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Uterine Anomalies: All You Need to Know

Mar 14 | 1:30 PM

Abnormal embryologic fusion and canalization of the Müllerian ducts lead to congenital uterine abnormalities. Although these anomalies are often asymptomatic, they have a reported prevalence of approximately 2-4% in reproductive age women and up to 5-25% in women with adverse reproductive outcomes. These anomalies increase the risk of adverse pregnancy outcomes such as preterm birth, fetal growth restriction, malpresentation, cesarean delivery, and preeclampsia. Let us hear from Dr. Anagani as she walks us through all the uterine anomalies and their manifestations!

[Music] good evening everyone i'm dr niveda and i welcome you all on behalf of team netflix uh today i have the great honor of introducing our speaker for this evening uh dr manjula nagani she's the clinical director and hod of obstetrics and gynecology at care hospitals dr anagani is the recipient of numerous uh awards including uh and honors including the fourth highest honor or for any civilian in india the padma shri she also holds the guinness world record of removing the highest number of fibroids in a single operation a pioneer in laparoscopic and minimally invasive surgery dr anakini has successfully performed over 20 000 laparoscopic surgeries in gynecology apart from being recognized for her service excellence dr nagini has also uh has also been widely acknowledged for her noteworthy publications and research work in medicine and the screen is all yours now the state is all yours thank you vediota for a wonderful introduction pleasure is all mine and um but i'm sure you can see me as in my slides right so today malaria anomalies why do i always think that this is very important it makes a difference i think because these things happen without it's not a autogenic it is not what anybody would want it is something without their fault the lady is going to be uh getting something by by heredity or by because of the environmental hazards which we have started giving because of the endome endocrine disrupting chemicals which probably we might change later or genetics so with so many epigenetics and everything coming into play does she have to live with them or can we do something for the mullein anomalies if yes then what all can we do and how they have to do so these questions keep coming to us when these girls are referred to us from all over the india and the world for this so there is this is these are associated with a variety of chronological and obstetrical problems the goals when we think of management of these things are very clear are we thinking of restoring the normal architecture or are we thinking of getting back the function that is preservation of fertility because for few things we can do both for a few things we will not be able to do so our goal and we should be realistic and we should be very very clear what are we going to achieve so when we are counseling the patient and the parents of the family for it we should be very very clear right in the front about telling them the expectations in the realistic way however what we need to understand is normal or near normal architecture cannot always be achieved we are human we are not god and merely creating a normal cavity does not mean it is therapeutic because the vascularity is different and myomaterial and cervical function might still be abnormal so the clarity of what you can actually achieve what we can give is something which we should have as a doctor and the patient should have in the receiving receiving end most of the time they are usually asymptomatic they are detected during the evaluation of the common gynecological and obstetric problems in adolescent time majority of the time we might be able to pick up because they come to us if there is an obstruction they come to us with pelvic pain endometriosis amenorrhoea primary amino area so these are things when they come if that age is gone then again in the adults when they're being evaluated for infertility or recurrent pregnancy loss these are the things with which they come and then we detect them so signs and symptoms when they come like i said in gynecology it can be amenorrhoea hypomenorrhea pain dysmenorrhea if there is a septum associated endometriosis is very very high so we'll again have a congestive dysmenorrhea and abnormal vaginal bleeding dysphoronia if there are septum vaginal vertical or transverse they can still have dyspherunia they can have white discharges dystocia and delivery i have seen a case where there is a complete transverse septum still the patient went into till ninth day a month for delivery and on table we have seen this september recepted so that they can have a pregnancy uh delivery so hydrocorpus hematocorpus recurrent infections anything is common so fertility emotionally malaria anomalies do not have the conception or implantation but only except septum not much of the things are associated with infertility or sub fertility so while women are with anomalies undergoing ivf will have a similar outcomes with the normal you try also so obstacle complications because of the smaller child uteruses or the septum and on which the pregnancy might sit what we do see is increased risk of miscarriage corneal pregnancies because of the pregnancy in the rudimentary horn or bike on your tutorials prematurity because the size of uterus is small and it cannot die dilate intra trend growth restriction because of the vascularity effects on these abnormalities anti-partum postpartum bleedings cervical incompetence especially when there is a diadelphis or we have a unicornic uterus and abnormal presentations again because the size of the uterus being small pregnancy associated hypertension because of again abnormal vascularity and pathy cesarean deliveries are high and neutron ruptures also can happen these are rudimentary heart so in general obstetric complications are most common in women with receptor and least common in those with the arched uterus so when it comes to different pregnancy loss most of the women usually have a normal reproductive histories but increased when it is a first or second trimester losses which is very difficult to assess the reasons for that but there is a review which created 4500 women with recurrent pregnancy loss they found 13 percent had a uterine anomaly so it's not less 13 percent is associated with the anomalous uterine cavity can present with recurrent pregnancy loss preterm delivery is quite common because of decreased size of uterine cavity protein succlades is not recommended to them fetal survival with bicarbonate septic uterus and after high risk pregnancy care also similar in spite of whatever surgery you want to do it is about 50 to 60 percent with septum it can go up to 90 too the efficacy of surgery after lowering uh for lowering the rate of free preterm is also not established but in recent times we actually see that yes uh yeah genetically sometimes we do end up having a preterm because we don't want the uterus to rupture so this is a slide which tells that what is the rates of abortion which is maximum in case of a um septum or uv cornea tutorials and after correction in the the number of cases which can go to term it's 51 percent with septum and that preterm is seen in unicorn 8 and 65 percent can go to term in case of arcuate and 66 in 66 in arcuate and bicoordinated 65 percent so clinically to make it simplified i think this is the best way of understanding how malaria anomalies happen three common developmental defects one either they're completely absent that is a genesis cervical agencies uterine genes vaginal agencies juvenile anything absent simple second lateral fusion defects so you either have a septum you either have a unicorn uterus or you have a biconian uterus or you have an arcuate uterus or a diedell phase i hope i'm being very clear it's a longitudinal fusion effect second third would be vertical fusion defects so you have a vaginal septum cervical genesis or dysgenesis so if we simplify we can simplify this abnormalities like this it is much more easier for us to treat them then uh according to afs classification you have type one to six this is the way i'm going to come up with the cases and the management with a lot of videos for us to see how to manage it one is malaria genesis like i said so it can be vaginal cervical fungal tubal or combination type two is unicornate in unicornite you have presence or absence of rudimentary horn if it is absent it is b and if it is present it is again a 1 a 2 depending on with the endometrial cavity or without endometric cavity if endometrial cavity is present whether it is communicating or non communicating type 3 is digest phase 4 is bicarnate it can be complete partial or arcuate phi will be septum complete or partial finally six is des related anomalies where it's t shaped uterus and directed ons so this is the form on which we draw and then show that then ashrae came up with classification of uc vagina that is to make us easy uterine anomaly cervical anomaly and vegetarian normally in uterus starting from u0 is normal to u5 to a plastic and the c0 is normal cervix c4 to eplesia cervical vaginal is again normal vagina division so accordingly the septum centauri today is much more easier for us to do and write down there it can be like u0 with seeds c4 and b4 means it is cervical application with vaginal plasia with normal uterus so it is like that it is much more easier for us to do that so if you have to operate what are the indications of surgical repair if it comes to a genesis what are we trying to do we are trying to restore the normal anatomy simple but if it is congenital anomalies like uh anomalies then what are we treating can we treat and what all can be treat primarily the treatment is towards women with septum because it is easy to cut and the outcomes are good second bicon uterus yes we can look at if it is causing recurrent pregnancy look uh this thing then we can look as transman surgeries or obstructed hemi you try then you have a rudimentary horn excision so here we can give the surgical option to a genesis and conjointly trained anomalies which are having septa biconnect and obstructed in neutron unicarnate or archaeotutors usually are not candidates for any reconstructive procedures because surgery is not going to give them any outcome relief so only in these cases where the septum or you have a rudimentary horn or a bicone or a genesis such surgical options are given so let me take you all through this journey of mulinian genesis or abnormalities with all these classification first is that of a genesis or hypoplasia where uh early development failure of modern drugs for unknown reasons will be happening at around five weeks of gestation resulting in various degrees of hypoplasia of cervix uterus or upper two thirds of vagina so it can be vaginal agencies cervical agencies fungal agencies tubular combined the commonest is mrk syndrome so what are we aiming at repairing is restoration of anatomy so we all this way traditionally or years we have been having divide basically into pressure dietitian techniques and plastic surgical techniques so pressure dilation techniques is frank technique intermittent pressure dilatation in gram stool whereas a stool with a um you know the the there is a growth on it on which the girl keeps sitting on it so that it has intimated pressure there then the shitty procedure continuous precious technique where the dilator is put inside to create it and continuously it is uh closed then balloon with genoplasty all these are pressure direction techniques then we have the plastic surgical bra broadly into abby mackindo procedure and installer modifications of every mechanic so timing when do we do it just because we detected 13 14 years should we do it now ideally the girl should be psychologically mature and socially and sexually also mature so high estrogen levels will prevent the stenosis and patient can perform dietitian herself should be the basis so after 18 years this is the time when we do it and our technique is an anagani technique of new vagina which i'm going to show today because that's the easiest and best technique without any discomfort to the patient and the best outcomes without any complication rates least complication rates so every mechand has been split thickness graft is used to instead uh to put on the stent so that it can be inserted into the surgically created neo vagina modifications have been various modifications like peritoneum skin collapse amnion buccal mucosa bubble anything which can be used our modification in that anigani technique is used up in the seed that is oxidized regenerated cellulose material so what is the principle is when we put this non-adherent layer between the stent which is prepared that is a in the new vagina which we have created and the mold which we have put the epithelialization occurs in between these two layers and which prevents adherence so neo vagina creation is successfully dead with the least over time single procedure least mobility patient comfort can be done so let me take you all to this videos so this is the anagani technique where in malaria in a genesis we are going to use here you can see this is just the dimple so there is always a raffle between the um sub urethral area and the four shape so in either sides of the rashi they give vasopressin diluted 20 units in 100 ml of normal saline on either side is about 10 to 20 cc on either sides of the wrapper on which there is a septum which we call it so once that is done on either side you just give little nick in the center of the raffy and using the height dilator by shears technique we do on either sides of this rafe or the septum graded dilatations on either side now positioning is the most important thing the there will be an hyper extension hyperflexion of the thigh of about 130 um degrees and even a reflection at the knee joints so pelvis will be overhanging over the table so with this position the bladder and the bubble in the anatomical position which has to be there so you can see the graded dilatation of this highest gelatin relatives on either sides of the raffle finally the raphe in between is just cut so once that is cut there is a neojana which is created which is now we just have to make it more larger so you can see how simply how easily we created a vagina between the bladder and the urethra above you can see my assistant's finger in the rectum behind so we know where we are exactly without creating the cleaning of the rectum area so we go about nine to ten uh inches uh kephalad and four to five inches by sideways so till the peritoneum is reached we are dilating using again graded uh vaginal um speculums you can see slowly we are changing the uh the the retractors to the smaller single blade speculums and again we are dilating with a simple pressure till the uh kephal hydrogen then again a bigger speculums are then put so with this you can see we have reached almost the uh nine to ten zero till the peritoneum which we have done so this is the maximum which we can achieve which is much more better than what we expect see there that is the proton which is we can uh we can see it glistening so stop there once we reach it so later should be the maximum about four centimeters to five centimeters so this is what we achieve this is the length which is needed and the width which is needed which we achieve then we just put some zip guard or any vascular this thing and leave it there now we have to intern the vaginal mucosa because we need the normal mucus that developing normal sexual feelings normal vascularity normal anatomy so there is no sex side effects like secretions from the thing no abnormal hair coming because if you put a skin there you have a hair coming out and if you put gi tract there there will be ulcers forming so by putting the normal regenerating mucosa in turning inside this is the layer which is going to epithelialize between the graft which we are putting which between the stent which we are putting that is the mould which we create and the interseed so you can see that all the four there here if we are in turning the visual mucosa just imagine when you fall down on your skin only when the superficial layer goes you have a new skin which develops the regenerative technology that is the technology we use here that is a regenerative medicine so this uh general mucosa then grows inside uh between these two with in this layer and seeing is believing whatever i say is not which what is important what i can show you in the results what is important because till now we have finished about 95 surgeries of this i think it is already reached almost a century of doing a new vagina procedure since we started in 2005 so this is zipcard where we have put that now now we take a number eight glory in half glove and we take uh um either the the middle finger or the thumb as a mold so once we do it we put a vaseline gauze inside inside it a soft mould is now being prepared soft mold is being prepared so that it will not going to hurt the patient so this is just to create the space that that does not shelve inside so we put about four vaseline causes inside which gives the enough length of the normal penile length what is needed to create create the new vagina and keep the patency of the new vagina which we have created so once that is done we um then use the regular barber thread to close this uh mold which we have created so you can see so now we are just going to tie it then liberal amounts of antiseptic ointment is then put again we put a condom on it next so you can see the length is well appreciated what we need once next would be a liberal amount of antibiotic which is being put so for a micelle then you can put a metal gel also from icing then we have we put the condom on it which is something which does not stick onto it so we put a lot of holes into it so that there will not be any secretions just staggered inside which we need it to come out so again we try it again a liberal amount of antibiotic on it and intercedes then which is a addition prevention barrier is then being applied onto it there one intercede the second intercept to cover it completely so never never try to save money and then put only one use liberal amount of antibiotic cream and put a intercept so you can see the malt which is already prepared now you just watched viola the way that the whole mold goes so easily inside the neo vagina which we have created once that is put take out the specula and now the labia majora is just approximated above and below this new vagina which we have created now the post-op care is what is important she'll be in bed the girl comes to us for a holiday of one week's time stays in the hospital for about five to seven days and then go back home she walks in walks out without any attachments or anything police catherine is in situ for about five to seven days and she'll be on liquid diet for three to four days then we start them on a solid diet and after six days we remove the mold and the foliage catheter and then we give lip a lot of douches of the of normal saline then you can see the normal vaginal mucosa which forms i will show you how it looks on day seven then we remove the thing so that's it this is how new agenda nagani technique now this is in seventh grade you can see the glistening normal vaginal mucosa which comes in then we give a liberal amount of estrogen gel on a dilators we tell our teacher how to apply a dilator 10 minutes three times a day with liberal amount of estrogen because we want the epithelialization to become estrogenized so at the end of this is how it looks a normal visual mucosa normal is absolutely normal but thin then lot of estrogen gel four weeks post-op you can see the ease with which the speculum goes in without any pain the patient this is how four weeks post-op and this is eight weeks post-op the whole cusco's can be used and you can see here no lugosities because the pain is not there so this she's ready to have a normal sexual life and normal minimum of three months is given before she can get married and have a normal sexual life next comes the question when can she have a pregnancy and how can she have a pregnancy we advise surrogacy for these patients it is either the baby inside the other's uterus or others you trust inside your abdomen with lot of um some double immunosuppressants so we prefer the baby on the other thing and we had already three pregnancies and deliveries of these women with surrogate woman so this is the technique which we do for hnss next there is cervix also with this a genesis what can we do here this is a tricky point because if we create a cervix it might not function as well as normally because the motility it has to work towards pro uh tubal side when it's for the sperm and again during delivery also without getting stino's because of the fibrous tissue around the cervix so we have to have a good amount of counseling to the patient so we are looking at cervical vaginal reconstruction with uterine anastomosis plus or minus neo vagina if the veterinary is there and if there is a rudimentary horn that has to excise and it can be lap or open but restoration of anatomy here you can see your uterus you have two ions and janna is like this so can we get these both towards and create a cervix and all or remove this is what we are looking at so let me show you two videos here we created a new vagina first reach in the same technique which i have shown you before reach till the apex okay so once new vagina is created then we do a laparoscopy to see what's up what's happening inside here you can see a rudimentary horn which is functioning on one side and accent rudimentary horn on the other side so we separate uv fold first over then we open the rudimentary horn from top to bottom because i'm doing a retrograde technique in this case and once we do then i open from above downwards and opening is created and through the vagina we get the foliage there and this folic is put inside the uterus then the uterus is then sutured using a v-log or the um viking sutures so once uterus is there the police is pulled down then it sits on the vagina then you throw the channel anastomosis is then done so look at that the vagina is the police is pulled down then which electro vegetarian anastomosis is now being done here is a case of rudimentary on so cervix is not formed you know depth is not what we are looking at and these are the things which we could achieve this girl is normally menstruating now and if necessary sometimes we will have to do a regular dietations but this girl did not need all that so she was doing she's doing well even now enough she's married but pregnancy still is not a thing in this case because we have not looked at and we told her to go in for surrogacy in this case also because there's no cervix which are looking we can think of ioi in this case now the other case like i said is uterus is normal there is a cervix which is zero region which is zero the challenge is in this case is we can create new vagina neocervix and metometer drainage uterus anastomosis and we have to create deeper fornices and then keeping the patency of neocervix which we have created so here you can see very clearly fully developed uterus and both the ovaries and the tubes are good so now we open the uv fold push down the bladder where uv fold is being opened so always in mullein anomalies always look for the kidney anomalies associated other anomaly of the renal system so always save your bladder and save the kidney and the urethra of that so once that is done now we are creating a vaginal opening by using a new vagina is created and then we are seeing that that opening is in between the two uterus sacrals here so we have created and posterior called part of me done next anti-a colpotemy see that's the gauze piece which is put there this is the posture colopotomy leave it there then anterior bladder is pushed out now we are doing an anterior call pattern so once we know we know we have we can create a cervix which can be pulled out then depth of the furnaces are then has to be caught so this what we have created we are pulling it down that is a new cervix which we have created and around the cervix we keep take sutures in such that we are anastomosing the cervix to the vagina so we create this uh cervix your neocervics and the cervical vaginal anastomosis is being done and the furnaces are more deeper we we uh make the furnaces deeper so that we can have a proper cervix without getting flushed then through the cervix once that hematometer is drained we put a silicon catheter into the form into the uterus so that uh uterus patency can be maintained so now you can see the uterus is absolutely normal and the anastomosis holds good this is a train which will leave it so this is something which we can you know these patients can go in for again with you by a normal pregnancy so then we have a unicorn youtubers which we can uh talk about that is a class two where you have unicorn so what you have one molarian that is functioning one molar inductor is absent so you have four possible subtypes can develop that is like i said one is absolute rudimentary horn second is you have a rudimentary one which can be non-cavitatory no problem patient will not have pain then you can have a cavitatory which is communicating again patient will not have pain but if it's a non-communicating but cavitatory one this is one which causes severe abdominal pain subsequently requiring remo intervention so mri or ultrasound can identify usually an excision of the obstructed rudimentary blind horn is what we are looking at to prevent the endometriosis by eliminating reflux and development of pregnancy in it and causing the abstract the rupture of the uterus so the obstructed rudimentary non-commuting internet horn should be removed laparoscopically so this is an example where the the girl the the kid she was having a recurring pairing abdomen first time she was operated in the village uh where they did laparoscopy and aspirated and left it next second time she was referred to us then when she came to us this is how it looked with hematomatra and everything so like i said before the first step to be done is always the uv fold opening and pushing the bladder down so we do that first push the platter down like uh saving is your bladder and the ureters are the most important point then the next thing we did is first we opened where it was already opened before and aspirated the whole uh hematoma because we know there is definitely one functioning um unicorn uterus so we once we have aspirated everything now we know that is the normal uterus unique cornea to truss which is in continuation with that the hysteroscopy revealed a normal unique cornea uterus with normal posture of one side and a non-communicating rudimentary horn which is cavitatory then after taking the consent this rudimentary cavitatory non-communicating horn is excised then abnormal patient can go in for normal life after that where you can also have a pregnancy which is normal so if there is a rudimentary one which is not communicating we can just remove the rudimentary horn which is not communicating that we are doing an inverted laparoscopy workshop third class is a dietal phase where it is non-fusion of both malaria ducts individual horns are fully developed almost normal so we can have a furnace left with two services longitudinal transverse regional septum also may be present generally the duplication is limited to uterus and cervix but sometimes we can have bi-collis 15 to 20 percent will have unilateral anomalies and then um level 65 percent because of the absorpted hemi that is obira syndrome will need a surgical correction 75 percent of the septum is there then we have to cut it off um as this is going to defer the vaginal delivery or this pyruvia can be there so metroplastic can be considered for women with pelvic pain recurrent miscarriages or hdl free term otherwise we can just leave the dietary phase vermont alone we don't have to touch it so when it comes to bike on it it is again partial non-fusion the difference is that these these corners are not well developed the uh the the sulcus or the fundus is the indentation of more than one centimeter and the vagina surface is usually normal the central myometrium can extend in cervical loss or it can be again bicarbonate by college too but what is very important is the cornu are smaller than the die delicious uterus so you can have the complete partial or minimal so pregnancy outcomes are very good we do not have to do surgically but however if there is a recurrent pregnancy loss we can do a surgical procedure that is a stressful procedure surgical correction is not warranted in a symptomatic moment but abnormalities typically does not prevent a conception or implantation this is where we look at stressful procedure where it is bicarbonate uterus we take an incision here and here and then we start unifying the both the surgeries or if we have a myometrium then we can have an in cutting from the uterus and cut it and then use the suturing of the like a unification surgery classify is one which definitely needs surgery that is septate because it's the final uh fibrous septum which is failing to resolve so it can be muscular or fibrous or combination of gold and this has a poorest substitutional outcomes so it might need two to three settings or depending on your experience you can talk to them ninety five percent of the time you can do in single septum or if starts bleeding then you can have a two second the frontal clip is less than five centimeter deep the the both the important thing is to differentiate between bicone weight and the septum because the reproductive outcomes are very very uh different the fundal schlep the intercontinental distance is usually less than four centimeter when it comes to septum more than four centimeters when it comes to the bicone so clinical presentation is primary or secondary fertility poor reproductive outcome recurrent pregnancy losses and abortions are more dysphoria with associated endometriosis primary infertility again recurrence by spontaneous abortions or primary term delivery go in and do the surgery this is one thing i always tell that cn treat applies retreat applies for endometriosis and treat applies for separate uterus procedure of choice would be trans cervical hydroscopic lysis of concrete this thing we can because it is least mobility no need of abdominal surgery faster return to normal less infections we can attempt vaginal delivery uh also in this case various techniques like scissor or even rigid scissors or you know the high frequency needle or whatever you want the knife collins knife can be utilized um the the procedure is to cut or remove the septum the goal is to see that there is a cavity is widened and there is no scepter which is there pre-operative thinning is not necessary but if two services are there keep the fully in between end point when there is a fresh bleeding or visualization of both corn in the same field free movement of scope from one side to other and closer visualization of hysteroscopic light under lap post stop no treatment is necessary usually but we give e plus p for three cycles estrogen and progesterone indication for representative plastics if you are having more than one centimeter um septum which is left over outcome is very good with 64 percent oppressive fitness rate but i think it never think we had as high as 80 to 90 pregnancy rates now let me show you some beautiful videos two more videos of the septum you can see let's see and say it is septum what we are dealing with less than one centimeter in the indentation here is a beautiful austria the other one which is having a beautiful austria in this case we are using the collins knife because there is a muscular septum which is there and i want to finish it in one sitting and not two settings so by the way scissor can be utilized if it's a fibrous septum it's ever thing so it's always under vision and one side we start doing and then go to the other side to make the septum thinner you do it and remember the see look at the way the septum gives way 0.5 centimeter away from the austria you stop it and then you thin it from this side again and in by doing this we are making it more thinner of septum and then we do in the center so first from the right side next from the left side then from the center backwards always under vision so you can see the cavity is open both oscillations on the same thing the full thing you can go and the flesh bleeding is the end point next you see you have so many times robert's uterus here everything looks like unicornic uterus now when you do here uterus is normal it's not unicornate it just you said unicorn it you do a die test one side is positive one side is absent so you don't do anything again but you know uterus is good then you do hysteroscopy you see a beautiful unicorn your uterus and there is no communication to the other side is this a unique ornate no we have done laparoscopy we know it is not unique on it and uterus is good so that's when you this is you know this is robert's uterus this is the suha levantes line so along the suha levante's line which is the because of the diet that is a blue dye which is the methylene blue dye and along the fibrous line by the fibrous thing takes up the um the line so you take the use the scissor and start opening under vision at one point above the internal horse so once we start opening in the horizontal position you can because this is a fibrous you will not bleed so if you're still worried you can give association into the cervix so you see now you're entering into the other side of the cavity so this is a full-length septum which has closed the cervix and created a law robert's uterus so once you go inside go inside and see look at the austria then now the full-length septum is now being opened till the fun does so this is how we need to know never give up you know what we are dealing and then take care of the surgery as it has to be because the best outcomes is only by the best surgery so you can see in the center under vision in the fibrous line tell the phrase here we are using scissor to open it completely now you do a die test again at the end of it you can see how the die test comes positive so this is how we can achieve the normal patency so the other technique if you have to do is the transmy material repair that is the you have jones metroplasty and tom king's metroplasty jones is when we dissect the whole uh um why am i telling also i'll tell you sometimes we might end up doing it resecting the whole septum and then suturing anteriorly and posteriorly like this now tompkin says we just incise without resecting any tissue so resect it and anti-randy or post your post year you just switch up why did i say because in one case i had to end up doing modified tompkins because we end up having an incision so this is how it is in septic uterus when we were completely uh doing the septal resection we ended up opening into the um abdominal cavity so that we had even before the soul septum is cut now the option is leave it come back after three months to resuture it or finish it using a modified tompkins procedure from above so we opted from the other thing so when we did it see now when we went on doing we perforated so we opened it from above we did a modified laparoscopic tom canes where now the septum is totally cut from above and then on either sides of the septum we went from above till the internal oz and we cut the septum till the interlocks there you can see the whole septum is now cut that's it then we did a tube test by using them and then the whole myometrium is now sutured the end of it we can really repeat a histoscope to see how the cavity is intact and then we end up giving e plus p it is as good as you are doing a mimectomy so don't get worried you do the justice to the patient that is what this is a and view where the uterus is intact with the cavity with the consideration materials and nothing nothing is overflowing into the abdomen at the end of it so then we put the intercede so that there won't be any additions bear with me another five minutes then we can have a question answer session so outcomes are very very good it will be as high as 90 percent pregnancy rate both with abdominal or with hysteroscopy infertility sub fertility is there also it's been created various studies which say that metaplasty is the best positive effect whether uses scissor or whether it is bipolar the outcomes are good fertility is best after doing it so reduction of pregnancy complication will be seen after doing a resection but is the frequency of malpra male presentation retained placenta iugr everything comes down so whether there's improvement in preterm birthday minimal data is available because most of them we iatrogenically do a uh preterm with irritable uterus reduction of dysmenorrhea is drastically comes down with hysteroscopic technique the complication we should know but we have gone very close sometimes rupture can happen and caesarean is something which is if it is very thin recommended most of the cases i end up doing cesarean for this because i do not want to have a risk of rupture because it is infertility cases which i'm treating post-separate section which is you can come confirm the thing then come to the class six that is accurate near complete reception we do not do anything for that it's a highly controversial but sometimes when the when the infertility specialist start doing the um the touch technique just inserting it further narration to increase so this started getting that we just cut little bit of it so that you know um generally thought it is compatible with normal pregnancy and delivery final class is the es related where you can have a transverse septum surface circumferential riches cervical collars smaller uterine cavities shortened upper uterine segments t shaped or irregular oviduct abnormalities so what do we do little metroplasty and these are the cases where insect clutch is needed when the pregnancy so this is one such cases where you can see by the shape of it it's a t-shaped uterus even outside and inside so and the cavity is very very small so we here we do apart from the metroplex total metroplasty of superficial and even the later metroplasty so both osteoare never visualized undivision because it is a t shape then you go with the scissor or college knife do the central uh metroplasty first now later on both right and left you can see how we are doing the cutting the notches of lateral metaplasty till the ostia is visualized so it should the cavity should be in such a way that both austria should be visualized when the scope is at the level of internal os this is the left metroplasty which we are doing so at the end of it cavity is still well formed with central and right and lateral metroplasty and the osteo are well visualized under one viewpoint if necessary in recent times we start putting a autologous stem cell in such cases so that the endometrium develops normally you can see the osteo is now little visualized then they are doing and then the digest everything you can see the giveaway of the uterus so to conclude um patient is asymptomatic we don't have to do anything surgical repair is to restore anatomy or fertility in a genesis it is anatomy obstructed hemorrhage we just have to remove the horn died alphas we don't have to do anything bike on it only if there's recurrent pregnancy loss then only we do something separate we should uh operate if more than one centimeters of septum is left over second seating is recommended and complex nutrient anomaly cases option of adoption or surrogacy should be addressed and thank you richard thank you netflix and uh thank you nivedita for giving me this opportunity thank you amit our honor that you are on netflix uh thank you so much and it was a wonderful wonderful presentation they very systematically explain and their videos were amazing to watch very beautiful videos we have a lot of compliments actually about the session being a very wonderful presentation and uh so we have one question uh by dr you could explain a little more about this thank you anita for this question i was waiting for everybody to ask that question because this is something everybody out there should be looking out for when you are doing infertility thing we all do a methylene blue test when we do a methylenedo test the way to know if the subseptum or not is by visualizing 70's line what is it the smooth endometrial lining will never hold catch hold of the methylene blue like that but if it is a fibrotic element there that holds on to the methylene blue that means that we are dealing with an arcuate or a subseptic or a separate uterus so when you see a suha level this line which is a blue line which is the methylene blue line which goes there that will help us in two things telling us yes there is an anomaly second helping us guide the resection along the resection that is the fibrous element that is the a vascular line that is where you have to actually cut without compromising the quality of the myometrium without compromising with the vascularity of the uterus so all of you out there please understand what is soil empty line which is helping us with the surgery thank you so we have another question uh what is the or which is the most commonly encountered anomaly that you have seen in your practice septum septum is the most common especially with the increased rates of endometriosis you have to always look out for septum because the retrograde menstruation leading to endometriosis is one of the thing which we have to understand so commonest would be sub-septum to be precise but because ours is a tertiary kid with lot of references from everywhere your vagina comes next then comes the unicorn weight and everything else but septum stops everything ah thank you so much ma'am for coming on to netflix and we'll see you again good night take care

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Dr. Murtuza Zozwala & 1169 others

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dr. Manjula  Anagani

Dr. Manjula Anagani

Padmashree Awardee | Laproscopic Surgeon | Guinness World Record Holder for removing largest number of uterine fibroids | Co-founder - Pratyusha

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dr. Manjula  Anagani

Dr. Manjula Anagani

Padmashree Awardee | Laproscopic Surgeon | Gu...

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