Hysteroscopic Septal Resection by Loop Electrical Excision Procedure (LEEP) for Correction of a Double Uterus

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Hysteroscopic Septal Resection
by Loop Electrical Excision
Procedure (LEEP)
for Correction of a Double Uterus

A patient who is unable to carry a pregnancy to term is sometimes found, on hysterosalpingogram, to have a septate form of double uterus. In such cases, resection of the septum often corrects the problem and results in a successful pregnancy.

Before the introduction of the hysteroscopic operative instruments, this operation required a laparotomy as well as a hysterotomy with resection of the septum, i.e., Jones, Strassman, and Tompkins operations. The introduction of operative hysteroscopic instruments offers a new form of treatment that avoids a laparotomy, resulting in a shorter hospitalization and faster recovery.

Physiologic Changes. A septate uterus is thought to cause fetal wastage because it cannot provide sufficient endometrium, which, in turn, provides nourishment for the developing placenta. When the septum has been removed, adequate endometrium returns, and nourishment becomes available.

Points of Caution. Loop electrical excision can be associated with severe bleeding. Perforation of the uterus and injury to the adjacent intestine or bladder are possible but rare. Expansion of the endometrial cavity with 5% dextrose in Ringer's solution improves visualization and reduces hemorrhage, therefore allowing accurate loop electrical excision and electrocoagulation of vessels that are bleeding.

Technique

The hysteroscope is inserted into the endometrial cavity after dilation of the cervix. The LEEP device is inserted down the operative channel of the hysteroscope. The endometrial cavity is expanded with 5% dextrose and Ringer's solution. The LEEP electrocoagulation machine is set on a blend between cutting and coagulation current. The hysteroscope is advanced up the uterus along the septum. The LEEP device is aimed at the fundus, where the uterine septum and endometrial tissue join. The internal os of the Fallopian tubes must be identified, and the electrical incision must be kept medial to the os of the tubes. By progressively coagulating and cutting the base of the septum with the LEEP device, the surgeon is able to resect and remove the entire septum.

The base of the septum has been electrocoagulated thoroughly to prevent bleeding.