A Hysteroscopic View ND Motashaw, Svati Dave, Louis G Keith
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1A Hysteroscopic View
2A Hysteroscopic View
ND Motashaw MD (Bombay), FRCS (Edin.), FACS, FICS, FRCOG (Hon., Lond.) Past Prof Emeritus of Obstetrics and Gynaecology King Edward Memorial Hospital and Seth GS Medical College Hon Prof of Obstetrics and Gynaecology Nowrosjee Wadia Maternity Hospital Consulting Obstetrician and Gynaecologist Breach Candy Hospital, Hinduja Hospital Parsee General Hospital, Mumbai Svati Dave MD, DGO, DFP Consultant Obstetrician and Gynaecologist Mumbai Louis G Keith MD, Ph.D. Professor Emeritus Department of Obstetrics and Gynaecology Former Head, Section of Undergraduate Education and Medical Student Affairs Feinberg School of Medicine Northwestern University, Chicago
3Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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A Hysteroscopic View
© 2007, Nargesh D Motashaw, Svati Dave, Louis Keith
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 2007
9788180619946
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, A-14, Sector 60, Noida 201 301, India
4Dedicated to
my loving parents
Darashaw and Jer
Whose foresight provided me and
my brothers the opportunity to acquire our
medical education and to my sister
Gool
who has stood by
our side and supported us throughout our life
5Foreword
Nargesh Motashaw was the first physician from the South Asiatic region— India, in particular, who was interested in learning hysteroscopy. In 1972-73 she came to Hamburg and worked with me at the Elizabeth Hospital. With her knowledge of how to manage CO2 and liquid distending medias, she has been using the method since that time. She has shared the results of her experiences worldwide, always stressing the importance of the method and the necessity of using hysteroscopy based on clear indications. She knew from first hand experience that only this method can inform the gynecologist totally about the changes in the uterine cavity and allow him/her to reach a proper diagnosis. She also knew from personal observation of the various surgical techniques that could be used to treat submucous myoma, polyps, synechia and septate uteri respectively, whereby abdominal operation was avoided to the patients' benefit.
Today diagnostic and therapeutic hysteroscopy is a matter of course for a well trained gynecologist. Modern hysteroscopy asks three things from the combination of technical equipment, instruments and apparatuses. First, the distension medium must dilate the potential flat uterine cavity a sufficient distance between the optic of the endoscope and the uterine wall. Second, the cold light source must illuminate the dark cavity, and finally the hysteroscope must transmit a true and crystal clear image. The distension media are gas–CO2, mostly used for diagnosis, and fluids if surgical procedures are performed.
Although distension of the uterine cavity clearly improves the physician's ability to visualize its internal anatomy, the physiologic changes of the endometrium often present problems. Unlike other body cavities, such as the urinary bladder, gallbladder or the abdominal cavity which are lined with a tough epithelium that bleeds only when severely traumatized, the lining of the uterine cavity consists of a highly sensitive multifunctional mucous membrane that bleeds at the slightest touch. In addition, the endometrium is the only tissue involved directly in the phenomenon of menstruation. Aside from menstrual blood, the endometrium also produces various secretions and fluids associated with the process of reproduction. In order to understand and, if possible, obviate any difficulties that may arise from these changes, including the frequent obstruction of vision by blood and mucus, the hysteroscopist must be cognizant of all these factors.
The book A Hysteroscopic view edited by Nargesh Motashaw, Svati Dave and Louis Keith presents the many experiences with hysteroscopy from a well-known and renowned Indian gynecologist and her partner, both of whom are known all over the world. No gynecological illness, no malformation, no complication has been omitted. The reader is immediately informed how he/she should treat the case.6
Hysteroscopy is currently being practiced in many countries all over the world. It is a recognized as valuable instrument for diagnostic and therapeutic management. Conventional surgical techniques, which require a laparotomy and uterotomy, are seldom applied today. Although ultrasonography has contributed much recently to gynecological diagnosis, the practice of hysteroscopy and other endoscopic procedures will continue to dominate and grow because of their accuracy and the fact that operative procedures are possible. As one of the pioneers of hysteroscopy, I welcome this new well written and illustrated book by A Hysteroscopic view. I wish the book a success.
Hans J Lindemann
7Foreword
Nargesh Motashaw has been a contributor to the development of gynecologic endoscopy since its modern beginning in 1970. In the early years she was involved in the development and evaluation of devices and techniques for laparoscopic and transcervical gynecologic techniques in studies sponsored by the World Health Organization and the U.S. Agency for International Development. She was one of the first international members of the AAGL. She has been honored numerous times by Indian and international organizations for her work in gynecologic endoscopy. She has remained active in the field.
In this text on Hysteroscopy Dr. Nargesh Motashaw provides an extensive review of the literature and bibliography. Recognizing the significance of the transcervical route to the diagnosis and management of many gynecologic conditions she has written extensive chapters on the management of menorrhagia by hysteroscopic myomectomy and endometrial ablation. She has also prepared a broad review of the recent history and status of transcervical female sterilization amongst other interesting chapters. She describes some personal special cases and sprinkles the text with her opinions and preferences for equipment and techniques. Her long experience is reflected in these observations.
As one who has known Dr. Nargesh Motashaw over these thirty years as a colleague, she combines in this text an historical review of modern gynecologic endoscopy, substantial commentary on the literature, and the viewpoint of a female gynecologist who early recognized the potential of the new endoscopic technology, and worked to help develop it as well as integrate it into the health system of India.
Robert S Neuwirth
8Preface
Dear Friends,
I was fortunate to be the first President of the Indian Association of Gynecological Endoscopy. At that time, Professor Hans Lindemann was one of our frequent guest speakers and visited us on several occasions. Since then, our friendship and collaboration has continued and grown. Sometime during 1972-1973, I visited him in Hamburg and saw the master at work. In those early days, there were no video cameras and monitors. With great patience, however, he showed me the various pathological conditions that develop inside the uterus by allowing me to look through the eye-piece. That visit started my interest in hysteroscopy, and this book is the result of many years of working in this area of gynecology.
The late Dr Karl Storz founded his company well over 50 years ago and introduced the cold light source in 1960 and the Hopkins rod lens system in 1966. This pioneering achievement was adapted by many instrument companies all over the world. In the case of the Storz company, their hard work, expertise and diligence preceded the introduction of many useful instruments which I have had the pleasure of working with on countless occasions. Because of my satisfaction with their products, I mention them with reference to particular operations where I have used them.
Hysteroscopy cannot take place in a vacuum. In terms of patients, thorough counseling must always precede a hysteroscopic operation. Hysteroscopy in many places has replaced the blind procedure of dilatation and curettage where by polyps, myomas, septa, lost IUDs, intrauterine adhesions and carcinoma were missed.
Dysfunctional uterine bleeding (DUB) is now often treated by operative hysteroscopy. DUB is a common cause of menometrorrhagia, often treated in the past by medical therapy followed by a hysterectomy. The hysteroscope now permits endometrial ablation which was initially performed using unipolor resection, a technique which is still popular despite the appearance of a large number of second generation techniques such as thermal balloons, MEA, Cavaterm or Versapoint bipolar electrosurgical system (Novasure).
One of the advantages of hysteroscopy is that it can be performed under general, spinal, epidural and local anaesthesia. In addition, the Bettocchi 2.9 mm optic can be introduced without any anaesthesia. In hysteroscopy, although safety is a characteristic feature, complications can occur. A special chapter on complications will open your eyes to the rare and serious consequences that can occur on occasion, even in the best of hands.
Much has changed since I performed my first hysteroscopy. Today, ultrasound/laparoscopy are often combined with hysteroscopy when a submucous myoma type II penetrates into the 9myometrium, or at time of a septal resection to know the limit of excision or in cases of removal of osseous fragments in the body of the uterus.
I owe my heartfelt thanks to Dr. Svati Dave for constantly being by my side and helping me to execute a large number of the most difficult surgeries. Initially, she was bored and weary viewing through the telescope and then the rigid and flexible optic teaching attachment. Finally, when the picture came on the screen as the endo-vision camera came into use and her complaints of backache diminished greatly, so did those of others in the operating theater who always asked and were granted, “just one quick look”, because they know the value of seeing with one's own eyes.
I always admired Dr. Louis Keith for his in-depth knowledge of Obstetrics and Gynecology. I am grateful to him for his constant encouragement, words of wisdom and expert advice over the years and was particularly pleased when he agreed to read the entire manuscript from cover to cover, as his experience with endoscopy goes back to more than 30 years.
Many will wonder why I set out to record my experiences when so many books are available. Well, the answer is quite simple. I started hysteroscopy at the beginning and was taught by masters from all over the world. As my mind was prepared to accept fully an operation when others viewed it with great skepticism, I was able to accumulate a great deal of experience as well as a large body of literature, quite often provided directly to me by the authors.
Now is the time to share all of this and that is exactly what I set out to do in this book.
Nargesh Motashaw
10Acknowledgements
I cannot thank Mrs Sybil Karl Storz enough for her constant encouragement in the advancement of endoscopy and for helping me in the procurement of various instruments. I will always be indebted to her.
I would like to express my special appreciation to Dr Louis Keith for his excellent review of my chapters. I am grateful to Juan L Giraldo, Arnold J Kresch for generously providing me the photographs through AAGL and a special word of thanks to Linda Michels – Managing Editor, JMIG, Maryline Haldi – Product Manager, Wallsten Medical SA and Karl Storz for granting me the permission to reprint the photographs from their publications.