Essentials of Hysteroscopy

Essentials of Hysteroscopy
DEFINITION
Hysteroscopy is a procedure used to view the inside of the
uterus through a telescope-like device called a hysteroscope.
Hysteroscopy offers a valuable extension to the gynecologist’s
armamentarium. It can improve the diagnostic accuracy
and can permit better treatment of uterine diseases. The
hysteroscope is placed in the vagina and introduced into
the uterus (Figs. 1A and B). A hysteroscope is introduced
in a sheath that provides an inflow and outflow channel for
insufflation of the uterine cavity. In addition, an operative
channel may be present to introduce scissors, graspers, or
biopsy instruments. A hysteroscopic resectoscope is similar
to a transurethral resectoscope and allows entry of an electric
loop to shave off tissue, for instance, to eliminate a fibroid.
A contact hysteroscope is a hysteroscope that does not use
distension media.
INDICATIONS

■ Diagnostic hysteroscopy: Hysteroscopy allows access
to the uterotubal junction for entry into the fallopian
tube; this is useful for tubal occlusion procedures for
sterilization and for falloposcopy

■ Asherman’s syndrome (i.e., intrauterine adhesions):
Hysteroscopic adhesiolysis is the technique of lysing
adhesions in the uterus using either microscissors
(recommended) or thermal energy modalities.
Hysteroscopy can be used in conjunction with laparo-
scopy or other methods to reduce the risk of perforation
during the procedure

■ Endometrial polyp: Polypectomy

■ Abnormal uterine bleeding: In patients with abnormal
uterine bleeding, hysteroscopy provides more accurate
diagnosis than dilatation and curettage

■ Adenomyosis

■ Endometrial ablation (some newer systems specifically
developed for endometrial ablation such as the NovaSure
does not require hysteroscopy)

■ Myomectomy for uterine fibroids

■ Congenital uterine malformations (also known as
Müllerian malformations)

■ Evacuationofretainedproductsofconceptioninselected
cases

■ Removal of embedded intrauterine devices (IUDs).
CONTRAINDICATIONS

■ Pregnancy

■ Heavy uterine bleeding

■ Pelvic inflammatory disease

■ Cervical malignancy

■ Recent uterine perforation.
Figs. 1A and B: (A) Hysteroscopy; (B) Hysteroscopic visualization of submucous myoma.
A B
Prof. Dr. R. K. Mishra

482 SECTION 3: Laparoscopic Gynecological Procedures
HISTORY (FIGS. 2A AND B)

■ First hysteroscope with cystoscope of Desormeaux by
Pantaleoni in 1869

■ First hysteroscope with built-in lens to magnify the image.
DELIVERY DEVICES

■ Maximum recommended intrauterine operating
pressure is 150 mm Hg

■ Intrauterine pressure is a function of inflow pressure and
outflow pressure

■ Inflow pressure may be produced by gravity, pressured
cuffs with (pressure) gauges, or approved pumps.
DISTENDING MEDIA

■ Group A: Isotonic ionic solutions (normal saline and
Ringer’s lactate)

■ Group B: 5% dextrose in water

■ Group C: 1.5% glycine, sorbitol, and cytal

■ Group D: Hyskon (32% dextran 70).
FLUID MONITORING
It is the role of the circulating nurse to maintain a flow sheet
record of inflow and outflow of hysteroscopic media during
the case.
For groups A, B, and C, the inflow and outflow must be
estimated for every 500 cc of fluid used and measured at the
conclusion of each bag of distending media.
For group D, the inflow and outflow must be measured
for every 100 cc of fluid used.
The operating surgeon should be simultaneously
informed of fluid balance status as it is recorded on the flow
sheet. Spillage should be avoided.
Use of a table drape to collect excess fluid for accurate
recording of fluid output is required.
EXCESSIVE FLUID ABSORPTION
The recommended volume of input to output discrepancy
at which point the surgeon must assess serum electrolytes
(especially sodium concentration) is:

■ Group A: 1 L

■ Group B: 1 L

■ Group C: 1 L

■ Group D: 250 mL
Once these volumes of discrepancy have been reached,
serum electrolytes must be obtained and the operating
surgeon has the option of:
Terminating the case: Awaiting the results of the electrolyte
levels and proceeding accordingly.
Administering Lasix intravenous (IV) and judiciously
proceeding with the case until the results are available.
RESECTOSCOPE

■ The resectoscope has been used for male prostate surgery
for over 50 years

■ The resectoscope with in-built wire loop or other shape
device uses high-frequency electrical current to cut or
coagulate tissue (Figs. 3A and B).
Procedure
Patient position is shown in Figure 4. Inside of the uterus
is a potential cavity such as a collapsed air-dome and it
is necessary to fill (distend) it with either a liquid or a gas
(carbon dioxide) in order to see.
Diagnostic hysteroscopy and simple operative
hysteroscopy can usually be done in an office setting. More
complex operative hysteroscopy procedures are done in
operating room setting (Figs. 5A and B).
The volumes that are recommended in this section are
not based on established “standards of care”
, since such
Figs. 2A and B: History of hysteroscopy. (A) First hysteroscope with cystoscope of Desormeaux by Pantaleoni;
(B) First hysteroscope with built-in lens to magnify the image.
A B

483
CHAPTER 39: Essentials of Hysteroscopy
Figs. 3A and B: Resectoscope.
Fig. 4: Patient position in hysteroscopy.
standards have not yet been clearly formalized. For example,
many surgeons use 1 L as a cutoff for 5% dextrose in water
(D5W), while few others use 3 L. There is no established
limit for the volume of D5W that can safely be given as an
IV solution being directly infused into the circulation of a
healthy person. No reports of major morbidity associated
with the use of D5W have been reported in the literature.
Additional patient assessment following a large volume
discrepancy between input and output may immediately
involve determination of serum electrolytes. If a significant
time has passed since the (presumed) absorption of fluid,
other clinical parameters (if available) may become more
informative (evidence of tissue edema, an increase in cardiac
output associated with volume overload, change in pulse
oximetry or ventilation parameters, and change in patient
temperature, if room temperature fluid is used).
A resectoscope is used with continuous flow and a loop
electrode to perform most of the hysteroscopic surgery. Any
of the irrigation system for distending media available today
is not sufficiently accurate. They are not rapid in response
(so as to maintain a constant pressure), affordable, and easy
to use. At present, many gynecologists use a simple system of
placing a blood pressure cuff around each 1 L bag of normal
saline solution to be used and apply 150 mm Hg pressure as
measured on a gauge attached to the pressure cuff. This is
connected to the inflow port on the resectoscope and flow
is then adjusted using a stopcock on this port. Outflow from
the resectoscope is via tubing that connects directly to a
suction canister under full wall suction. The outflow port
also has a stopcock that can be used to adjust the outflow.
The circulating nurse’s primary responsibility during
the operative hysteroscopy is to maintain pressure on the
pressure cuff and watch the inflow and outflow balance. The
nurse might appropriately report this balance to the surgeon
and anesthesiologist every 15 minutes or whenever there is a
significant volume of use (500 cc).
The resectoscope’s monopolar electrocautery loop is
attached to an electrical generator with variable power
(wattage) settings. For any given power setting selected,
there are also various blends of cutting or coagulation that
can be chosen. It is advisable to use blend 1 which applies
80% current of the time and gives just a little coagulation as
compared to pure cutting. For most cases, resectoscope is
used at 50–80 W on blend 1 and to coagulate bleeders (if not
initially controlled with the blend 1 settings), using 50 W at
pure coagulation is recommended.
Once the hysteroscopic portion of the case is completed,
a final tabulation of inflow and outflow volumes for the
distending media is done. Direct your attention to the
laparoscopy once the hysteroscopy is complete. A uterine
manipulator is placed through the cervix.
Laparoscopeshouldbeinsertedafterthat.Forthis,Veress
needle is introduced. Insufflation of the abdomen with CO2
gas so as to create a pneumoperitoneum is accomplished
after“confirmingtheproperplacement”oftheVeressneedle.
A B

Figs. 5A and B: Vaginal speculum examination before hysteroscopy.
Once the pneumoperitoneum is created, the Veress
needle is replaced by a trocar and sleeve. The diameter of
the umbilical (main) trocar is 10–12 mm, so this instrument
can cause considerable injury if not placed properly and
atraumatically into the abdominal cavity. The presence
of adhesions (scar) that adhere the bowel to the anterior
abdominal wall is a consistent source of concern for
laparoscopic surgeons.
If abundant adhesions are anticipated such that the
surgeon believes that the complication rate with the blind
Veress needle and trocar insertion is unacceptably high,
then “open method” may be chosen. Hasson introduced this
technique in which the direct insertion of the trocar without
the creation of a prior pneumoperitoneum is accomplished
by performing a cut down under direct observation of the
layers of the abdominal wall. Suture holds the layers of the
inner abdominal wall (fascia and peritoneum) to the trocar
sleeve to prevent the release of gas through the incision site
during the case. Extreme care must be exercised in making
the peritoneal incision since bowel injury to adherent bowel
may occur under direct observation as well.
Accessory trocar sites are usually required during the
laparoscopic case. Typically, use two additional sites for
placement of 5 mm (or uncommonly 10 mm) trocars in the
suprapubic midline and left lower quadrant. All accessory
trocars have the advantage of being able to be inserted
under direct observation, so injury is less common. One
injury associated with placement of the accessory trocars is
laceration of the deep inferior epigastric vessels (which may
be difficult to see either directly or via transillumination).
Injury to the inferior epigastric vessels can be consistently
avoided by placement of the additional trocars either lateral
to the internal inguinal ring or medial to the umbilical
ligaments (two structures that are usually easy to identify
under direct laparoscopic observation).
Tools that are selected for the performance of the
laparoscopic surgery should allow the surgeon to minimize
postoperative adhesion formation. The surgical principles as
discussed above are very important in terms of achieving the
desired outcome. Gentle tissue handling during laparoscopy
takes a great deal of time to develop. Avoidance of bleeding
with gentle tissue handling is important and so is careful
A
B

485
hemostasis using (selective) bipolar cautery. Continuous
irrigation and aspiration of the tissues to remove char and
minimizedryingshouldbesecondnaturetothelaparoscopic
infertility surgeon. Use of cutting instruments that minimize
lateral tissue damage is also a primary importance.
Once the case has been completed, the instruments
are removed from the abdomen allowing for the efflux of
CO2 gas. Usually, it takes additional 5 minutes to move the
abdominal wall and contents about with only one remaining
trocar sleeve is in place to try to allow any trapped gas to
escape. Incisions are closed with subcuticular stitches, so
as to avoid cosmetically unpleasant “railroad” type skin
scars. The fascia is closed where incision in the fascia is
>5 mm. In the immediate postoperative recovery time
period, common problems include nausea and vomiting,
most likely related to the CO2 gas or the narcotic pain
medications used perioperatively. Zofran is often the most
effective antiemetic agent for postlaparoscopic vomiting.
The nausea and vomiting do not typically persist for
>12 hours postoperatively.
Shoulder pain due to retained CO2 gas, which if trapped
under the diaphragm (at base of the lungs), causes irritation
of the phrenic nerve to cause the sensation of shoulder pain.
Lying on one’s abdomen with a pillow under the hips and
lower abdomen (or the knee chest position) may allow the
CO2 gas to recollect in the pelvis rather than under the lungs
and reduce this discomfort.
Subcutaneous crepitance (crackling) under the skin over
the abdomen and extending superiorly to the chest and neck
or inferiorly to the buttocks and thighs is typically a minor
complication due to escape of the gas into the abdominal
wall. A rare patient develops a very low blood pressure (not
related to blood loss) and usually responds immediately to a
bolus of IV fluid solution.
Incisional pain is usually mild but the internal (visceral)
pain after surgery can be intense and may require narcotics
or anti-inflammatory agents. Reportedly, a heating pad
applied to the abdomen may also be helpful.
If a large volume of fluid is left in the abdomen at the
conclusion of the case, then leakage through the incision
sites is common for up to 2 days.
Thesurgeonshouldbecalledifthereisafever(>100ºC)or
chills, heavy or prolonged vaginal bleeding, heat or swelling
of the incision sites, frequency or burning on urination,
severe pelvic pain, persistent nausea or vomiting, faintness
or dizziness, and inability to spontaneously urinate.
Postoperative urinary retention occurs more often in
cases that last longer than 2 hours. If the patient is not able
to void within 4–5 hours of postoperative period (and after
removal of the Foley catheter), then patient should be straight
catheterized again for the residual volume of urine and
should try to void spontaneously once again. Do not allow
patients to go home until either they can void spontaneously
or they have an indwelling Foley catheter placed (for about
1 day).
COMPLICATIONS OF OPERATIVE
HYSTEROSCOPY

■ Trauma:

z Cervical laceration

z Uterine perforation

z Injury to intra-abdominal viscera—rectum, bladder,
and intestine

■ Intravasation: Predisposing factors for venous
intravasation of distending media:

z Uterine tuberculosis

z Submucous tumor

z Hypoplastic uterus

z Recently traumatized uterine cavity

z Proximal tubal obstruction

z Excessive pressure of instillation

z Infection

■ Exacerbate latent salpingitis

■ Pelvic inflammatory disease (PID)

■ Febrile reaction

■ Bleeding

■ Peritonitis.
A possible problem is uterine perforation when either
the hysteroscope itself or one of its operative instruments
breach the wall of the uterus. This can lead to bleeding
and damage to other organs. If other organs such as bowel
are injured during a perforation, the resulting peritonitis
can be fatal. Furthermore, cervical laceration, intrauterine
infection in prolonged procedures, electrical injuries, and
complications caused by the distension media can be
encountered.
The use of distending media can lead to serious and
even fatal complications due to embolism or fluid overload
with electrolyte imbalances. Particularly, the electrolyte-free
insufflation media increase the risk of fluid overload with
electrolyte imbalances, particularly hyponatremia, heart
failure as well as pulmonary and cerebral edema.
The main factors contributing to fluid overload in
hysteroscopy are:

■ Hydrostatic pressure of the insufflation media

■ Amount of exposed blood vessels such as being increased
in endometrial ablation and submucous myomectomy

■ Duration of the hysteroscopy procedure

■ Women in fertile age are at increased risk of resultant
hyponatremic encephalopathy, likely because of
increased level of estrogens.
Theoverallcomplicationratefordiagnosticandoperative
hysteroscopy was 2% with serious complications occurring
in <1% of cases using older methods.

SAFETY MEASURES
Dilatation of the Cervix
The cervix must be dilated in order to enter into the uterine
cavity with a hysteroscope. Most resectoscopes have an outer
sheath diameter of about 9 mm, so that cervical dilation
using mechanical dilators must be at least this amount. It
is optimal to avoid overdilation of the cervix since leakage
of the distending media through the cervix and around the
hysteroscope (especially under pressures of about 150 mm Hg)
then becomes possible.
Some cervical canals are difficult to negotiate with
dilators. Different dilators have a variable amount of
curvature to choose from. It is possible to perforate the
lower uterine segments during dilation. Clinical situations
in which perforation is more common include dilation of the
pregnant uterus, fibroid uterus, uterus of a women exposed
to diethylstilbestrol (DES) in utero, uterus after exposure to
prostaglandins for cervical ripening, and infected uterus.
Many cases of perforation occur at the onset of dilation
and the subsequent dilators then continue to open the
perforation site.
Occasionally, a rent in the lower uterine segment occurs
during dilation. It is thought that rapid dilation or a difficult
dilation involving a stenotic inflexible cervix may enhance
the frequency of these tears. It is possible for a tremendous
amount of distending media to become intravasated through
these rents and into the large vessels of the lower uterine
region if they are transected.
Cervical incompetence following hysteroscopic surgery
is rarely reported but theoretically possible. The cervix is
composed of a tough fibroconnective tissue and smooth
muscle. Automatic closure of the internal os of the cervix is
the general rule even following manual dilatation of up to
15 mm.
Bleeding
The pressure maintained in the uterine cavity may (but
generally should not) exceed both the venous and the
arterial pressures, so that active blood flow from transected
vessels may not become apparent until the uterus is
deflated. At lesser pressures, bleeding can be identified and
usually controlled. If there is excessive bleeding following
destructive procedures such as endometrial ablation, it can
be frequently controlled by tamponade using an inflated
Foley catheter balloon (10–30 mL for up to 16 hours) in the
uterus. Sometimes, the excessive flow can be controlled with
estrogen hormonal therapy (if due to denuding the lining).
Excessive Intravasation of Distending Media or
Carbon Dioxide Gas
Whenever vessels get transected during hysteroscopic
surgery and either fluid or gas gets entered into the uterine
cavity under pressure, there is a possibility of intravasation
(entry of these substances into the circulation).
Five percent dextrose in water is a good distending media
for diagnostic hysteroscopy. Major complications with this
solution are very rare. In fact, there are no reports in any
of the world literature where major morbidity or mortality
with the use of D5W at hysteroscopy is reported. Possible
complications include water intoxication (a reduction in
serum osmolality) with a dilutional reduction in sodium
concentration, volume overload (when the circulating
volume in the vascular system exceeds the ability of the
heart to adequately pump this volume and the excess
fluid typically begins to collect in the tissues of the lungs),
hypothermia (significant reduction in body temperature)
if room temperature solutions are used without warming,
the patient with devices such as a “Bair Hugger”
, and
hyperglycemia (significant excess in circulating glucose
concentration that may not be rapidly metabolized, if the
patient has insulin resistance or diabetes mellitus).
The major complication, that most hysteroscopic
surgeon’s focus on avoiding, is water intoxication. The risk
of water intoxication from D5W in a healthy woman with
normal renal function is very low, since the kidneys can
typically produce in excess of 1,000 cc of dilute urine in
response to a decrease in serum osmolarity.
Adhesions
Following hysteroscopic surgery, there is a chance of
adhesion (scar) formation if significant electrocoagulation is
used within the uterine cavity in the infertility patient.
Intraoperative estrogen IV (25 or 50 mg of Premarin) is
given and at least a 30-day course of higher dose Premarin
postoperatively (1.25 mg or preferably 2.5 mg, if tolerated)
should be used.
Burn Injury to the Bowel
When resectoscopic electrosurgery is performed in the area
of the uterine ostia (near the entry site of the fallopian tubes),
there is a chance of thermal injury to adjacent tissue outside
the uterine cavity. This is because the uterine wall in these
regions is very thin and heat from the cautery can travel
through the uterine wall and burn adjacent bowel.
Infection
Endometritis is uncommon after operative hysteroscopy and
antibiotics are usually not “routinely” given. The potential
benefits of antibiotics outweigh their risks when exposure to
infection occurs.
HYSTEROSCOPY IN ABNORMAL UTERINE
BLEEDING (FIG. 6)
Hysteroscopy in Cases of Infertility
Diagnostic laparoscopy in hysteroscopy is shown in
Figures 7 to 12.

487
Fig. 6: Submucous myoma. Fig. 7: Septate uterus.
Fig. 8: Forgotten intrauterine device (IUD). Fig. 9: Salpingo-catheterization.
Figs. 10A to C: Bicornuate uterus.
CONCLUSION
Hysteroscopy is a valuable, simple, and low-risk technique,
which allows an adequate exploration of the uterine cavity
under visual control. It ensures speed and safety with the
diagnosis and treatment. Hysteroscopic-guided biopsy and
histopathology are considered as the “new gold standard” in
evaluating a case of abnormal uterine bleeding. Hysteroscopy
provides the possibility of immediate diagnosis and prompt
and effective treatment. It allows finding out the source of
bleeding and perform a directed biopsy of the suspected area.
A B C

Figs. 11A to F: Intramural myoma.
Figs. 12A to C: Submucous myoma.
It affords a more accurate diagnosis than dilatation and
curettage for intrauterine pedunculated pathologies. But for
hyperplasia and endometrium carcinoma, histopathology
is 100% diagnostic. Endometrial polyps and pedunculated
fibromyomas can be removed under direct vision with the
hysteroscope. Endometrial atrophy diagnosis is best made
by hysteroscopy. It is a very helpful technique in patients
with intrauterine synechia. Since it can detect their presence,
extension, and nature, these can also be removed. It can be
concluded that hysteroscopy offers an invaluable advantage
of direct visualization of any abnormality within the uterine
cavity. It does not substitute other diagnostic procedures;
rather, it complements them. Hysteroscopy is a safe, simple,
quick, and economic technique, well-accepted by the
patient, with great potential in gynecology.
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