before referral.

Operative techniqueA laparoscopy was performed on all patients. A laparoscopic needle was placed through the operative

channel of the operating laparoscope. The needle was guided transfundally into the uterine cavity, andméthylène blue dye was injected (Fig. 1), which distended the uterine cavity. A hysteroscope was inserted into

'Department ofGynecology and Obstetrics, Emory University School ofMedicine, Atlanta, Georgia.2Department of Obstetrics and Gynecology, University of Louisville School of Medicine, Louisville, Kentucky.3Division ofReproduction Endocrinology and Infertility, Department ofGynecology and Obstetrics, Emory University

School ofMedicine, Atlanta, Georgia.191

192 Rock et al. Journal of Gynecologic Surgery

FIG. 1. A needle was inserted through the laparoscope and into the fundus, and méthylène blue dye was injected.Hysteroscopic hysterolysis was facilitated because the blue dye could be visualized at the junction where the anterior andposterior walls were densely adhered.

the cervical os. Hysteroscopic hysterolysis was facilitated because the blue dye could be visualized at thejunction where the anterior and posterior walls were severely adhered. Thus, the plane of dissection could beidentified readily. Uterine synechiae were usually thick and avascular. The adhesions were readily cut, andthe upper portion of the uterine cavity was identified. The volume of the uterine cavity was restored. Normaltubal ostia were noted bilaterally. The laparoscopic needle was noted protruding through the top of the uterinecavity. Bilateral tubal patency was documented at the time of laparoscopy. At the termination of theprocedure, a Foley catheter was placed in the uterine cavity, where it remained for 8 days. Each patientreceived antibiotics (ampicillin), which were continued until the catheter was removed 8 days later. Patientswere placed on conjugated estrogen (Premarin 1.25 mg) bid postoperative days 1-25 and Provera 10 mg days16-25.

RESULTS

All patients resumed menstruation. In the first patient, a normal uterine cavity was noted, and bilateral tubalpatency was documented on hysterogram. The second patient was noted to have recurrent synechia involvingapproximately one fourth of the uterine cavity. The right fallopian tube was noted to spill. However, the leftfallopian tube did not fill or spill. Minimal filling defects were still noted on the left side of the uterine fundus.Subsequently, a repeat hysteroscopic uterine lysis was performed, and a subsequent hysterogram was withinnormal limits. The third patient was noted to have minimal filling defects in the lower uterine segment.Bilateral tubal patency was noted, and repeat hysteroscopic lysis of uterine synechiae was performed. Asubsequent hysterogram was within normal limits.

DISCUSSION

This report describes a useful technique to assist the surgeon in the treatment of severe Asherman'ssyndrome. At the time of laparoscopy, a needle was placed into the uterine fundus, and méthylène blue was

injected to distend the upper portion of the uterine cavity. It was possible to dissect easily as the uterine funduswas distended and the blue dye was visualized through the hysteroscope. Interestingly, uterine patency was

Volume 9, Number 4, 1993 Hysteroscopic Lysis of Uterine Adhesions 193

documented in all patients as the dye was injected. The surgeon could easily identify the plane of dissection to

complete the lysis of uterine adhesions. This technique is particularly useful to avoid dissection in the wrongplane and lessen the risk of uterine perforation.Uterine perforation is more common with patients with severe disease. Kontopoulos reported perforation in

two of six patients with severe disease, even with guidance.2 A newer method of adhesiolysis described byDabirashrafi et al.3 may be effective: operative hysteroscopy is performed with guidance of an abdominalultrasound with an injection of 500 ml of normal saline in the abdomen and 250 ml of normal saline in thebladder. Dabirashrafi et al. believe that this method will allow uterine perforation and mild myometrialdamage to be prevented without laparoscopy.3If complete obliteration of the uterine cavity is present, our technique will not be of value in determining the

plane of dissection. In this situation, tubal patency will not be documented when méthylène blue is injected.Marked resistance to injection of dyewill be noted. The surgeon may proceed with lysis of synechiae based onhis or her ability to identify the plane of adherance of the uterine walls or may proceed instead with an

abdominal approach.

REFERENCES

1. Buttram VC Jr, Turad G. Uterine synechiae: Variations in severity and some conditions which may be conducive tosevere adhesions. Int J Fértil 1977;22:98.

2. Kontopoulos VG. Hysteroscopic lysis of intrauterine adhesions. A report of 61 cases. Acta Eur Fértil 1986;17:473.3. Dabirashrafi H, Mohamad K, Moghadami-Tabrizi N. Three-contrast method hysteroscopy: The use of real-time

ultrasonography for monitoring intrauterine operations. Fértil Steril 1992;57:450.

Address reprint requests to:John A. Rock, M.D.

Professor and ChairmanDepartment of Gynecology and Obstetrics

Emory University School ofMedicineP.O. Box 21246

Atlanta, GA 30322