hysteroscopy

HYSTEROSCOPY

PRESENTED BY DR PAWAN JHALTA

MODERATOR DR NISHI SOOD

DEFINITION

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

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.

INSTRUMENTS

TelescopesLight sourceDiagnostic and Operative sheathsDistending mediaCameraAccessory instruments

TELESCOPE3 parts – a) eye piece b) barrel c) objective lensAvailable 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.

`

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.

OPERATIVE SHEATHS It has channels for a) 3 - 4 mm telescope b) instillation of medium c) operating instrumentsTypes 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.

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.

RESECTOSCOPE

Electrosurgical endoscopeConsists 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

viewElectrode can be ball, barrel, knife, or cutting loop

type.

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.

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

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.

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.

CO2 AS DISTENDING MEDIAUsed 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 canalDISADVANTAGES – 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

LOW VISCOSITY DISTENDING MEDIADelivered 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 pumpProper 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

NORMAL SALINE

0.9% Normal Saline is commonly usedAdvantage Widespread availability Low operative cost Physiological disposal by peritoneal absorptionDisadvantage Efficient conductor of electrons so electrosurgery

with monopolar devices is not possible. Not suitable for office hysteroscopy. Fluid overload and pulm oedema risk

Glycine (1.5%) and Sorbitol (3%)

ADVANTAGE Inexpensive and readily available Media of choice for monopolar cauteryDISADVANTAGEHypo-osmolar solution causing dilutional

hyponatremia and hypervolemiaInterferes with oxygenation and coagulationCerebral oedema,cardiac and skeletal muscle

dysfunction.

MANNITOL (5%) AND GLYCINE (2.2%)

Iso-osmolar Can be used with electrosurgical instruments Decreased risk of fluid overload and

hyponatremia .

HIGH VISCOSITY MEDIA -HYSKON

High viscosity liquid distending media32% high molecular weight dextran solution Colourless viscid mediumUsual volume required- Diagnostic – 100 ml Operative 200 – 500 ml Upper safe limit 500 ml. 1ml of hyskon withdraws 20 ml of water in

circulation

AdvantagesBeing highly viscous small quantities arerequired for examination.Provides excellent visualization due to its high

refractive index and as does not mix with blood.

DisadvantagesExpensiveCaramalize on instruments and may freeze the

stopcocks of the instruments making them inoperable.

Morbidities ocaused are • Pulmonary edema• Coagulopathies • Electrolyte imbalance• Anaphylactic reactionMechanical pump is necessary to deliver these

fluids.

ENERGY SOURCES

• Mechanical energy • Monopolar• Bipolar standard electrode.• Bipolar versapoint .• LASER• Resctoscopes.

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.

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

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

CONTRAINDICATIONS

• Recent history of PID as it may precipitate acute symptoms

• Acute cervicovaginal infections• Extreme bleeding• Pregnancy

DIAGNOSTIC HYSTEROSCOPY

• Office hysteroscopy (outpatient hysteroscopy)• Vaginoscopic approach• Inpatient hysteroscopy

Anaesthesia Local paracervical blockGenaral anaesthesia

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.

Distension media normal saline CO2Operative findings polyps myomas synechiae septa vascular pattern gland openings endometrial hyperplasia growth

EctocervixEndocervix

Internal os

Endmetrial cavity

Panoramic view of normal endometrial cavity

polyp Submucus myoma

Septum adhesion

Endometrial carcinoma

• OPERATIVE HYSTEROSCOPY PROCEDURES

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

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.

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

TRANSCERVICAL RESECTION OF ENDOMETRIUM

• Loop shaped electrode is used monopolar energy bipolar energyContinuos flow resectoscope provides efficient resection of

endometrium and myometrium(2.5-3 mm).AdvantagesProvides tissue for histopathologySuitable for thick endometriumSubmucus fibroids and polyps can be excised at the same

time

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

resectoscope

HYSTEROSCOPIC LASER ENDOMETRIAL ABLATION

Advantages Tissue coagulation upto 5-6 mm Perforation is less likely than resection Small fibroids and polyps can be vapourisedDisadvantages Expensive capital and running cost Slowest of all techniques Greater risk of fluid overload Need for special laser safety procedures and

guidelines

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.

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

HYSTEROSCOPIC ADHESIOLYSChallenges - 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

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

UTERINE SEPTUMTECHNIQUE 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

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.

ESSURE SYSTEM

Hysteroscopic tubal cannulationINDICATION 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.

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

Hysteroscopic myomectomy

• Leiomyomas appear as white spherical masses covered by network of thin fragile vessles

• PRE OPERATIVE ASSESSMENT- -Diagnostic hysteroscopy -Endometrial biopsy -Transvaginal ultrasonography

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*

Pedunculated leiomyoma Partially intramural myoma

Myoma with predominantly intramural development

Factors For GnRH analoguesParameters

•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

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.

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

COMPLICATIONS OF HYSTEROSCOPY

INTRAOPERATIVE POSTOPERATIVE

INTRAOPERATIVE COMPLICATIONSPERFORATION – • 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

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

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..

• 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.

• Allergic reactions – most common with dextran 70

• Others - Derangement of coagulation profile, water intoxication, hyponatremia and cerebral oedema.

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.

THANK YOU