Hysteroscopy

HYSTEROSCOPY
DR.GURURAJ DESHPANDE
MS(OBG)

ASSOCIATE PROFESSOR DEPT.OF.OBG
KAMINENI INSTITUTE OF MEDICAL SCIENCES
NARKETPALLY

Contents
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HISTORY
INDICATIONS
COUNSELLING
ANAESTHESIA
POSITION
EQUIPMENTS
DISTENDING MEDIA
PROCEDURE
COMPLICATIONS
CONCLUSION

HISTORY:PANTALEONI 1869 T0 1970
A LONG GAP

INDICATIONS
DIAGNOSTIC
• Unexplained abnormal uterine bleeding(AUB)
• Pre and post menopausal
• Selected infertility cases
• Abnormal HSG
• Unexplained infertility
• Recurrent pregnancy loss
• Should be used prudently only after other
investigations

THERAPEUTIC INDICATIONS
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IUD removal
Biopsy of intrauterine lesions
Hemangioma and A-V malformations
Resection of uterine septum
Uterine synechiae
Cannulation of fallopian tubes
Sterilization
Uterine polyps
Submucous myomas
Endometrial ablation

PATIENT COUNSELLING
 Benefits Vs Risks
 Other treatment options

 Realistic success rate
 Informed written consent

ANAESTHESIA
 Patient anxiety
 Cervix status

 Procedure
 Paracervical block and IV sedation
 Transcervical topical anesthesia

 Spinal/epidural
 GA

DIAGNOSTIC CONTINOUS FLOW
HYSTEROSCOPE

Operative sheaths and working
channel for accessory instruments

OFFICE HYSTEROSCOPE (BETTOCCHI
HYSTEROSCOPES)

Unipolar resectoscope consisting of
working element, 8mm resectoscope
sheath,4mm telescope

UNIPOLAR LOOP ELECTRODE FOR END
ABLATION,MYOMA,POLYP

UNIPOLAR ELECTRODES
(LOOP,NEEDLE,ROLLER,BALL)

DISTENDING MEDIA
 Need to distend uterus to view as uterus is

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almost closed structure.
Minimum 45mm of Hg for diagnostic
Upto 70mm of Hg for operative
If more than MAP ,more chances of overload
Gaseous and liquid
High and low viscosity medium

Carbon dioxide
 Neatness
 Doesn't damage instruments

 Doesn't mess up office/OR
 CO2 and bleeding incompatible
 CO2 and blood form obscuring bubbling

foam
 Cannot flush debris
 CO2 embolism rarely

CO2
 Insufflation should not exceed 100ml/min
 Unlike laparoscopy which are in litres/min

 Use only hysteroinsufflator
 Ideal for diagnostic office hysteroscopy

HYSKON
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32 percent dextran 70 in dextrose
Immiscibility with blood
Excellent visualization even in active bleeding
Compatible with electrosurgery and lasers
Outflow less due to high viscosity
Hyskon allergic reaction 0.05% treat like
anaphylaxis
 Pulmonary edema 0.11% due to overload as it
pulls water into intravascular space.

HYSKON
 Fibrinoplastic action leading to bleeding

diathesis
 Clogs instruments if instruments are not
washed immediately with hot water
 Remains in bloodstream for 4-6 weeks

LOW VISCOCITY LIQUID MEDIA
MEDIUM

OSMOLALITY mosm/kg
of water

SODIUM IN mEq/L

SERUM

290

135-145

GLYCINE 1.5%

200

SORBITOL 3%

178

MANNITOL 5%

280

GLYCINE 2.2%

280

NS

308

154

RL

273

130

NORMAL SALINE
 Safest
 Instilled with 2-3 litres bag from 6-8 feet

 Continuous high flow required
 Cannot use monopolar cautery as it contains

electrolytes, bipolar can be used.
 Still overload can occur which can be treated
with diuretics
 Stop if deficit is 1.5 litres

1.5%GLYCINE AND 3%SORBITOL
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Taken from urology
Hypotonic
Metabolized to CO2 and free water
Female brain cells cannot pump cations due to
progesterone action so more prone for cerebral
edema.
 Check osmolality and sodium minimum pre op
intra op and 4 hr post op
 Stop if >500ml deficit,
 Can use monopolar

5%MANNITOL AND 2.2%GLYCINE
 Both are safer and isoosmolar
 Mannitol is diuretic also
 Studies have shown that glycine2.2% is very

safe upto 1000ml deficit
 Can use monopolar
 Keep strict inflow and outflow
 Take into account the fluids infused by
anesthesiologist as RL commonly given is
hypoosmolar

CONTRAINDICATIONS
 Active PID
 Active profuse bleeding

 Recent perforation
 Pregnancy
 Cancer cervix

 Systemic disorders affecting fluid and
electrolytes

PROCEDURE
 Cervical priming and dilatation if needed
 Per vaginal examination to know the position

of uterus
 Vaginoscopic technique
 Systematic examination
 Operations with correct use of electrosurgery
and lasers

COMPLICATIONS
 Due to position
 Anaesthetic complications

 Due to distending media
 Uterine perforation
 Bleeding

 Bowel and bladder injury
 Septicemia
 Death

CONCLUSION
 Hysteroscopy is a part of every gynecological

surgeon’s armamentarium
 Generally a low risk technique using natural
pathway.
 Supersedes laparoscopy in philosophy of MIS

Hysteroscopy

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