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Gynecologic Endoscopy II - Hysteroscopy

Chapter 21. Gynecologic Endoscopy II: Hysteroscopy


* Hysteroscopic lysis of intrauterine adhesion → first described in 1973, hysteroscopic
division of uterine septa hysteroscopic destruction of the endometrium by laser
vaporization electrosurgical resection, electrosurgical coagulation



* For diagnostic purposes, usage was limited ⇒ current quality of images is
excellent because small-diameter endoscopes



* Diagnostic hysteroscopy ⇒ can be performed without anesthesia hysteroscopic
surgical procedures ; removal of polyps, excision of leiomyoma, endometrial ablation,
division of adhesions & uterine septa uterine cavity sampling.



I. Diagnostic Hysteroscopy



    1. Diagnostic hysteroscopy can provide information that cannot be obtained by blind
    endometrial sampling


    2. Available in polyps & submucosal leiomyomas, biopsy not available in endometritis,
    hyperplasia



    3. Medications




    • Unexplained abnormal uterine bleeding
    • Selected infertility cases - Abnormal hysterogram, Unexplained infertility
    • Recurrent spontaneous abortion


    4. Conventional curettage should be performed



    5. With infertility pts HSG is the best initial imaging study



  • In the presence a suspicious or identified abnormality in the endometrial cavity

    =>hysteroscopy can be used



  • Mandatory hysteroscopy to cover the high occurrence of false-negative radiologic
    images ⇒ No increased pregnancy outcomes




II. Operative Hysteroscopy



  1. Foreign Body - IUD removal



  2. Septum - laser or electrosurgical knife or loop more reproductive outcome compared
    with abdominal metroplasly with low morbidity & cost



  3. Endometrial polyp




    • Can be removed with blind curettage, many are missed
    • More successfully treated with hysteroscopic guidance



  4. Leiomyomas




    • Pedunculated leiomyoma ⇒ removed by transecting the stalk, with scissors or
      a resectoscope
    • For larger lesions ⇒ electrosurgical morcellation with a resectoscope
    • Selected submucus leiomyoma that extend into the uterine wall

      ⇒ resected using a
      loop electrode


      - extent or intramural involvement ; sonohysterography

      - Preoperative GnRH agonists can decrease the size or mass


5. Menorrhagia



  • Does not respond to medications

    ⇒ managed by endometrial ablation or resection


  • Ablation by uterine resectoscope with a blunt ball or barrel-shaped electrode


  • Resection by an electrosurgical loop electrode


  • Complication ; fluid overloud, electrolyte imbalance bleeding, perforation, intestinal
    injury


  • Preoperative GnRH agonist or danazol

    ⇒ may reduce op-time, bleeding, and the amount or fluid required


  • Successful in reducing or eliminating menses without hysterectomy

    : 75 ~ 90% or Pts --> satisfied with surgical procedure after l year



6. Sterilization


    Insertion of a plug, injection of a sclerosing agent, destruction of the intramural
    portion of the oviduct



7. Synechiae



  • Asherman's syndrome ⇒ presence of adhesions in endometrial cavity.


    Thin, fragile adhesions ; may be dived with the tip of a rigid diagnostic
    hysteroscopy


    - Thicker lesions ; by semirigid or rigid scissors or energy based instruments such
    as a resectoscope or an operative hysteroscope with a laser




III. Patient Preparation



1. Diagnostic Hysteroscopy



  • To identify or exclude the presence of anatomic or structural abnormalities in the
    endometrial cavity.



  • Few complication associated with anesthesia, perforation, bleeding and the distention
    media



  • After procedure, slight vaginal bleeding & lower abdominal pain
    - severe cramps, dyspnea, upper abdominal & right shoulder pain ; can develop if
    CO2 passes into the peritoneal cavity.



2. Operative Hysteroscopy



  • More dangerous than with diagnostic hysteroscope


  • Urinary tract damage hypotonic distention media

    ⇒ intravascular volume expansion, especially dangerous in cardiovascular diagnosed pts.

IV. Equipment & Technique



1. Patient positioning & cervical exposure

2. Anesthesia

3. Cervical dilatation

4. Uterine distension

5. Imaging

6. lntrauterine manipulation





1. Patient positioning & Exposure



  • (modified) dorsal lithotomy position
  • The smallest speculum possible should be used



2. Anesthesia


  • The anesthetic requirement ; vary greatly depending on the patient's level of
    anxiety, the status of her cervical canal, the procedure, and the outside diameter of
    the hysteroscope or sheath



  • With narrow-caliber ( <3 mm ) hysteroscope ⇒ anesthesia is not needed
    The pain of cervical dilatation ⇒ minimized or avoided by inserting laminaria 3 ~ 8
    hrs prior to procedure



  • For diagnostic purposes ; intracervical block (3ml of 0.5-1% lidocaine into ant lip of
    the cervix)


    - Paracervical block 4-and 8-o'clock position (injected into uterosacral ligament)

    - 5 ml of 2 % mepivacaine into the endometrial cavity with a syringe

    - Additional anxiolytics or analgesics, if necessary



3. Cervical dilatation

  • Dilated as atraumatically as possible
  • Uterine sound ⇒ should not be use



4. Uterine distention

  • Necessary for creating a viewing space by co2 gas, high-viscosity 32% Dextran 70
    , low-viscosity fluids (glycine, sorbitol, saline, dextrose in water)


  • 45mmHg or more pressure needed to minimize extravasation

    ⇒ mean arterial pressure should not be exceeded by this pressure



    1) Sheaths



    • Sheath or diagnostic hysteroscope ; slightly wider than telescope

      ⇒ allowing infusion of media



    • Sheath of operative hysteroscope ; one or two additional channels

      ⇒ allowing passage of media, or insertion of semirigid instruments or laser fibers



    2) Media



      ⇒CO2 ; excellent media for diagnostic hysteroscope to avoid CO2 embolus

      ⇒100mmHg 〉 flow rate 100ml/min 〉



    • Normal saline ; useful & safe medium
      ⇒ do not cause electrolyte imbalance



    • Dextran 70 ; useful for pts who are bleeding, anaphylactic reactions, fluid overloads,
      electrolyte disturbances can occur



    • 1.5% glycine & 3% sorbitol ; most often used in operative hysteroscopy.
      used with electricity

      hypotonic solutions ⇒ extravasation cause fluid & electrolyte imbalance

      absorption monitoring ⇒ by collecting out flow from the sheath & subtracting it
      from the total infused volume


      1 liter 〈 ⇒ mandate the measurement of electrolyte levels

      2 liters 〈 ⇒ procedure stopped



    3) Delivery systems



    • Syringes for office diagnostic procedure


    • Continuous hydrostatic pressure by elevating the vehicle containing the distention
      media above the level of the pt's uterus


      10mm tube, bag is 1 ~ 1.5meters above the uterine cavity ⇒ 70 to 100mmHg of
      intra-uterine pressure


    • A pressure cuff around the infusion bag


    • Infusion pump



    5. Imaging



    1) Endoscopes



    • Flexible & rigid
    • In resolution power ; rigid 〉 Flexible
    • 4mm in diameter ; most commonly used
    • Hysteroscopic optics


      0。 => panoramic view for diagnostic hysteroscopy

      12 to 15。 => diagnosis, ablation, resection

      25 to 30。 => both diagnostic & therapeutic hysteroscopy<



    2) Light sources & cables



    • For direct viewing ; 150 watts
    • For video & operative procedures ; 250 watts



    3) Video imaging



      For prolonged operations



    6. Intra-operative Manipulation



      1) Grasping, cutting, punch biopsy devices

      2) Narrow, flexible, enough to navigate the 1 to 2 mm diameter operating channel

      3) Cervical tenaculum, dilators, uterine currette



    V. Complications



    1. Anesthesia



    1. Local anesthesia ; intracervical or paracervical injection of 0.5 - 2 % lidocaine
      mepivacaine solutions.

      maximum recommended dose -- lidocaine ; 4 mg / kg, mepivacaine ; 3 mg / kg
      vasoconstrictor -> reduces the amount of systemic absorption of agent



    2. Complication



    • Allergy ; agitation, palpitation, pruritus, coughing, shortness of breath, urticaria
      bronchospasms, shock, convulsions

      Tx.) oxygen, IV fluids, adrenaline, prednisolone, aminophylline


    • Cardiac effects : impaired myocardial conduction ; bradycardia, cardiac arrest, shock

      Tx.) => atropine, adrenaline


    • Neurologic complication ; paresthesia of tongue, tremor, convulsions

      Tx.) => diazepam



    2. Perforation



    • May occur during dilatation of the cervix or during the hysteroscopic procedures


    • Perforated during dilatation of the cervix

      => usually no other injuries perforated during hysteroscopic procedures

      => suspect bleeding or injury of the adjacent viscera


    • If injury (+) => laparoscopy or laparotomy is needed



    3. Bleeding



    • Trauma to myometrial vessel or other vessel of pelvis

    • Diluted vasopressin into the cervical trauma

      : minimizing the depth of resection in the lateral endometrial cavity near the uterine isthmus


    • Electrosurgical coagulation


    • Foley catheter insertion in to the endometrial cavity




    4. Thermal Trauma



    • If perforation (+) => pelvic organ can be damaged


    • If suspected => laparoscopy is the appropriate first step

      most perforations does not need to repair, but pelvic organ damage (+)

      => laparotomy is indicated




    5. Distention Media



    1) Carbon Dioxide => can cause serious embolism


    2) Dextran 70 => allergic reactions, coagulopathy, volume overload, heart failure


    3) Low-viscosity Fluids


    • Check baseline serum electrolyte levels
    • Measurement of the absorbed volume => at every 5 to 15 minutes
    • The lowest intrauterine pressure ; 70 to 80 mmHg
    • Absorbed volume 1 L < check electrolyte level 2 L < stop procedure
    •