A framework approach for hysteroscopic uterine septum incision: partial and complete

Objective: To demonstrate safe and efficient techniques for hysteroscopic partial and complete uterine septum incisions with radiofrequency electrosurgery. Review of these techniques may be particularly helpful for a surgical trainee or a less experienced hysteroscopic surgeon.

Design: Video instruction of the hysteroscopic uterine septum incision techniques.

Setting: Academic hospital setting.

Patient(s): One patient with a partial uterine septum and 1 patient with a complete uterine septum and a duplicated cervix (2 distinct external cervices) (1).

Intervention(s): Hysteroscopic partial and complete uterine septum incisions with a 7-mm unipolar knife electrode. Importantly, the demonstrated techniques can be performed using any hysteroscopic cutting instrument with which the surgeon is comfortable.

Main outcome measure(s): Surgical techniques that can be used to safely and efficiently incise a uterine septum and determine when the incision is complete.

Result(s): For a partial uterine septum, surgical techniques include uterine septum shortening, uterine septum thinning, and measurement of the residual septum length with the operating instrument to determine when the incision is complete. Visualization of the tubal ostia should be used throughout the procedure to maintain a horizontal incision plane. For a complete uterine septum with a duplicated cervix, we additionally demonstrate how to make a window through the septum at the level of the internal os to incise the uterine body portion while preserving the tissue wall inferiorly that separates the duplicated cervices.

Conclusion(s): Uterine septum incision is typically a short procedure that can be successfully performed with operative hysteroscopy. However, if a systematic approach is not followed, the surgeon can quickly and unknowingly become disoriented, resulting in inadvertent uterine perforation, incomplete septum incision, or excessive septum incision causing myometrial thinning, which has been shown to increase the risk of uterine rupture during pregnancy. In practice, the choice of technique used for septum incision should be made intraoperatively and will depend on the septum size and shape. Often, septum shortening, thinning, and residual measurement are best used in combination to achieve a successful result. Surgeons will find the use of these techniques helpful to maintain intraoperative orientation and provide a framework to guide adequate removal of either a partial or complete uterine septum.