Materiaal voor resectoscopie Steven Van Calenbergh AZ Turnhout

Hysteroscopisch materiaal (Semi-)rigiede hysteroscoop Optiek van 2 - 4 mm & lengte 35 cm Koude lichtbron Rod lens systeem The modern panoramic hysteroscope ranges in diameter from 2-4 mm. Built according to the Hopkins system, a stainless steel barrel houses a series of lenses including a group of distal objective lenses, a series of glass rods of high optical quality that are separated by air lenses, and a proximal set of lenses that prepares the image for final viewing. As with the modern laparoscope, the optical field is illuminated using cold light that is delivered via a circumferential fiber bundle system emanating from the proximal fiber cable post. 2

Hysteroscopisch materiaal Optische karakteristieken van de hysteroscoop Focus op oneindig Vergroting omgekeerd evenredig met afstand tot object,en hoe groter de vergroting hoe minder licht Monoculair : beperkte diepteperceptie Panoramisch zicht van 60 - 90o The monocular optical system of the modern panoramic hysteroscope is without depth perception and remains focused at infinity; bringing the telescope closer or farther from the object to be viewed magnifies or reduces the image. Magnification is inversely related to the distance of the objective lens to the operative site. The transmitted image represents the summation of the degree of field of view allowed by the outer objective lens and the angle of this lens to the central axis of the telescope. Modern hysteroscopes provide a 60-90o outer field of view. This view is wider in gaseous than liquid media because of the lower refractive index. 3

Hysteroscopisch materiaal Optische karakteristieken van hysteroscoop Uiteindelijk gezichtsveld is het resultaat van Breedte van gezichtsveld van buitenste lens (60-90°) Hoek van die lens ten opzichte van de axis (0-30°) Centered lens = 0o Offset (fore-oblique) =12º, 25º, or 30º Hoe groter de hoek hoe meer licht verloren gaat Richting van gezichtveld steeds recht tegenover aansluiting lichtkabel If the outer lens is centered along the axis of the telescope it is referred to as 0o. Rotating a 0o lens over 360o does not change the image. Alternatively, the distal outer lens may be offset (fore-oblique) to the axis of the telescope at 12o, 25o, or 30o, providing a significantly expanded field of view when the lens is rotated. Larger angles of view proportionally sacrifice image illumination. Customarily, the direction of the fore-oblique angle of view is always opposite the axis of the fiber cable post. 4

Hysteroscopisch materiaal Conventionele single-flow hysteroscoop 1 ingang voor distentiemedium, eventueel ook één voor materiaal (7 French=2mm) Diameter van buitenste schacht 3–5 mm Enkel voor diagnostisch of beperkt operatief werk (biopt, beperkte adhesies) Laat geen flushing toe van de caviteit Geïnfundeerde vloeistof wordt geklaard door lekkage via cervicaal kanaal en tubae en door intravasatie Uniquely fashioned by each manufacturer, the conventional hysteroscopic sheath attaches to a matched 3-4 mm telescope and may include up to 3 ports with stopcocks for the passage of hysteroscopic instruments and the instillation of distention media. Ranging 4-5 mm in outer diameter, simple diagnostic sheaths usually have one port for distention media and are fashioned to tightly accommodate a telescope. Originally designed to utilize carbon dioxide as a distention medium, the narrow interface between the sheath and telescope makes instillation of liquid media difficult. Newer diagnostic sheaths ably accommodate liquid media by virtue of independent inflow and outflow tracts for so-called continuous flow. Operative sheaths range in outer diameter of 7-8 mm due to the additional volume required to accommodate the addition of one or more operative instruments. The conventional single-flow hysteroscopic sheath is outfitted with two oppositely positioned stopcocks that open to the same channel, permitting instillation of media from either side. This sheath is fundamentally a single channel system, where distention medium and operative instruments share a common route in and out of the uterus. Since active flushing of the uterine cavity is not possible with this kind of system, clearing of the operative field only occurs secondary to passive leakage of the distention medium around the sheath at the cervical junction and by the small addition of trans-tubal leakage. Furthermore, this sheath has the disadvantages of making it difficult to accurately direct operative instruments to a specific location within the uterine cavity. Since clarity of the operative field is paramount for the safe performance of hysteroscopic surgery, this type of sheath is not appropriate for operative cases where bleeding, tissue fragments, or thermal debris would be significantly encountered. 5

Hysteroscopisch materiaal Continuous-flow operatieve hysteroscoop Dubbele schacht (in- en outflow); 1 tot 2 ingangen voor instrumenten Onafhankelijke in- en outflow kanalen In door binnenste schacht: in dichtst bij optiek! Uit door buitenste schacht Mogelijkheid tot aktief flushen van de caviteit The continuous flow operative hysteroscopic sheath was invented to overcome the inherent deficiencies of single-channel sheaths. This sheath has two separate channels fitted with stopcocks that independently serve to instill and remove distention media; the inner sheath carries distention medium to the uterine cavity, and a fitted outer sheath evacuates this medium by gravity or intermittent suction via a set of perforations along its distal margin. This allows for continuous flushing and rinsing of the uterine cavity, enabling a clear view of the operative field during all phases of an operative procedure. Equipped with a 3 mm operating channel, the design allows instruments to be accurately placed anywhere within the uterine cavity. More contemporary assemblies are outfitted with intake and outflow ports that swivel and allow the medium to be instilled equally from either side while minimizing the risk of obstructing or dislodging the inflow tubing. Recently, the continuous flow design has been incorporated into simple diagnostic sheaths of larger dimension. 7

Hysteroscopisch materiaal Klassieke operatieve instrumenten Meestal semirigiede Vanaf 7 F (2 mm) in diameter en 35 cm in lengte Schaar Knabbeltang Biopsietang (Aspiratiecanulle) Due to their likeness to classic surgical instruments, adequate construction, flexibility, and durability, semirigid operative hysteroscopic instruments are preferable for operative hysteroscopic surgery. Classic configurations include scissors, biopsy forceps, and tissue graspers. A 2-3 mm disposable aspirating cannula can be useful for removing visually obstructive clots and tissue debris. 8

Hysteroscopisch materiaal De resectocoop Continuous flow 3 - 4 mm telescoop Buitenste diameter 7-8 mm Werkelement Elektrode en aansluiting elektrocoagulatie Passief (in rust is werkelement in schacht, trekken om werkelement naar buiten te brengen en loslaten om te reseceren) of aktief (in rust is werkelement uit schacht, trekken om te reseceren) systeem The contemporary gynecologic resectoscope is a modified urologic resectoscope with a shorter, blunter insulating beak at its distal end. It ranges in outer diameter from 24-28 F (9.5 mm), and 30-35 cm in length, and has a working distance of 18-19.5 cm. The resectoscope consists of a panoramic rigid hysteroscope, a working element, an inner sheath, and an outer sheath. The electrodes and the power cord from the electrosurgical device attach to the working element, which contains a built-in, finger-controlled, passive spring system that moves the electrode forward and backward. In the resting position, the electrode is inside the sheath. It advances past the outside sheath against the resistance of the spring, and then returns to its neutral position by the recoil force. Slightly angled away from the distal optic, the electrode extends 3-4 cm within the visual field. 9

Distentie Als intra-uteriene druk onvoldoende is: ↑ druk van de pomp (max. 150 mmHg) Outflowkanaal deels of volledig toezetten Als nog steeds onvoldoende distentie: Lekkage cervix? (pozzi-tang) Lekkage tubings of obstructie tubings/inflow Significante intravasatie (controleer deficiet!) Uterusperforatie! The purpose of uterine distention media is to create a cavity by overcoming myometrial resistance with sufficient pressure to prevent bleeding. 10

Distentie Factoren die intravasatie beïnvloeden: Inflowdruk Duur van de ingreep Ingrepen waarbij grote bloedvaten geopend worden: (Grote) myomata (>intramuraal) Uitgebreide adhesiolysis/metroplastie (Te) diepe endometriumresektie Partiële perforatie The purpose of uterine distention media is to create a cavity by overcoming myometrial resistance with sufficient pressure to prevent bleeding. 11

Meten is weten !

Hysteroscopisch materiaal Monopolaire luselektrode: Kan enkel in elektroliet-vrije spoelvloeistof Stroom keert terug naar patiëntenplaat . CAVE Fijne draad zorgt voor hoge stroomdensiteit Electroresektie=two-step proces: Activatie van elektrode vóór weefselcontact, creeert steam pocket en dan langzaam snijden, zodat pocket bewaard blijft.

Hysteroscopisch materiaal Bipolaire luselektrode: Maakt resectie in elektrolietomgeving mogelijk>NaCl Stroom keert terug naar het passieve gedeelte van de elektrode zelf

Hysteroscopisch materiaal Klassiek monopolair Loop 45 - 90o hoek Bal Barrel Puntje Bipolair Loop 90° hoek Bal Puntje There are three basic designs of monopolar resectoscopic electrodes, each attaching proximally to the working element and distally to the overlying telescope. They are angulated up to 15o away from the optic to remain in the field of view during the operation. The conventional monopolar cutting loop ranges 8-9 mm in diameter and is angled 45-90o. Cutting loops are primarily used to shave or remove submucous myomas and endometrial polyps, or to resect the endo-myometrium. Monopolar desiccation electrodes with ball, barrel, or ellipsoid configurations have substantially larger surface areas and are typically utilized to perform endometrial ablation and focal hemostasis. 15

Hysteroscopisch materiaal Lichtbronnen Tungsten Oranje-getint licht Inadequaat voor video-opnames Halogeen Voldoende voor visualisatie, echter rode tint Minder geschikt voor video-opnames Xenon 6000oK = daglicht Ideaal voor video-opnames Modern endoscopic light sources accomplish bright and accurate imaging by having a very high color temperature (degrees Kelvin, oK) which emits more high frequency wavelengths (blue). The spectral emission of light as it loses heat (at lower oK) shifts from blue to red, causing the image to appear with a reddish tinge. Older generation light sources utilize 150-250 Watt tungsten/iodine vapor or halogen-quartz incandescent lamps, which produce minimal blue light and are basically inadequate for photo or video imaging. A 150- to 300-W mercury halide or 300-W xenon vapor arc lamp provide outstanding illumination because of their high content of blue spectral light. Although the light is extremely hot at its source, most of the heat will be dissipated along the length of the light cable. Nevertheless, a significant amount of heat may still be generated at the end of the light cable sufficient to cause thermal injury to the patient or burn paper drapes or clothing with prolonged direct contact. The best system should be equipped to handle fiber cable light cords from a variety of manufacturers and with a continuously adjustable delivery system to supply variable light intensities. 16

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