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As you do resections, and take a myoma that is about 70% intracavitary and 30% intramural – a classic submucous myoma – as you distend the cavity and begin the resection, what happens? Well, the uterus knows how to do one thing – it knows how to contract; it is a smooth muscle. As you put that pressure head inside, the uterus will come down on the myoma. What it does is that it will squeeze this myoma out towards you. Often times as you are doing these cases, you are getting there and at this point you are flush with the cavity. That is where I take it down to; at that point, you are safe. I don’t go digging around in the intramural portion; I don’t think that is optimal. But then you stop, take out the chips, let the uterus contract some more and put the instrument back in. Often times what you are going to find is that there is still myoma sitting there. It allows us to get at the intramural portion. At the point where that stops happening, I call it a day. I think whatever little portions of myoma are left, what I have found in following these patients over a lot of years is that it infarcts; it is not going to become clinically relevant. But what we do is get out a lot more of the fibroid than what we think we would first be able to get out when we look in.
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There are now devices where we are able to coagulate fibroids and these are very useful. You still have to have a fragment so you can send it off for pathology, because we have seen leiomyosarcomas. You have to have continuous flow. I&O’s should be checked every 10 to 15 minutes. This is the one thing I care that my nurses do; I don’t need them to put together my instruments, put the tips on or plug anything in, but I need them to follow the I&O’s. This is the one thing that is somewhat difficult to do while we are doing the surgery. When I get in, I am looking at the entire cavity and trying to figure out if this is more than fifty percent intramural, in which case I may want to change how I am going to approach this fibroid. I need to see where it is sitting – is it sitting up by the ostia, an area that may be somewhat dangerous? I will use a cutting current, pure-cut current of 110; with the loop, it ought to cut through like butter. If it is not doing it, it may be a more calcified fibroid and you may need to go up. Just like a LEEP procedure, you want to put it on just before you contact it.
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The hardest cases are the ones that are near the ostia. A patient who has been put on a GnRH analog may have a thinned out uterine wall and it is relatively easy to get out and perforate into that area and get into trouble. Those arising from the fundus can be difficult; if you get a myoma that is coming from a fundus, it is very hard to make this motion that we like to make of bringing the instrument back towards us . If you are pulling that loop back towards yourself, it is almost impossible to perforate the uterus and cause a problem. But the ones in the fundus, you can’t do that well. In those kinds of cases, you have to use a back and forth and across type of motion. If you think that in those cases you need to drop a laparoscope in, then you drop a laparoscope in. If it is going to keep you safe and keep you from having a problem, use the laparoscope. Another problem is the sin of the stalk, where you are looking at a fibroid and there is a nice little stalk that is sitting up there, you’re thinking about it and the O.R. is urging you on to just cut it. But now what’s the problem? What is your ground? You just lost your ground. So now you have the slippery thing sitting there, floating around in the cavity and you can’t anchor it . If you are using unipolar cautery, your ground is sitting out here and you have no way to ground it and you are going to have trouble getting it out. I have heard of cases up to 6 to 8 cm of people transecting these stalks and then not knowing what to do. If you leave it in there, hoping it will slough out, you have a problem. Your stalk is your saving grace; it ought to be the last thing to go.

From the standpoint of GnRH analogs and endometrial ablation and even preparation for myomectomy, that is the kind of endometrium you would like to see. The perfect patient is the postmenopausal patient, in terms of the endometrium. It is very low, very thin and very avascular. I have seen patients walk in with submucous fibroids that have had hemoglobins in the 2 to 3 range that were still out walking and talking and they had just chronically brought their hemoglobins down. The one that I can think about most recently had nothing more than a 1-cm submucous fibroid and that was the sole source of her bleeding and she was in the low 3’s with her hemoglobin. We know that we can significantly increase patient’s hematocrit on GnRH analogs and iron. This was just one of the original studies looking at the use of GnRH analog versus iron alone. There is no question that the to of them together are better. We can reduce myoma volume. I find this to be less of an issue when I am doing a laparotomy/myomectomy. I find it to be helpful when I am doing a resectoscopic myomectomy. Doing a 1.5 to 2.0 cm myoma is incredibly simpler than doing a 3 to 4 cm myoma. There is not that much difference in size, if you were to take it out, put it on a table and look at it, but the difference from a standpoint of difficulty hysteroscopically, where you have minimal ability to distend and that cavity is only so big, is tremendous. In these situations, if you can get just a small bit of shrinkage, that may help facilitate surgery.
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The most common use of the resectoscope is removal of intrauterine lesions. Using unipolar or bipolar, you are going to create open vessels. With the pressure head that you have to create uterine distention, there is going to be enough force to be able to drive fluid into these vessels. How long does it take with a 20-gauge IV in a patient and a bag on pressure to go through one liter of fluid? It doesn’t take very long at all. That is why you have to watch patients like a hawk and you have to be constantly vigilant about the I&O’s. You can go from being 500 behind, 500 behind, 500 behind – and you are 1500 behind. If you are using normal saline, that is not a big deal, but if you are using glycine or sorbitol that has absolutely no saline in it, it can be a huge deal.
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All of the instruments that you use, whether it is a diagnostic hysteroscope, an operative hysteroscope or a resectoscope, ought to have continuous flow. You have to have this ability to put your media through an inner channel and then through a separate channel, create a current. Ten years ago, this did not exist. It now exits for all of our hysteroscopic instrumentation. It allows us to be able to work in bloody cavities fairly quickly. We can clean out those cavities and get good visualization.

As an office standard for diagnostic work, I will put a little bag of LR on a pressure cuff, pump it up and there it is not an issue. As soon as we go to operative work, where we are using glycine or sorbitol, I have a problem with using a pressure bag. It becomes hard for my nurses to be able to see what I put in. You also don’t know how much pressure you are using and how much pressure you really need. So what I have gone to in most cases with those specific media, is hanging the bag up at 6 foot or so; that will generally give you enough of a pressure head that you will be able to adequately distend the cavity, your nurses can follow the I&O’s and you will be able to track it in the way that it should be tracked, which is at a minimum, every 10 to 15 minutes and if you get above 700 cc over, more often than that.
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Sonohysterogram has done more for me as a preoperative test than probably any test. A lot of you have ultrasounds in your office, which makes it so easy. I use the same kind of catheter that I use for intrauterine inseminations. I catheterize, take 10 cc of saline, remove the speculum, put the vaginal probe in and it lights up intracavitary masses so well. What it has done for me is to allow me to figure out just how much of the mass is in the cavity. If I look at myoma and ten percent of it is sitting in the cavity, while eighty to ninety percent of it is sitting back behind the cavity, that is a terrible patient for a resectoscopic procedure.

Prior to surgery, I don’t tend to use laminaria unless a patient has profound cervical stenosis. If they have significant cervical stenosis, I will put in one laminaria and let it sit overnight. It isn’t necessarily going to dilate them, but it will allow the cervix to soften, so when you go to dilate, it will be a little bit easier. The problem is, if you stick a bunch of laminaria in somebody, you may end up with a vastly over-dilated cervix and then your problem is going to be fluid flowing out that you will have trouble keeping track of and problems with keeping good distention.
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I limit my medical treatment now to really treating for fibroids. In the past, we had done this for endometrial ablation. I think a lot of people are moving towards balloon ablations, and this may become less of an issue. Hemoglobin can be markedly altered in patients with submucous fibroids. For diagnostic hysteroscopy patients, those seen in the office or even in the O.R., the ideal time to bring these patients in and hysteroscope them is after they have finished their periods, when you have a very low, very basal endometrium. There is very little vascularity at that point in time. It is very forgiving. If you hit the side wall or fundus, there isn’t much there to cause a problem. As you start to get out further, you build up the lining. As you get out even further, you risk the potential in patient who at risk for pregnancy for disrupting pregnancy.

Distension is everything. Distension is our ability to see. I will tell you that during my hysteroscopic training, I was handed hysteroscopes – this was before the time we had nice video monitors – and when we lined up to look, we didn’t even know what we were seeing. You ought to be able to get a really good picture most every time that you go in to do a hysteroscope, even in patients with a lot of bleeding. If you work hard enough with the media and have good inflow and outflow, you can get a reasonably good picture.
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This is our ideal media, one that is isotonic, because if you get intravasation, which will undoubtedly occur in your operative cases, it is not a big problem. Ease of instrument cleaning – they all don’t have that. Minimal impact on body fluid volumes, ease of delivery and then nonhemolytic and nonconductive, so we can use electrosurgery; these are the classic media. When I went through training, there was a big emphasis on the use of CO2. CO2 is very unforgiving; if you put CO2 in and hit a blood vessel, blood and CO2 does not go well together. Even in the office setting, I have given up the use of CO2 as a media. I’ll hang a bag of LR and put it on a little bit of pressure, or use normal saline – these are nice media because they are isotonic. If you intravasate a little bit of normal saline, there is no difference from what the anesthesiologist has given in the IV bag. We get into issues with the nonelectrolyte-containing media, such as glycine and sorbitol. Most of you still probably have unipolar instruments, and to do resectoscopic surgery, you have to use one of these media.
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The problem is that glycine has no sodium and sorbitol has no sodium. The tonicity of these agents is less than 200 milliosmoles and that is where we can get into trouble. Hyskon was used in the past, but it isn’t really available to us any more. You don’t ever want to use water; it is the worst possible media that you could use. This is our balance – we want to have good distention – we want to be able to look in and see everything that we need to see. If you have too little of that, the uterus will collapse and you will see nothing. But after some point where you have maximally distended the uterine cavity, all you are going to do is to drive fluid into the vasculature and that is what we want to avoid. Don’t believe that you lose much intraabdominally. We know this from when we do concomitant laparoscopy; you use very little hysteroscopic fluid through the tubes, even in patent tubes. The mechanism is just like when you do a hysterosalpingogram – when you pressurize the cavity, you can see that smooth muscle area up in the cornua closing and it keeps you from losing very much. You can lose fluid down through the instrument and you can lose some through cervical lacerations. But what you have to believe as you are watching your I&O’s like a hawk is that whatever fluid you can account for, the working assumption has to be that it is intravascular, because any other assumption can lead to a significant complication.

The advantage of using the feroblique hysterscope is that the uterine cavity is this roundish cavity and ideally what you want to try to do is cause minimal trauma, using that 30-degree angle and rotating rather than torquing around the cervix. The more you can rotate, the less trauma you do and the better your visualization is, especially when you get into the office setting, because patients do not tolerate this type of motion around the cervix well at all.
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You almost always ought to have some sort of back up; I have had my instruments dropped, broken, everything that can possibly go wrong has gone wrong. It is worthwhile to check the instruments before surgery. I have had resectoscopes that if you look at the common resectoscope, at least the unipolar one, at the end of the resectoscope is a little ceramic sheath which protects the metal resectoscope and the loop, which you are going to have electrical surgical current going through, from touching one another. I can tell you that at least once in my career, the ceramic tip had been completely broken off. That is a very dangerous situation, if I happen to stick that instrument in without looking at it. I could have easily burned the patient.
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Dilators can traumatize tissue. If you are doing an office hysteroscopy, that is a problem. Ideally, you like to get in with a 3-mm, 4-mm or less instrument. We have very nice, very small hysteroscopes that you can get into almost any cervix besides the most stenotic cervix, without dilation. It is worthwhile to try to do that first, to try to visualize. Most of the hysteroscopes come with these inserts that are very hard and rigid. I don’t usually those; I usually look at the canal and follow the canal on up and then pop into the uterine cavity. You want to stay away from the side walls, but again, that will create bleeding.

The ingrown toenail is a common problem. Improper nail trimming in combination with chronic trauma from tight shoes often causes ingrown toenails.A spicule of the nail plate lacerates the soft tissue of the lateral nailfold and leads to painful irritation, inflammation, infection, and growth of excessive granulation tissue. Many treatments have been described, such as nail edge separation, partial matrix phenolization, and the classic wedge excision. These classic treatment modalities may lead to severe damage of the nailfold or to frequent relapses.
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Our goal was to find a treatment without producing severe nail matrix damage. Therefore, based on the technique of Wallace, Milne, and Andrew, we developed a new noninvasive therapy for ingrown toenails.
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With the patient under local anesthesia, the lateral edge of the nail plate including the spicule is splinted with a lengthwise-incised small flexible plastic tube, for example, a sterile drainage tube (diameter, 2.64 mm; Sterimed) normally used after cutaneous surgery for drainage. The splint has to be pushed proximally so that the nail spicule is totally covered by the split plastic tube.

The plastic tube is then attached with wound closure strips. After this procedure, the treated toe should be washed once daily with a solution (eg, povidone-iodine) for up to 3 or 4 weeks. The splinted spicule grows out without injuring the nailfold and the granulation tissue subsides. In addition, the patients must be advised about proper nail trimming.

Since 1993, we have successfully treated 62 patients (age, 15 months to 83 years) including patients with diabetes mellitus, AIDS, leukemia, chemotherapy, drug-induced immunodeficiency, and Buerger’s disease. So far, no recurrences or complications have occurred.

The nail splinting technique is simple and easy to perform and does not require any special equipment.
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In contrast to invasive treatments, our technique does not cause permanent damage to nail matrix or nailfold. After splinting, the patients experience instant relief of pain. Moreover, with the splint in place, patients are immediately able to resume walking in their usual shoes.