Hysteroscopy and Fluid Management

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Peter Dragonas, MD: I’m Dr. Peter Dragonas. I’ve spent many years at Harvard Medical School in the discipline of gynecology fertility, endoscopy and now in New York. I’m very proud and privileged, indeed, to present Dr Philip Brooks from UCLA and Cedars Sinai Hospital, who’s been a teacher of mine off and on with the many forums that I’ve attended through AAGL and also the American Fertility Society with new names today but, at any rate, one of the most important and challenging problems over the last twenty - twenty-five years, since hysteroscopy, the use of a telescope to look into the uterine cavity was introduced, is how to do a proper job. And when surgical principles were applied to operating in the uterine cavity, the problem of fluid management was found to be the single most important aspect in maintaining the integrity of the physiology of the patient and we always have to remember the old maxim of medical school when it comes to patient care, which ACMI underwrites everyday, and that is first do no harm. Dr Brooks.

Philip Brooks, MD: Right. Thank you.

Peter Dragonas, MD: It’s a privilege to be here.

Philip Brooks, MD: Thank you, it’s a privilege to be here, as well. I’m grateful to ACMI, as well, for the long-time support of Fluid Management Systems. What you said is really important. We have gone down from the old ages of not having distension to using CO2 which has its own problems, but certainly can’t be used very much for operative procedures because of the bleeding, the bubbles and the risks, as well, to high viscosity liquids and now to low viscosity liquids, which are much more physiologic and much safer. However, the problem of overload of the patient is such a critical one that you have to balance the ease of use and clarity of vision with the safety, as well.

Peter Dragonas, MD: Would you tell us a little about the present-day instrumentation that you consider to be the safest and the easiest to learn, even for the practitioner who is not associated with a university hospital setting?

Philip Brooks, MD: I think it is imperative now, according to the guidelines of the AAGL that came out that talked about fluid monitoring, that it is imperative to have safe, effective instrumentation that monitors intra-uterine pressure as well as fluid deficit. And so we are developing computer-driven, gentle, safe pumps that keeps uterine distension perfect, clear vision and reduce the risk of intravastion and bleeding, so our technology includes some of the measuring systems, some that are just pure measuring systems have nothing to do with intrauterine pressure, some of them that are real high powerful pulsifial pumps that are distracting and have some difficulties and then, of course, my favorite pump, the one that we use, is the ACMI Dolphin Pump that balances both purity, as well as pressure control and measurements of fluid deficit, without pulsifial instrumentation, without the distraction, without the problem of clarity of view.

Peter Dragonas, MD: Well, I’m thinking back to my early days in Boston at the Free Hospital for Women, which has now been incorporated into Brigham and Women’s, and I even remember a very serious event taking place and I was told at that time that the practitioner was using CO₂ gas and an aeroembolism had gone through an open vessel and ended up in the wrong place and the outcome was not very happy. So, with that in mind, what do you tell, what would you say is the bottom line on this, Dr Brooks?

Philip Brooks, MD: Well, I think the bottom line is to learn about your instruments, to understand what you need for the minimal amount of effort with the greatest amount of safety. When you can use low pressures, low volumes, minimal trauma and very safe, effective instrumentation, you are capable of providing the best safety and the best performance for your patients.

Peter Dragonas, MD: In addition, can you comment on why we went from CO₂ to a fluid medium and what fluid mediums you recommend today?

Philip Brooks, MD: The major push to go from CO₂ was the development of electrosurgical equipment and CO₂ just won’t work in the presence of electricity very well. The reason is that the smoke, the steam, the bloody bubbles when you get an open blood vessel, just doesn’t work well with carbon dioxide. The high viscosity liquids did very well; the problem with them, however, is that there were allergic reactions and there’s a limit to how much you could use and with the advent of continuous flow systems, low viscosity liquids provide the safest, the easiest, the clarity of view and the best opportunity to do careful and complete, and now I only use liquids, I use liquids for diagnostics, saline in my office, physiologic saline solution, and we’ve helped develop a system of in-flow and very compact disposable system for office hysteroscopy, we’ve used liquids for both monopolar or bipolar interoperative surgery, whether it’s mechanical or whether it’s electrosurgical, we still use the continuous flow systems with low viscosity liquids. They’re the least expensive, they’re generally the safest if you know how to control the risk of overflow. You can drown a patient, I think there was a wonderful poet who once said, it doesn’t matter whether it’s a stream, a river, a lake or an ocean, if you can’t swim, you’re going to drown.

Peter Dragonas, MD: I’m not a very good swimmer myself. Tell me, Dr Brooks, and I’m talking to the community, they would ask you, the community of hysteroscopic surgeons, if you will, or potential hysteroscopic surgeons, what kind of things do you operate on in the cavity of the uterus?

Philip Brooks, MD: Well, primarily, we do surgery for abnormal bleeding, infertility and reproductive wastage, those are the most common indications, and what we find are polyps, uterine fibroids, mild adenomyosis or mild irregular surfaces of the uterus, anomalies of the uterus, such as septum that can be operated on, hysteroscopically, and those are the major operative procedures, and then, of course, the advent of ablation devices to destroy the endometrial surface in patients who have progressive, worsening menorrhagia.

Peter Dragonas, MD: Last night, I attended a conference here on the product to be used for contraception which will be inserted into the isthmus. Do you think that there’s a place for using your hysteroscopic saline methods from ACMI in preparation for placement of devices into the cornua, or isthmus portion of the tube and uterus?

Philip Brooks, MD: When you talk to a hysteroscopist, you’re going to get a hysteroscopy answer.

Peter Dragonas, MD: Well, that’s good.

Philip Brooks, MD: And for me, the evaluation of the uterine cavity is best provided by a look with a hysteroscope so, for me, the answer is in evaluating the patient, if it’s a proper cavity and cornua and whatever, and certainly the insertion, and certainly the insertion of a cornual device requires direct vision, so hysteroscopy for both evaluation and for operation, will be a cinch.

Peter Dragonas, MD: Yes, but for this particular type of instrumentation, we’re talking about, what I heard through the ACMI in the fluid management system, will the fluid management system we’re talking about, be the best prevention against any possible disaster, even though you’re going to do something else? But one further comment is, as in laparoscopy, and you may have taught me that years ago, when you do a laparoscopy, even if you’re trying to look for an active or suspected appendicitis, the most important thing to do is do an overall topographical examination.

Philip Brooks, MD: That’s correct.

Peter Dragonas, MD: And so I want you to comment on that, if you don’t mind.

Philip Brooks, MD: Well, studies have shown that there is a great deal of unsuspected pathology in the uterus, even in asymptomatic women, so that diagnostic hysteroscopy is essential and, whenever you’re using distension, you need to monitor the hazards that are potentially possible from the distension medium so that answer to your question is that there needs to be adequate control in monitoring both intrauterine pressures, as well as the fluid deficit and fluid usage.

Peter Dragonas, MD: In this meeting hall and this exhibit hall, we’ve seen an unbelievable number of people who are doing endometrial ablation. Now, in preparation for that procedure, do you see a use for your equipment that you are, shall we say, endorsing?

Philip Brooks, MD: Yes, I certainly believe, again, as a hysteroscopist, I don’t believe that any patient who has been through ablation should be done without a diagnostic hysteroscopy first to rule out atypia, polyps, abnormalities that would otherwise be unsuspected.

Peter Dragonas, MD: So, in other words, you could use the fluid management system that you’re prescribing in preparation for doing an endometrial ablation, do your diagnostic work and you may even not want to progress to an endometrial ablation if you have suspicious pathology. Is that right?

Philip Brooks, MD: Absolutely. And the point is, is that you need fluid management no matter what you do. If it’s just a diagnostic procedure, then a low pressure, gravity-fed system might be adequate, such as the Disten-U-Flo system that we developed for office use. If you’re going to have more detailed and you want to be prepared for operative procedures, then you need to use a more sophisticated and a more precise fluid management system when there is any kind of risk of fluid overload. So, the point is, you have to weigh the risks of any procedure and you have to deal with the preparation of the patient and preparation of the physician to obviate those risks.

Peter Dragonas, MD: In the traditional operating room setting, as we do with diagnostic laparoscopy, I was always set up requesting a full complement of equipment so that whatever I found, even on a diagnostic level, I could come forward to doing something that needed something surgical or even diagnostic, including video. So how, is there a difference to preparing in your operating room at Cedars Sinai versus in your office?

Philip Brooks, MD: Well, certainly in my office I don’t do extensive operative procedures and I won’t use electrosurgery . . .

Peter Dragonas, MD: Of course.

Philip Brooks, MD: . . . and so in my office, I just do some of the minor procedures which are very much lower risk. But I agree with you, when I am in the operating room, even if I’m doing a diagnostic hysteroscopy, I am doing it with equipment in the room at all times that I can convert to an operative procedure and, in fact, in my many years of consulting with industry, my dream was to develop systems where you could very easily adapt from a diagnostic instrument to change the insert or could change the operative instruments in a diagnostic sheath to an operative sheath and go ahead with either mechanical or electrical procedure to perform the surgery that you need at the time. So the answer to your question is yes, absolutely, I believe it is mandatory to have all the equipment available at all times for the ability to do what you have to do when you find it.

Peter Dragonas, MD: One of the things I learned from watching your talk on fluid management was that one of the problems is, other than the amount, the pressure, the flow, the material of the fluid, was that certain equipment is not really well designed enough to filter out tissue and it clogs the system and then you’re in trouble again.

Philip Brooks, MD: That’s true.

Peter Dragonas, MD: Can you comment about that, please?

Philip Brooks, MD: Yeah, we’ve working hard from the early days of using urologic instruments to the development of instruments specific for gynecologists to use inside the uterus and we’ve worked on those issues. Sometimes, even the best of our efforts are not good enough because we do get debris, especially hyperplastic or atypical endometrium might very well clog outflow ports. The best thing is to have the gentle pump that can maintain the pressures and to help aspirate the tissue directly through larger channels as it flows through gravity which goes to little tiny outflow holes, so that’s another added benefit of a pump fluid management system.

Peter Dragonas, MD: I’m thinking of everything you do and then the next question is, if I was happily a resident and I’d have to go back in age, which I’d like to do, realistic, I can’t anymore . . .

Philip Brooks, MD: I’d find you a place in our hospital.

Peter Dragonas, MD: No, but the point is, the resident has the ability to learn the contemporary techniques and new and latest and innovative instrumentation, but how about the doctor, you’re in Cedars Sinai in Los Angeles, what about the doctor in Redding, California, for example, he’s away from the scene, he’s a hard worker and he wants to do the best job he knows how and he wants to follow the maxim of first do no harm, how does he get the training and what’s the learning curve, Dr Brooks?

Philip Brooks, MD: Well, number one, he has to be encouraged to come to meetings like AAGL. Number two, there are workshops that we run all over the country and training programs. Number three, thank the lord for people like OBGYN.net who put these kinds of programs on the internet, make it available to anybody at any place.

Peter Dragonas, MD: Would you be happy to give out your e-mail address for any practitioner who needs help in not only acquiring the knowledge and use of this product, but also the experiences that you’ve had over the years?

Philip Brooks, MD: Sure. I can be reached as Philip Brooks through OBGYN.net and they will transmit any questions, any problem, and I would be happy to communicate with anybody directly who has a question or problem.

Peter Dragonas, MD: Well, I can vouch that Dr Brooks will respond to you because, even though I was on the east coast, he was on the west coast, and we knew each other from meetings, he was also responsive, always responsive to all his colleagues around the country and around the world and that’s why he stands here today with great pride and looking back over the years to his hard work and all that, what he says is pretty much the golden rule today in November of 2002. Thank you.

Philip Brooks, MD: Thank you very much.