Hysteroscopy

endoscopy in gyanecology

1. Hysteroscopy Moderator : Dr. Diana

2. Hysteroscope is an endoluminal endoscope that can be used as an aid to visualize uterine cavity or to direct the performance of variety of intrauterine procedures.

3. Historical aspect 1869 : Pantaleon visualize polypoidal tumour in uterus. 1925 : Rubin used cystourethroscope to visualize uterus; he used water to distend uterus and to wash lens. Later he used C0 2 1960-70 – low viscosity fluids like saline or ringer lactate with pressure 50-100mmhg; popularly used in diagnostic hysteroscopy. Cheap and easily available. 1971 – Hyson - used by Menken - 30% dextran in 10% glucose ( K Y jelly is been used in India as distending media for diagnostic hysteroscope )

4. Instruments Hysterocsope : -Telescope : eyepiece, barrel & objective lens. - Angle options : 0 , 12 ,15, 25, 30 & 70 degree. - 0 degree provides a panoramic view. - angled one improve the view of ostia in an abnormally shaped uterine cavity.

5. Rigid hysteroscope - in-patient and complex operating room procedures. - 3-5mm in diameter - more durable and provide superior image.

6. Flexible hysteroscope - most commonly used for office hysteroscopy - flexibility; tip deflection of 120-160 degree. - irregularly shaped uterus & navigation around intrauterine lesions.

7. Light source . - halogen and xenon; xenon generator provides white light, which gives a superior color and intensity.

8. Camera Equipment

9. Diagnostic sheaths -to deliver the distention media -fit by means of a watertight seal lock - 4 to 5 mm in diameter, with a 1 mm clearance between the inner wall and the telescope, through which the distention media is transmitted.

10. Operative sheaths - larger diameter - 7 to 10 - allows space for instillation of medium, for the telescope, and for the insertion of operating devices.

11. Resectoscope -three basic electrodes: a ball, barrel, and a cutting loop. Accessory instruments - alligator grasping forceps, biopsy forceps, and scissors, morcellator - monopolar and bipolar electrodes -A new bipolar system named VersaPoint ™ (saline may be used as distention media)

12. DISTENTION MEDIA - muscle of uterine walls requires a minimum pressure of 40 mm Hg to distend the cavity . - types of distention media - gaseous -liquid - high-viscosity and low-viscosity fluids  

13. Carbon dioxide - colorless gas -ideal for office hysteroscopy.  - given through insufflator - it allows entry evaluation of the endocervical canal.   - disadvantages – gas embolism, no effective way to remove blood and debris.

14. High viscosity fluids - Dextran 70 ( Hyscon  ) Low viscosity fluids with electrolytes -normal saline and lactated ringer’s solution -easy availability and low cost - miscibility with blood hence obscuring the vision - pulmonary and cerebral edema

15. Low viscosity fluids without electrolytes -1.5 % glycine is the most commonly used medium.   -Other non-electrolyte media - 5% glucose and sorbitol / mannitol .

16. Procedure Preparation of the patient : Detailed history and complete physical examination In proliferative phase of menstrual cycle Informed consent bimanual examination

17. Therapeutic Hysteroscopy Anesthesia Local - Paracervical block plus fentanyl 100 mcg IV or ibuprofen 600 mg with diazepam 5mg po 1hr before Spinal – allows monitoring of sensorium with respect to hyponatremia General anesthesia with paracervical block

18. Vasopressin in Paracervical Block Less force (about ½) needed for dilation Less fluid absorbed (about 1/3) Ed’s solution= 5U (1/4 ml) vasopressin in 30ml 1% chloroprocaine or lidocaine (+3ml NaCO3). Inject 6-10ml each side . Alternatively misoprostol (200-400 microgram) can be use 12-24 hrs prior .

19. Indications D iagnostic tool: - Abnormal uterine bleeding : - Premenopausal - Postmenopausal - Infertility : - Intrauterine adhesions ( Asherman’s syndrome) - Submucous fibroids. - Endometrial polyps. - Uterine malformations( abnormal hsg or tvs )

20. Recurrent spontaneous abortion Unexplained infertility

21. Therapeutic tool

22. Correct uterine malformation like septate uterus by resection of the septum. ( bicorneate uterus is corrected by laparotomy using metroplasty ) Polypectomy . Intrauterine adhesions Myomectomy

23. Used as a therapeutic tool - Removal of foreign bodies and IUCD. - CANNULATION OF FALLOPIAN TUBE - to canalize the tube: interstitial obstruction secondary to cellular debris and tubal spasm. - to place intra tubal device for sterilization .

24. treatment of hemangiomas and arteriovenous malformations 

25. Management of Intramural fibroids

26. Wamsteker’s classification

27. Indication

28. Myomas treated hysteroscopically - All submucosal myomas : ( two step procedure are considered) - Single Intramural fibroid <5 cm that lie close to endometrium

29. Contraindications Pregnancy. Current or recent pelvic infection. Current vaginitis , cervicitis and endometritis . Recent uterine perforation. Active Bleeding.

30. Complications Intra-operative bleeding - increase the pressure of distention media above the mean arterial pressure, this compresses the wall of the uterus sufficiently to stop bleeding. -bleeding vessel can be coagulated with a 3 mm ball electrode . 

31. Bleeding can be controlled by inserting a Foleys balloon and inflating it to 3 to 5 ml. The balloon can be kept in situ for 6 to 12 hours rare cases when the bleeding is arterial- uterine artery embolization or even hysterectomy may be needed.

32. Delayed postoperative bleeding - associated with endometrial slough, chronic endometritis or spontaneous expulsion of intramural portion of previously resected submucous myoma Uterine perforation

33. Complications related to distention media : due to CO2 insufflation : -Cardiac arrhythmia due to excessive absorption. -Gas embolism. due to fluid : Anaphylactic reaction Pulmonary edema Adult RDS

34. Acute hyponatremic state- fluid deficit equal or greater than 500 ml should alert a surgeon to a likelihood of hyponatremia and hypoosmolality , which can furthur lead to cerebral edema an CNS abnormality. Close monitoring of inflow and outflow and thereby the deficit can avoid these complications .

35. Complications Late onset: Infections, PID Vaginal discharge: common after ablative procedures and it is self limiting . - Adhesion formation

36. Prevention of adhesion formation: - Second or third look hysetroscopic adhesiolysis . - Barrier methods ( sepra film,amnion graft) -Mechanical methods ( IUD, lippes loop, foley’s balloon) - Hormone treatment ( estrogen, progesterone, GnRH analouges ) - Pharmological agents( antibiotics, antihistaminics , NSAIDS)

37. Robotic Surgery

38. ACOG Committee Opinion Number 444 – November 2009 “ Evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic and abdominal hysterectomy. When it is not feasible to perform a vaginal hysterectomy, the surgeon must choose between laparoscopic hysterectomy, robot-assisted hysterectomy or abdominal hysterectomy.”

39. da Vinci ® Gynecology Improving the Quality of Life for Women

40. Gynecologic Conditions da Vinci ® Surgical System da Vinci Gynecologic Surgery da Vinci Hysterectomy for Early Stage Gynecologic Cancer da Vinci Hysterectomy for Benign Conditions da Vinci Myomectomy da Vinci Sacrocolpopexy

41. Drawbacks with Conventional Laparoscopic Surgery Surgeon operates from a 2D image Straight, rigid instruments (limited range of motion) Instrument tips controlled at a distance Reduced dexterity, precision and control Unsteady camera controlled by assistant Dependent on assistant for surgical support through an accessory port Greater surgeon fatigue Makes complex operations more difficult

42. How to overcome these drawbacks? Improve visualization Improve instrument control Enhance dexterity for technically challenging aspects of the procedure Use superior ergonomics

43. da Vinci Hysterectomy Dexterity for complex dissections ( e.g endometriosis) Vaginal cuff suture closure with ease Improved visualization and access around the cervix for a colpotomy

44. da Vinci Sacrocolpopexy Easier, quicker and more precise suturing Complete control of the camera and all three operative arms A reproducible approach