Hysteroscopy

Author: Dr. Kevin Quadros (MBBS – MD OBGY)

It is a technique in which a telescope is introduced into the cervical canal and uterine cavity for visualization of the endocervical canal &uterine cavity. Fibroptically transmitted light provides illumination. The Video camera attached to the scope allows monitoring on a T.V screen with facility for magnification.

Equipments Used:

A Hysteroscopic  set which includes:

1. Telescope Flexible/Rigid, Angle of view 0 30 70.
2. Uterine Distention System
3. Cannula: Diagnostic, Operative, Resectoscope.
4. Ancillary instruments: Scissors, Forceps, Loops.
5. D & C Set.
6. Video camera & monitor.

Indications are: Diagnostic:

1. Abnormal anomaly uterine bleeding
2. Infertility
3. Lost IUCD
4. Recurrent abortion
5. Suspected Ca endometrium
6. Intra-uterine space occupying lesion
7. Congenital

OPERATIVE:

1. Polypectomy
2. Myomectomy
3. Adheosiolysis
4. Metroplasty
5. Tubal stenting
6. Endometrial Ablation

Contraindications: Medical

1. Patient unfit for operation
2. Bleeding disorder
3. Fulminant infection
4. Pregnancy

Surgical:

1. Uterine perforation
2. Acute genital infection
3. Confirmed carcinoma.

Complications:

1. Anaesthesia related complications.
2. Instrumentation complications eg. perforation, false passage, difficult dilatation.
3. Distention media complications eg. TURP Syndrome
4. Operative  complications eg. Cautery burns, Haemorrhage and Sepsis.

Procedures done: Hysteroscopically are:

1. METROPLASTY: Synonymous with uteroplasty or hysteroplasty. Is plastic surgery or Reconstructive surgery on the interior of the uterus with the use of the hysteroscope. Visualisation and manipulation of the interior of the uterus was indeed a milestone in the treatment of Infertility and Recurrent Pregnancy Loss (RPL).
2. Transcervical resection of endometrium: TCRE affords reasonable longterm effectiveness in the treatment of dysfunctional uterine bleeding.Can also be useful for management of benign intracavitary pathology like submucous myomas or polyps
3. Adhesiolysis (Ashermans syndrome)
4. Cervical biopsy
5. Dilatation and curettage
6. Endometrial and uterine biopsy
7. Polypectomy and myomectomy
8. Removal of embedded IUD
9. Cannulation of fallopian tubes

Procedure:

Hysteroscopy   has   been   done   in   the   hospital, surgical centers and the office. It is best done when the endometrium is relatively thin, that is after a menstruation. Diagnostic can easily be done in an office or clinic setting on suitably selected patients. Local anesthesia can be used. Simple operative hysteroscopy can also be done in an office or clinic setting. Analgesics are not always necessary.  A paracervical  block may be used using a Lidocaine injection in the upper part of the cervix. The patient is in a lithotomic position during the procedure.  Hysteroscopic intervention can also be done under general anesthesia (endotracheal or laryngeal mask) or Monitored Anesthesia Care (MAC). Prophylactic antibiotics are not necessary.

Cervical dilation:

The diameter of the hysteroscope is generally too large to conveniently pass through the cervix directly, thereby necessitating cervical dilation to be performed prior to insertion. Cervical dilation can be performed by temporarily stretching the cervix with a series of dilators of increasing diameter. Misoprostol prior to hysteroscopy for cervical dilation appears to facilitate an easier and uncomplicated procedure only in pre-menopausal women.

Insertion and inspection:

The hysteroscope with its sheath is inserted transvaginally guided into the uterine cavity, the cavity insufflated, and an inspection is performed.

Insufflation media

The uterine cavity is a potential cavity and needs to be distended to allow for inspection. Thus during hysteroscopy  either  fluids or  CO2  gas is introduced to expand the cavity. The choice is dependent on the procedure, the patient’s condition, and the physician’s preference. Fluids can be used for both diagnostic and operative  procedures.  However,  CO2  gas  does  not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. Gas embolism may also arise as a complication. Since the success of the procedure is totally depending on the quality of the high-resolution video images in front of surgeon’s eyes, CO2 gas is not commonly used as the distension medium.

Electrolytic solutions include normal saline and lactated Ringer’s solution. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Since they conduct electricity, these fluids should not be used with monopolar electrosurgical devices.   Non-electrolytic  fluids  eliminate  problems with electrical conductivity, but can increase the risk of hyponatremia. These solutions include glucose, glycine,   dextran  (Hyskon),   mannitol,   sorbitol  and a   mannitol/sorbital   mixture   (Purisol).   Water   was once used routinely, however, problems with water intoxication and hemolysis discontinued its use by 1990. Each of these distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid. Glucose is contraindicated in patients with glucose intolerance. Sorbitol metabolizes to fructose in the liver and is contraindicated if a patient has fructose mal-absorption.

High-viscous Dextran also has potential complications which can be physiological and mechanical. It may crystallize on instruments and obstruct the valves and channels. Coagulation abnormalities and adult respiratory distress syndrome (ARDS)  have  been  reported.   Glycine  metabolizes into ammonia and can cross the blood brain barrier, causing agitation, vomiting and coma. Mannitol 5% should  be  used  instead  of  glycine  or  sorbitol  when using monopolar electrosurgical devices. Mannitol 5% has a diuretic effect and can also cause hypotension and circulatory collapse. The mannitol/sorbitol mixture (Purisol) should be avoided in patients with fructose malabsorption.

When fluids are used to distend the cavity, care should be taken to record its use (inflow and outflow) to prevent fluid overload and intoxication of the patient.

Interventional procedures

If abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments  to  enter  the  cavity  is  used  to  perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid resection, and endometrial polypectomy. Hysteroscopy has also been used to apply the Nd:YAG Laser treatment to the inside of the uterus. Methods of tissue removal now include electrocautery bipolar loop resection, and morcellation.