Conventional bipolar resectoscopy is widely recognized as the first choice for major hysteroscopic operations. We recently proposed an alternative approach to operative hysteroscopy called Integrated Bigatti Shaver (IBS®) that improves visualization during the procedure, reducing several problems of conventional resectoscopy such as fluid overload, water intoxication, uterine perforation and long surgeon's learning curve. In cooperation with Karl Storz GmbH & Co., we created a new shaving system that, when introduced through the straight operative channel of a panoramic 90°optic, allows performance of many major hysteroscopic operations. The present randomised comparative study was designed to compare 50 cases performed with conventional bipolar resectoscope with 50 cases performed with the IBS®. Several types of major intrauterine pathologies such as polyps and submucosal myomas (according to ESGE classification) were included in the study. Two cases of via falsa were reported. In one case, the procedure was immediately stopped with no further complication for the patient, whereas in the second patient, the complication did not compromise the operative course. Dilatation time, overall procedure time, resection time and fluid balance were carefully monitored during each procedure in the two groups. The aim of the study was to compare the two techniques to confirm several advantages offered by the IBS® such as reduced dilatation of the cervix, better visualization during the procedure because tissue chips are removed at the same time as the resection, no need for coagulation or cutting current, utilization of normal saline and a much faster learning curve.

This study presents an animal model for the observation of adhesion formation, from a vascular viewpoint. In 60 Wistar rats, a 4 cm midline incision was made and a 0.5 cm square piece of silastic 0.2 mm thick was fixed on the right side of the peritoneum with two separate angular stitches of nylon 9/0. The rats were randomized in six groups of 10 animals and were operated on again on days 2, 4, 6, 8, 10 and 12 respectively. Biopsies for scanning electron microscopy were obtained by resecting a 2 x 2 cm square of parietal peritoneum around and covering the silastic patch. Foreign body reaction induced by the silastic patch and ischaemia caused by stitching are the stimuli for adhesion formation. The results showed a gradual progression in the type and tenacity of adhesion formation. The maximal degree of peritoneal reactive angiogenesis was noted between days 8 and 12, together with a decrease and a redistribution in the extent of adhesions. In the early stages, vascularization is part of the organization of adhesions while their extent is limited. Two parallel mechanisms take part in trauma healing: while omento-parietal adhesions are vascularized, new peritoneal tissue with its vascular network develops and covers the silastic surface and the traumatized area. This theory is supported by the presence of fibroblasts differentiating into mesothelial cells on day 8. Theoretically, a valid treatment in preventing adhesion formation should increase the peritoneal neoangiogenesis and the repair of peritoneal lesions, but at the same time prevent the vascularization of adhesions. The present model offers the possibility of testing the effect of any treatment or device for preventing post-operative adhesions in a relatively short time.

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At present, conventional resectoscopy can be considered the gold standard procedure for major hysteroscopic operations [1]. Despite well-recognized advantages of resectoscopy, several problems, such as fluid overload, uterine perforation due to monopolar or bipolar current, lack of visualization resulting in a time-consuming procedure, and long learning curve, remain still unsolved. We have made, in cooperation with Karl Storz GmbH & Co., a new shaving system that, introduced through a straight operative channel of a panoramic 90°optic, allows to perform all kinds of major operative procedures such as polypectomy, G0, G1, and G2, submucosal myomectomy, and endometrial ablation. We have performed 44 operative hysteroscopy, including 24 polyps, 15 submucosal myomas, two polyps + submucosal myomas, three endometrial ablations. The polyps' size ranged from 5 to 40 mm, and all procedures were performed with the IBS®. The mean time for polyps' resection was 3′28″. Ten cases of myoma's resection were performed exclusively with the IBS® of which four Type 0, two Type 1, four Type 2, the size ranged from 10 to 30 mm and the mean resection time was 14′. For five cases of myoma's resection, we started the operation with the IBS®, and we ended the procedure with the conventional monopolar resectoscope. The myomas' size ranged from 20 to 40 mm of which three Type 0, two Type 2, and the mean resection time was 32′. When the IBS® was used, the dilatation number reached 8.5 Hegar size that increased to 9.5 when we switched to conventional resectoscopy. We used sorbitol-mannitol at the beginning of the study and in all cases that we suspected the possibility of conversion to conventional monopolar resectoscope. As our learning curve improved, we switched to normal saline. No coagulation was needed when the IBS® was used. Two overload complications occurred: one was not depending on the method but to a malfunctioning of the Endomat® system. The second complication occurred during a G2-3 cm myoma's resection. This preliminary study is intended to evaluate the feasibility of this new technique that offers considerable advantages such as reduced dilatation of the cervix, better visualization during the procedure as tissue chips are removed at the same time of resection, no coagulation or cutting current is needed, the use of normal saline instead of sorbitol and mannitol, and a much faster learning curve.

From June 2011 to June 2013, all hysteroscopic myoma resections at the Ospedale San Giuseppe of Milan were performed using either the IBS® or the Versapoint® bipolar resectoscope. Dilatation time of the cervical canal, resection time, fluid balance, and complete single-stage removal of the myoma have been studied. The outcome was stratified for groups of myomas larger and smaller than 3 cm. Seventy-six myomectomies were performed with the IBS® and 51 with the Versapoint®. Both groups had a similar distribution of difficult cases like G2 and larger than 3 cm myomas. The results show no difference in terms of cervical dilatation, resection time, and fluid deficit between the two groups, but, for myomas less than 3 cm and G2 myomas, the IBS® has been able to treat respectively 93.5 % (p=0.3753) and 62.5 % (p=0.5491) of cases in a single step procedure. The overall number of necessary second procedures has been statistically significantly less in the IBS® Group than in the Versapoint® Group (p=0.0067). Although no significative difference in terms of time of resection, the IBS® has proven to be able to approach all kind of submucosal myomas in a single-step procedure and in a very precise and easy way. The IBS® can be considered a valid alternative to the conventional resectoscope.