CHAPTER 16

Unification of Bicornuate Uterus

Incomplete fusion of the müllerian ducts leads to a variety of disorders, ranging from subseptate uterus to complete failure of fusion with uterus didelphys (Fig. 16–1). The subseptate uterus is treated hysteroscopically by sectioning the septum with a scissors, laser, or electrosurgical device. The uterus didelphys requires no treatment other than section of the vaginal septum to prevent traumatic tears (Fig. 16–2).

The bicornuate uterus may require a unification procedure to enhance the size of the uterine cavity if reproductive outcome problems are demonstrated (e.g., abortion, preterm labor) (see Figs. 16–1 and 16–3).

Diagnostic differentiation between a septate and a bicornuate uterus cannot be accomplished by hysteroscopy or by hysterosalpingography (Fig. 16–4). The diagnosis is made laparoscopically by observing the broad and indented fundus, the typical heart-shaped configuration. A hysterogram is performed to gain some insight into the size and configuration of the divided cavities (Fig. 16–5A–C).

At laparotomy traction, sutures are placed at each fundal extreme away from the site of transection. A 1 : 200 vasopressin solution is injected into the uterus along and within the lines of resection (Fig. 16–6). A wedge-shaped incision is made through the body and fundus of the uterus in the vertical plane (Figs. 16–7A, B). The resultant tissue removed includes the heart-shaped defect (Fig. 16–7C). The two separate cavities are now ready to be joined to form a single uterine cavity (Figs. 16–7D, E). Closure is made beginning on the posterior wall with simple or figure-of-8 stitches placed submucosally and carried intramuscularly (Figs. 16–8A, B). The closure is carried over the fundus and is completed on the anterior surface (Fig. 16–8C). The author typically uses 0 Vicryl for the intramuscular layer (Fig. 16–8D

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