hysteroscopy and its uses

1. HYSTEROSCOPY
PRESENTED BY
DR PAWAN JHALTA
MODERATOR
DR NISHI SOOD

2. DEFINITION
HYSTEROSCOPY IS A PROCEDURE THAT
INVOLVES DIRECT VISUAL INSPECTION OF
CERVICAL CANAL AND UTERINE CAVITY.

3. HISTORY
First described by Panteleoni in 1969 and done
as an office procedure only .
1st optical hysteroscopy was introduced by David
in 1907.
First distension media used was CO2.
In 1980s hysteroscopy replaced blind D&C as a
standard procedure for precise diagnosis of
intrauterine pathologies.

4. INSTRUMENTS
Telescopes
Light source
Diagnostic and Operative sheaths
Distending media
Camera
Accessory instruments

5. TELESCOPE
3 parts –
a) eye piece
b) barrel
c) objective lens
Available in various diameters-
a) 4mm standard – gives high quality sharpest image
b) 3 mm diameter – inferior to 4mm but gives
satisfactory image clearity.
Types
a) straight on i.e. 0 degree, distant panoramic view
b) fore oblique i.e. 30 degree – has an advantage that
just by rotating it all walls and cornual ends can be
visualised.

7. `

8. DIAGNOSTIC SHEATHS
Usually 4 – 5 mm in diameter
Required to deliver the distending media into
uterine cavity
Telescope fits into the sheath and there is
1mm gap between sheath and scope through
which distending media is transmitted and is
controlled by external stopcock.
Imprecise or loose coupling telescope and
sheath results in leakage of distending
medium.

9. OPERATIVE SHEATHS
It has channels for
a) 3 - 4 mm telescope
b) instillation of medium
c) operating instruments
Types
A) STANDARD OPERATING SHEATH
Single cavity for medium,telescope and
operative tools.
Disadvantage of not being able to flush the
cavity with distending medium and operating
tool manipulation within the cavity is difficult.

10. B) ISOLATED MULTIPLE CHANNEL OPERATING
SHEATH –
Double flushing sheath that allows media
instillation by inner sheath and return by
perforated outer sheath, constant flow of
medium leads to very clear operative field.

12. RESECTOSCOPE
Electrosurgical endoscope
Consists of
Inner sheath - which has a common channel for
telescope, distending media and electrode
and
Outer sheath - for the return of distending
media.
Lens is angled towards the electrode for clear
view
Electrode can be ball, barrel, knife, or cutting
loop type.

15. KARL STORZ (BETTOCHI HYSTEROSCOPE)
• External diameter of 2.9 mm and can be used
both as panoramic hysteroscope and micro
contact hysteroscope.
VERSASCOPE SYSTEM
• Flexible telescope made up of 50,000 fused
optical fibres.
• External diameter of 1.8 mm and length of 28
cm.
• It has a disposable sheath too.

17. LIGHT SOURCE
• Quality depends upon
a) wattage
b) remote light generator
c) structural integrity of light cable
• Wattage – 175 W for routine procedures and
300 W for special interventions
• Light generator
– tungsten orange yellow light
– metal halide bluish colouration
- xenon white light
- LED source

18. CAMERAS
• The camera consists of a camera head, cable
and camera control.
• -Camera head attaches to the eye piece of
Hysteroscope.
• -The basis cameras is solid state silicon
computer chip or charged coupled device.
• -Each silicon element contributes one pixel to
the image produced.

20. DISTENDING MEDIA
Types
• Gaseous CO2
• Liquid –
High viscosity – hyskon
Low viscosity –
Ionic/electrolyte NS,RL,5%D,10%D,4% and 6%
dextran solution.
Non ionic 1.5% glycine , 3%sorbitol,
5% mannitol and cmbination of
2.8%sorbitol and 0.5% mannitol.

21. CO2 AS DISTENDING MEDIA
Used in office hysteroscopy
Rate of flow 30-40 ml/min( should be < 100 ml/min)
Intrauterine Pressure 60-70mmHg
ADVANTAGES –
Provides clean media
Allows entry evaluation of endocervical canal
DISADVANTAGES –
Doesn’t flush the cavity of debris
Mixes with blood to form foam obscuring the view
Flatten the endometrium
Emboli can form causing gas embolism and death

22. LOW VISCOSITY DISTENDING MEDIA
Delivered fluid must be circulated out and clear
fluid added in order to maintain view and
distension of cavity
Delivery systems used are
Gravity fall system
Pressure cuff
Electronic suction irrigation pump
Proper monitoring of infused volume is important
and infusion is stopped positive infusion
difference is
500 cc for hypo-smolar solution and
1000 cc for iso-osmolar solution

23. NORMAL SALINE
0.9% Normal Saline is commonly used
Advantage
Widespread availability
Low operative cost
Physiological disposal by peritoneal absorption
Disadvantage
Efficient conductor of electrons so electrosurgery
with monopolar devices is not possible.
Not suitable for office hysteroscopy.
Fluid overload and pulm oedema risk

24. Glycine (1.5%) and Sorbitol (3%)
ADVANTAGE
Inexpensive and readily available
Media of choice for monopolar cautery
DISADVANTAGE
Hypo-osmolar solution causing dilutional
hyponatremia and hypervolemia
Interferes with oxygenation and coagulation
Cerebral oedema,cardiac and skeletal muscle
dysfunction.

25. MANNITOL (5%) AND GLYCINE (2.2%)
Iso-osmolar
Can be used with electrosurgical instruments
Decreased risk of fluid overload and
hyponatremia .

26. HIGH VISCOSITY MEDIA -HYSKON
High viscosity liquid distending media
32% high molecular weight dextran solution
Colourless viscid medium
Usual volume required-
Diagnostic – 100 ml
Operative 200 – 500 ml
Upper safe limit 500 ml.
1ml of hyskon withdraws 20 ml of water in
circulation

27. Advantages
Being highly viscous small quantities are
required for examination.
Provides excellent visualization due to its high
refractive index and as does not mix with
blood.
Disadvantages
Expensive
Caramalize on instruments and may freeze the
stopcocks of the instruments making them
inoperable.

28. Morbidities ocaused are
• Pulmonary edema
• Coagulopathies
• Electrolyte imbalance
• Anaphylactic reaction
Mechanical pump is necessary to deliver these
fluids.

29. ENERGY SOURCES
• Mechanical energy
• Monopolar
• Bipolar standard electrode.
• Bipolar versapoint .
• LASER
• Resctoscopes.

30. STERILIZATION OF INSTRUMENTS
• Standard : gas sterilization with ethylene
oxide.
• Cidex OPA(0.55% ortho phthaldehyde)
• 12 min soak at 20Ċ and 5 min at 25Ċ in an
automatic endoscope reprocessor.
• Require 3 one minute rinses to remove
residual solution.

31. INDICATIONS OF HYSTEROSCOPY
DIAGNOSTIC HYSTEROSCOPY
Evaluation of abnormal uterine bleeding
Infertility workup along with laparoscopy
Prior to IVF
Postoperative evaluation
Diagnosis of polyps, fibroids and uterine
synechiae

32. OPERATIVE HYSTEROSCOPY
• Endometrial ablation
• Resection of septae, myomas and polyps
• Adhesiolysis
• Extraction of lost IUCD
• Targetted biopsy
• Treat AV malformations and hemangiomas
• Sterilisation
• Gamete transfer in ART
• Tubal cannulation of proximal tubal
obstruction

33. CONTRAINDICATIONS
• Recent history of PID as it may precipitate
acute symptoms
• Acute cervicovaginal infections
• Extreme bleeding
• Pregnancy

34. DIAGNOSTIC HYSTEROSCOPY
• Office hysteroscopy (outpatient hysteroscopy)
• Vaginoscopic approach
• Inpatient hysteroscopy
Anaesthesia
Local paracervical block
Genaral anaesthesia

35. TIMING - proliferative phase 6th to 10th day of
menstrual cycle
- isthmus is hypotonic
-proliferative endometrium has better
endoscopic view and
-no risk of unexpected pregnancy
Timing of cycle not important in emergency
cases or OCP users.

36. Distension media normal saline
CO2
Operative findings
polyps
myomas
synechiae
septa
vascular pattern
gland openings
endometrial hyperplasia
growth

37. Ectocervix
Endocervix
Internal os

38. Endmetrial cavity

39. Panoramic view of normal endometrial cavity

40. polyp Submucus myoma
Septum adhesion

41. Endometrial carcinoma

42. • OPERATIVE HYSTEROSCOPY
PROCEDURES

43. ENDOMETRIAL ABLATION
• Indications
-abnormal uterine bleeding not responding to
medical therapy
-recurrent endometrial hyperplasia
-high risk for surgery
• Pre-operative preparation – danazol or GnRH
analogue treatment for endometrial thinning
• EXCLUDE ENDOMETRIAL CARCINOMA

44. ROLLERBALL ENDOMETRIAL ABLATION
• Ball electrode is used and start from fundus
then anterior and lateral walls and posterior
wall is ablated at last
• Isthmus is spared
• Power 50-150 W
• Depth of 1-2 mm is targetted and heat
actually reaches 3-5 mm depth also
depending on time of contact
• Endometrium sloughs and regeneration is
prevented because basal and spiral arterioles
donot survive 100 degree centigrate heat.
Uterine walls scar in 6-8 weeks and shrink.

45. Advantages
Easier to learn and perform than resection.
Shorter operating time than laser ablation
Less risk of uterine perforation and hemorrhage
than resection.
Disadvantages
No tissue for histology
Cannot treat submucus fibroids
Use of mnonopolar energy and nonphysiologic
media

46. TRANSCERVICAL RESECTION OF
ENDOMETRIUM
• Loop shaped electrode is used
monopolar energy
bipolar energy
Continuos flow resectoscope provides efficient resection
of endometrium and myometrium(2.5-3 mm).
Advantages
Provides tissue for histopathology
Suitable for thick endometrium
Submucus fibroids and polyps can be excised at the same
time

47. • Disadvantages
• Most skill dependent hysteroscopic procedure
• Greatest risk of uterine perforation.
• Use of electrolyte free media with monopolar
resectoscope

48. HYSTEROSCOPIC LASER ENDOMETRIAL
ABLATION
Advantages
Tissue coagulation upto 5-6 mm
Perforation is less likely than resection
Small fibroids and polyps can be vapourised
Disadvantages
Expensive capital and running cost
Slowest of all techniques
Greater risk of fluid overload
Need for special laser safety procedures and
guidelines

49. SECOND GENERATION ENDOMETRIAL ABLATION
THERAPY
The HydroThermAblator System
A single-use 3 mm hysteroscope coated with polycarbonate
is inserted into the endometrial cavity. Saline is instilled at
low intrauterine pressures of <45 mm Hg and then heated
to 90°C. This low pressure is used to prevent flow of heated
saline through the fallopian tubes.
After the treatment is complete, cool saline is used to
replace the heated saline prior to removal of the device
from the cavity.
Endomyometrial necrosis to a depth of 2-4 mm is achieved
after 10 minutes of treatment. The endometrial cavity is
uniformly ablated with this method, including both cornua.

50. UTERINE SYNECHIAE
• Flexible or semi-rigid scissors or
resectoscope with Nd-YAG laser is used
• TECHNIQUE –
Flimsy and central adhesions are cut first
then marginal and dense adhesions are
cut,
start cutting from below and move up
maintain the hysteroscope in midchannel

51. HYSTEROSCOPIC ADHESIOLYS
Challenges
- numerous vascular channels are
opened so risk of intravascular absorption of
media is high
- anatomy is disturbed so risk of
perforation is more.
• POST OPERATIVE CARE-
-Pediatric foley’s catheter can be inflated for 7-10
days
-IUCD insertion
-Conjugated estrogens 2.5 mg daily for 2-3
months

52. UTERINE POLYPS
• Multichannel operating hysteroscope is used
• Retractable electric snare is inserted which
encompasses the base of polyp and is then
tightened
• Cutting current of 30-40 W is applied
• Snare removed and polyp is grasped with
aligator jaw forceps
• Site of removal is inspected and if any
bleeding observed it is coagulated with ball
electrode

54. UTERINE SEPTUM
TECHNIQUE
Hysteroscope is drawn to the level just above the
internal os and septum is cut from below
upwards with simultaneous laparoscopy.
Stop dissecting when both tubal ostia are clearly
visible in panoramic view and signal from
laparoscopist that fundus is approaching
Post op care-
-Foley’s catheter
-conjugated estrogens and
- HSG after 6-8 weeks

55. TUBAL STERILISATION
• With the Essure system, a 5-mm hysteroscope is
used to introduce a delivery catheter that contains a
3.85 cm flexible coil called a microinsert into the
proximal portion of the fallopian tube.
• The inserts are made of a stainless steel inner coil
wound in polyethylene fibers and an outer coil of nickel
titanium. After a microinsert is placed at the uterotubal
junction, the delivery catheter is removed and the
outer coil of the insert expands.
• Three to eight trailing coils of the insert should remain
visible at the tubal ostia.
• The inner polyethylene fibers induce tissue in-growth
into the insert, facilitating occlusion of the tubal lumen
by 12 weeks.

56. ESSURE SYSTEM

57. Hysteroscopic tubal cannulation
INDICATION
a) interstitial obstruction
b) transfer of gametes.
c) tubal sterilisation
• TECHNIQUE –
• In interstitial obstruction 5.5 F teflon cannula with
metal obturator is introduced, obturator removed and
a 3F catheyer with guide wire is withdrawn and dye
injected, dye spilling can be seen via laparoscope.
• Gamete transfer is done by 1 mm catheter cannulation.
Uterine distension media are toxic to gametes so CO2
is preffered that too at low flow rates and gas flow is
shut off when catheter enters the tube.

60. IUCD removal
• Multichannel hysteroscope with alligator
forceps is inserted and string is grasped and
drawn along with hysteroscope.
• If embedded IUCD is there rigid grasping
forceps are used and jaws grab the extruded
portion of IUCD and taken out by strong force

62. Hysteroscopic myomectomy
• Leiomyomas appear as white spherical masses
covered by network of thin fragile vessles
• PRE OPERATIVE ASSESSMENT-
-Diagnostic hysteroscopy
-Endometrial biopsy
-Transvaginal ultrasonography

63. EUROPEAN SOCIETY OF HYSTEROSCOPY
CLASSIFICATION OF INTRAUTERINE MYOMAS
• GRADE ‘0’ – Myoma with development limited
to uterine cavity, pedunculated or with limited
implant base
• GRADE ‘1’ – Myoma with partial intramural
development having an endocavitary
component >50% with angle of protrusion
between myoma and uterine wall <90*
• GRADE ‘2’ – Myoma with predominantly
intramural development, <50% endocavitary
component and angle of protrusion between
myoma and uterine wall >90*

64. Pedunculated leiomyoma Partially intramural myoma
Myoma with predominantly intramural
development

65. Factors For GnRH analogues
Parameters
•Anaemia.
•Type of myoma.
•Diameter.
•Residual distance to
serosa.
•No. of Myoma
•Location.
•Ability of the surgeon.
Disfavoring
None or Mild
Gr. 0 or 1
< 2cm
10 mm
Single
Anterior, posterior or
lateral pelvic wall
Highly skilled
In Favour Pretreatment
Pronounced
Grade 2
> 4 cms
< 8 mm
Multiple
Fundus, close to tubal ostium
Skilled

66. Technique of myoma resection
• MECHANICAL - Progressive shaving of myomas and
harvesting tissue for HPE eveluation
• ELECTRODE – Straight electrode for fundal myomas and
angulated for myomas on anterior and posterior walls.
Electrode must be activated only while returning towards
hysteroscope and never while advancing from lens.
• LASER –
A) 1mm laser fibre cuts myoma across.
B) 1mm ball is drawn over myoma multiple times for ablation.
C) Layer by layer by layer myoma is sliced until its base is
reached.
D) Myoma is devascularised by making multiple punctures
into its substance and then extracted piece by piece.

67. Hemangioma and Arterio-venus
malformation
• Can be diagnosed by their characteristic hysteroscopic appearance
and H/O unresponsive bleeding
• Women usually young and low parity.
• Hysteroscopy shows endometrial surface covered with irregular
bluish purple vessels but form an abnormal tangle of distended
channels which differ markedly from normal fine capillary net
pattern.
• Management – Nd: YAG or Holmium YAG laser is discharged
touching the vessels or surface of epithelium.
• Laser energy causes vessels to collapse, coagulate and the surface
to blench white

68. COMPLICATIONS OF HYSTEROSCOPY
INTRAOPERATIVE
POSTOPERATIVE

69. INTRAOPERATIVE COMPLICATIONS
PERFORATION –
• Incidence 1-9%
• Commonest complication
• Usually occurs during –
-cervical dilation,
-septum resection,
-adhesiolysis,
-lasers and electrosurgical devices.
Always do simultaneous laparoscopy with these procedures
to avoid it
• If perforation occurs –
procedure is postponed,
vital monitoring of patient,
antibiotics and iv oxytocin

70. BLEEDING –
Second most common complication
Management
Coagulation of bleeding vessel.
Foley’s catheter is inflated with 15-30 ml of fluid and
antibiotic prophylaxis.
Vasopressin and misoprostol.
Embolisation of uterine artery.
Hystrectomy in case of intractable bleeding

71. MEDIA RELATED COMPLICATIONS
• Gas embolism – most common with CO2 and
can cause circulatory collapse and death of
the patient
• Intravasation of media – more risk if
-prolonged operative procedures,
-large volumes of low viscosity media,
-procedures which lead to open venous chanels
-unidentified perforations
- if intrauterine pressure exeeds mean arterial
pressure of the patient.
.

72. • For every liter of hypotonic media absorbed, the
patient's serum sodium decreases by 10 mEq/L. If
the patient's sodium level is less than 120 mEq/L,
she is at increased risk for having devastating
complications. Hyponatremia can occur rapidly,
resulting in generalized cerebral edema, seizures,
and even death.
• In general, if a fluid deficit is greater than 1500
mL or if the sodium level is less than 125 mEq/L,
the procedure should be terminated.
• Out of all nonelectrolyte media, 5% mannitol has
the safest adverse-effect profile because it can
maintain a patient's osmolality despite
hyponatremia, improving neurologic outcomes.

73. • Allergic reactions – most common with
dextran 70
• Others - Derangement of coagulation profile,
water intoxication, hyponatremia and cerebral
oedema.

74. Postoperative complications
• Haemorrhage usually is a sequelae to
unrecognised bleeding during the operative
procedures, infection, deranged coagulation
profile
• Infections not a common complication usually
seen in patients with pre existing infections or
PID or in case proper asepsis is not
maintained.
• Thermal damage if unrecognised may cause
peritonitis, sepsis and even death. In case of
severe burns hystrectomy is the only option.

75. THANK YOU