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Art Of Hysteroscopy

Art Of Hysteroscopy

Hysteroscopy is an endoscopic surgical procedure performed for evaluation or treatment of the endometrial cavity, tubal ostia, or endocervical canal problems. It has a broad spectrum of indications.

What is a hysteroscopy used for?

  • Diagnostic purposes such as premenopausal or postmenopausal uterine bleeding,
  • Evaluation of infertility,
  • Recurrent miscarriage,
  • Treatment purposes such as for restoration of uterine cavity in intrauterine synechia cases,
  • Congenital uterine anomalies,
  • Removal of intrauterine polyps and fibroids and,
  • Retrieval of a lost intrauterine contraceptive device (IUD),
  • Hysteroscopic sterilization,
  • Retained products of conception,
  • Endometrial ablation.

What is office hysteroscopy?

Office hysteroscopy is used for either diagnostic or minor operative procedures including abnormal uterine bleding, submucous fibroids, endometrial polyps and intrauterine synchecia, removal of uterine septum. Office hysteroscopy is safe, with a low incidence of serious complications and failure rate.

Performing the procedure in the office with no speculum, tenaculum, or anesthesia will enable the patient comfort so that the patient can return to normal activities at the earliest. Major barriers to successful office hysteroscopy include pain, cervical stenosis, and poor visualization of the cervix.

Therefore, preoperative patient selection and counseling are very important. Poor candidates for office hysteroscopy include patients who have cervical stenosis, high levels of anxiety, comorbidities, limited mobility, or significant uterine pathology requiring operative procedures. Minimal distention pressure for adequate visualization will reduce patient discomfort. Performing any procedure requiring >3 L of fluid unless a weighted monitoring system is available is not recommended.

Equipment generally needed to perform hysteroscopic procedures in the office includes a hysteroscope with an outer sheath of less than 5 mm in outer diameter, distending media and infusion system, operative instrumentation, and a light source.

Although it is possible for the surgeon to look directly into the eyepiece, cameras and video monitoring systems make it possible to obtain photographs and video and enable the patient to see images.

What is operative hysteroscopy?

Operative hysteroscopy incorporates the use of mechanical, electrosurgical, or laser instruments to treat intracavitary pathologies such as removal of endometrial polyps, submucous fibroids, septa and adhesions or to perform targeted biopsy or an endometrial ablation/resection.

Resectoscopes typically consist of a 7 to 9 mm sheath. The hysteroscopic morcellator consists of a rotary blade that cuts lesions; tissue is then aspirated through the morcellator. The smaller hysteroscopic morcellators are used for endometrial polypectomy in an outpatient setting whereas larger hysteroscopic morcellators can remove prominent submucosal fibroids.

Which instruments are used in a hysteroscopy?

Diagnostic and operative hysteroscopes can vary from traditionally available rigid diagnostic (3-mm) and operative (5-mm) hysteroscopes to more complex state-of-the-art modern equipment including flexible fibrescopes, miniaturised semi-rigid/rigid diagnostic hysteroscopes and rigid operative (3.8–5-mm) hysteroscopes.

Flexible hysteroscopes range in diameter from 2.7-5 mm and the flexiple tip deflects in two directions ranging from 100 degrees to 180 degrees. Rigid telescopes are available in different angles of vision ranging from 0 to 30 degrees. Most diagnostic scopes are 30° allowing a thorough inspection of uterine walls, cornual recesses and tubal ostia with minimal movement of the shaft. Their external diameters vary from 1.2 mm to 4 mm.

The single flow sheath of the rigid hysteroscope is used in combination with a 4- to 5-mm outer sheath to create a continuous flow system and permit the passage of semirigid instruments such as scissors, graspers and biopsy forceps for endometrial biopsy, tubal cannulation, or intrauterine surgery.

Operative hysteroscopes are used to remove endocervical or endometrial lesions or to perform an endometrial ablation/resection. Operative hysteroscopes typically range from 8 mm to 10 mm in diameter and contain a retractable hand piece wherein electrosurgical tips, laser devices, or mechanical instruments may be attached.

Currently, there are three types of operative hysteroscopes: Operative sheath with instruments inserted through channels or fixed to the sheath, electrosurgical resectoscope and hysteroscopic morcellator.

What are the energy sources used in hysteroscopy?

Different types of energy have been used for operative hysteroscopy including laser, unipolar or bipolar energies. Laser is rarely used in modern hysteroscopic procedures. The most commonly used energy for hysteroscopic surgery is unipolar energy. To avoid dispersion of the electrical current, a low-viscosity distending medium such as 1.5% glycine is needed. Compared to normal saline, its use is associated with a high risk of fluid overload.

Accordingly, a versatile bipolar electrosurgery system was developed allowing operative hysteroscopy using normal saline as a distending medium. As the electrical current is confined, it is safer than a unipolar device. This bipolar device can be used for cutting, coagulation or tissue vaporization including treatment of large endometrial polyps and submucosal myomas under 2 cm.

How uterine distention is maintained during hysteroscopy?

Hysteroscopy enables visualisation of the uterine cavity and allows the diagnosis and surgical treatment of intrauterine pathology. To achieve this, the uterine cavity needs to be distended by a medium which could either be fluid or carbon Dioxide.

Carbon Dioxide Gas

Carbon dioxide (CO2),a colorless gas, is used in outpatient settings for diagnostic purposes only as bleeding during operative procedures obscures visibility. The advantages of its use include the ease of cleaning and maintaining equipment and a clear view of the cavity in the absence of active bleeding or bubbles. Most gynecologists have abandoned the use of CO2 gas. The mixture of CO2 gas and fluid such as blood produces bubbles that impair visualization. In addition, it carries the risk of air embolism.

Fluid Media

Fluid media are used for operative procedures, as they allow continuous irrigation giving a clear picture and enable use of both mechanical and electrosurgical instruments. Many distending media have been used for hysteroscopy. Generally, normal saline is preferred to carbon dioxide as a distension medium as it allows improved image quality, permits quicker procedure, reduces the vasovagal episodes and has an added advantage of acting as a conducting medium for the use of bipolar energy for operative hysteroscopy. Normal saline bags of 1- and 3-l volumes should be stocked. It is better to use warmed saline (room temperature).

Delivery of the distension medium can be safely and effectively achieved using: simple gravity, pressure bags or automated delivery systems. It is practical to use pressure bags with a squeeze bulb to achieve adequate uterine distension (80–120 mmHg) with normal saline during routine hysteroscopy. Automated pressure delivery system is recommended in order to maintain a constant intrauterine pressure and a clear view intraoperatively as well as accurate fluid deficit surveillance which is advantageous for prolonged cases such as endometrial resection or hysteroscopic myomectomy.

Fluid distending media can be classified into two main types: electrolyte-rich (conducting) media, for example, normal saline; and electrolyte-poor (nonconducting) media. However, it is now possible to use electrolyte media with bipolar electrosurgical systems. It also is important to understand which media are hypo-osmolar.

Electrolyte-Poor Fluid

Electrolyte-Poor fluids include glycine, 1.5% (osmolality 200 mOsmol/kg -hypo-osmolar); sorbitol, 3% (hypo-osmolar); and mannitol, 5% (which is iso-osmolar to plasma; 285 mOsmol/kg). Glycine 1.5% is one of the most commonly used nonconducting media.

Devices that use monopolar energy such as the traditional resectoscope must only be used with nonconducting media to prevent potential injury to the patient. They are compatible with radio-frequency energy, which cuts, desiccates, and fulgurates intrauterine tissue. Excessive absorption of hypo-osmolar fluids can cause hyponatremia, hyperammonemia, and decreased serum osmolality, with the potential for seizures, cerebral edema, and death. Some clinicians have recommended mannitol, 5%, which is iso-osmolar and acts as its own diuretic. It may cause hyponatremia, but not decreased serum osmolality.

The use of a hyperosmolar solution of 32% dextran 70 has been abandoned. Its use even in low volumes has been associated with vascular overload and subsequent heart failure, pulmonary oedema and anaphylaxis. Further, it tends to caramelize quickly on instruments leading to damage.

Electrolyte-Containing Fluid

Normal saline solution and lactated Ringer’s solution are readily available and are isotonic. These solutions can be used during diagnostic hysteroscopy and in operative cases where mechanical, laser, or bipolar energy is used. The risk of hyponatremia and decreased serum osmolality is low but careful attention should be paid to fluid input and output, with particular attention to the fluid deficit as pulmonary edema and congestive heart failure can still occur.

Uterine illumination during hysteroscopy

Most light sources are either Tungsten or cold xenon (175 watt). Either type of lamp provides adequate illumination for operative procedures, photography, and videotaping for hysteroscopy. Xenon lamps are more expensive than halogen ones.

Illumination is primarily a function of the power of the light and the light transmission properties of the light head, but it is also influenced by the size and tissue propertises of the light head. Light heads are either Fibre optic or Liquid.

What do you have to know before hysteroscopy procedure?

Patient preparation should start from the patient's first presentation. You and your doctor should discuss the hysteroscopic procedure, its risks and benefits.

In premenopausal women with regular periods, the optimal timing for hysteroscopic procedures is just after your period stops when the endometrial lining is the thinnest. Some women with unpredictable menses can be scheduled at any time for operative hysteroscopy.

How safe is hysteroscopy?

Hysteroscopy is a very safe procedure. Complications from hysteroscopy are very rare, but some are potentially life threatening. The most common perioperative complications associated with operative hysteroscopy were uterine perforation (0.12%),resection of fibroids had the highest risk of uterine perforation (0.15%),fluid-overload syndrome occurred in 0.06%. The incidence of intra-operative hemorrhage in operative hysteroscopy ranged between 0.03 and 0.1%. In the absence of uterine perforation, heavy intra-operative bleeding occurred in 0.03% of the patients, in 83.3% cases during endometrial ablation.

Conclusion

Hysteroscopy is considered the gold standard for the evaluation and restoring of intracavitary problems in recent years with advanced experience of physicians, smaller diameter hysteroscopes, and common use of office-based procedures. It is minimally invasive and can be used with a high degree of safety.

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