Hysteroscopic myomectomy
Excision of submucous fibroids which are a common cause of excessive uterine bleeding and miscarriages could be done hysteroscopically . Such fibroids could be totally within the cavity (grade 0), more than 50% inside the cavity (grade 1) or less than 50% in the cavity (grade 2). Grade 0 and 1 are usually easy to remove even without prior downregulation with GnRH-a. However grade 2 might need more than one attempt to be removed. The most important risk factor in this procedure is the distance between the outer edge of the fibroid and the overlying uterine serosa.
Fibroids could be shaved using the same power setting used for endometrial resection. Large fibroid should be shaved from the periphery toward the central part. Otherwise small ones with an accessible stalk should be resected at the base of the stalk the same way endometrial polyps are treated. Bleeding usually indicates that healthy uterine muscle is reached.
It might be useful to inject syntometrine after completing excision of the visible fibroid and wait for few seconds. This would cause uterine contraction and might help with extrusion of any intramural part of the fibroid into the uterine cavity. After removing all fragments haemostasis should be secured with electrocautery.
The 9 pictures below show resection of a grade 0 submucous fibroid on the right side of the uterus. The fibroid was diagnosed before hand using saline infusion sonohysterography and 3D rendering as depicted by the first picture. The same fibroid was seen and removed during hysteroscopy.
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