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Culdoscopy to examine the contour of the uterus before hysteroscopic metroplasty for uterine septum

A 22 year old woman was referred to our department for consideration of metroplasty for a uterine septum. In 1996 she had gone into labour at 30 weeks of gestation and had been delivered spontaneously of a male infant. In 1999 she had an emergency caesarean section at 26 weeks of gestation for a prolonged fetal bradycardia with an oblique breech presentation, and was noted to have a subseptate uterus at the time of surgery. Subsequent ultrasound scans, however, gave the appearances of a bicornuate uterus. Due to her poor obstetric history, it was felt appropriate to correct the uterine anomaly, and it was hoped that this could be achieved hysteroscopically. In view of the conflicting diagnosis between a subseptate and bicornuate uterus, the woman agreed to culdoscopy and then hysteroscopic metroplasty if a bicornuate uterus was excluded. Clinical examination revealed a mobile normal sized anteverted uterus with no adnexal masses. Culdoscopy was performed under general anaesthesia with the woman in the lithotomy position. The posterior lip of the cervix was grasped and pushed cephalad to stretch the posterior fornix. A small stab incision was made in the midline 2 cm below the posterior margin of the cervix. A Veress needle was inserted through the incision into the peritoneal cavity, followed by a dilator and then a cannula 3.5 mm in diameter. The Veress needle and dilator were removed and replaced by a 2.7 mm, 30 degree, rigid, wideangled endoscope. Once correct placement was confirmed, irrigation with warm normal saline was started. Culdoscopy provided a detailed image of the posterior aspect of the uterus confirming a normal contour and excluding a diagnosis of a bicornuate uterus. Examination of the rest of pelvis showed normal anatomy with no pelvic adhesions or evidence of endometriosis (Fig. 1). We proceeded with hysteroscopic metroplasty using a 27 French-gauge resectoscope fitted with a Collins knife electrode.