Gynecologic Endoscopy II - Hysteroscopy
Chapter 21. Gynecologic Endoscopy II: Hysteroscopy
* Hysteroscopic lysis of intrauterine adhesion ¡æ 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
II. Operative Hysteroscopy
5. Menorrhagia
6. Sterilization
7. Synechiae
III. Patient Preparation
1. Diagnostic Hysteroscopy
2. Operative Hysteroscopy
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
2. Anesthesia
3. Cervical dilatation
4. Uterine distention
* Hysteroscopic lysis of intrauterine adhesion ¡æ 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
- Unexplained abnormal uterine bleeding
- Selected infertility cases - Abnormal hysterogram, Unexplained infertility
- Recurrent spontaneous abortion
- 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
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
4. Conventional curettage should be performed
5. With infertility pts HSG is the best initial imaging study
II. Operative Hysteroscopy
- Foreign Body - IUD removal
- Septum - laser or electrosurgical knife or loop more reproductive outcome compared
with abdominal metroplasly with low morbidity & cost
- Endometrial polyp
- Can be removed with blind curettage, many are missed
- More successfully treated with hysteroscopic guidance
- Can be removed with blind curettage, many are missed
- 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
- Pedunculated leiomyoma ¢¡ removed by transecting the stalk, with scissors or
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
- 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
¢¡CO2 ; excellent media for diagnostic hysteroscope to avoid CO2 embolus
¢¡100mmHg ¡µ flow rate 100ml/min ¡µ
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 ¡µ 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
- 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
- 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
- Sheath or diagnostic hysteroscope ; slightly wider than telescope