Safety measures in operative hysteroscopy

1,172 views
848 views

Published on

1 Comment
7 Likes
Statistics
Notes
No Downloads
Views
Total views
1,172
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
66
Comments
1
Likes
7
Embeds 0
No embeds

No notes for slide

Safety measures in operative hysteroscopy

  1. 1. SAFETY MEASURES INOPERATIVE HYSTEROSCOPYOsama M Warda MDProfessor of OB/GYNMansoura University-EGYPT
  2. 2. BackgroundA multicenter study of 92 centers and over 21,000operative hysteroscopy reported a complication rate 0.22%.The most common complication was uterine perforationThe most common complication was uterine perforation(0.12 %), followed by fluid overload (0.06 %),intraoperative hemorrhage (0.03%), bladder or bowel injury(0.02 %), and endomyometritis (0.01 %).Aydeniz et al (2002)2Safety measures in op. Hysterosc.O Warda
  3. 3. Safety Measures; topicsGeneral golden rolesApproach to outpatient procedureEndometrial preparationEndometrial preparationAntibiotic prophylaxisSafe entry and cervical negotiationDistending media managementOperative challenge.Safety measures in op. Hysterosc.O Warda 3
  4. 4. General Golden Rules(Hamou 1993)1. Proper patient selection.2. Surgeon’s experience.(very important)2. Surgeon’s experience.(very important)3. Good instrumentation (e.g. monopolar vs bipolar ).4. Clear visualization with continuous uterinedistention.5. Concurrent laparoscopy / ultrasound.4Safety measures in op. Hysterosc.O Warda
  5. 5. Approach to outpatient hysteroscopyThe most common reasons for failure to completean outpatient hysteroscopy are painpain, cervicalcervicalstenosisstenosis, and poorpoor visualization.visualization.stenosisstenosis, and poorpoor visualization.visualization.Advance in instrumentation, including narrowcaliber hysteroscopes, and use of local anestheticdecreased patient discomfort & facilitated anambulatory procedure. (Readmam et al,2004)5Safety measures in op. Hysterosc.O Warda
  6. 6. Endometrial preparationFor women with regular menses, the proliferativephase is best for visualization of the uterine cavity.For women with irregular menses, thinning of theFor women with irregular menses, thinning of theendometrium is considered before operativehysteroscopic resection of myoma or endometrialablation for better visualization, less bleeding andless operative time (Grow DR& Iromloo K 2006 )6Safety measures in op. Hysterosc.O Warda
  7. 7. Endometrial Thinning, cont.,Many pharmacological agents can be usedfor endometrial thinning such as COCs,for endometrial thinning such as COCs,progestins, desogestrel, raloxifene, all aresafer than GnRh agonists or danazoles .(Cicinelli et al 2007)7Safety measures in op. Hysterosc.O Warda
  8. 8. Prophylactic AntibioticsAntibiotics are not routinely administeredduring hysteroscopy for prevention of surgicalduring hysteroscopy for prevention of surgicalsite infection or endocarditis since post-hysteroscopy infection occurs in less than 1%of women (ACOG Practice Bulletin No. 74, Obstet Gynecol 2006)8Safety measures in op. Hysterosc.O Warda
  9. 9. Safe Entry and Cervical NegotiationNarrow caliber hysteroscopes (≤5mm) typicallydon’t require cervical dilation, particularly inpremenopausal women. If possible, mechanicalcervical dilation should be avoided since it can bepainful. (Readman E, Maher PJ: 2004)9Safety measures in op. Hysterosc.O Warda
  10. 10. Safe Entry and Cervical Negotiation;cont.For patients who require cervical dilation, cervicalpreparation with misoprostol (200-400mcg) may besufficient on its own or can facilitate mechanicalsufficient on its own or can facilitate mechanicaldilation. ( Crane JM, Healey S: 2006).The vaginal route for misoprostol may be moreeffective than oral. (Batukan C etal:2008)10Safety measures in op. Hysterosc.O Warda
  11. 11. Safe Entry and Cervical Negotiation; cont.In postmenopausal women, randomized trial datahave not consistently demonstrated thatpreoperative misoprostol decreases the need forpreoperative misoprostol decreases the need formechanical cervical dilation.(da Costa AR et al:2008), (BarcaiteE et al :2005).Pretreatment with vaginal estrogen (25mcg E2daily) for 2 weeks before surgery may augmentthe cervical dilation caused by misoprostol.(Oppegaard KS et al :2010)11Safety measures in op. Hysterosc.O Warda
  12. 12. Distending media managementAAGL Practice guidelines for the management ofhysteroscopic distending media (2013):18 evidence based recommendations were18 evidence based recommendations werepublished in the Journal of Minimally InvasiveGynecology, Vol.20, No.2, March/April 2013.Some of these guidelines will be tabulated in thenext 3 slides .12Safety measures in op. Hysterosc.O Warda
  13. 13. AAGL Practice guidelines for the management ofhysteroscopic distending media (2013):EVIDENCELEVELRECOMMENDATIONA1-Intra-cervical injection of 8 mL of a dilute vasopressin solution (0.05U/mL) immediately prior to the procedure reduces distending mediaabsorption during resectoscopic surgery.absorption during resectoscopic surgery.A2-The uterine cavity distention pressure should be the lowest pressurenecessary to distend the uterine cavity and ideally should bemaintained below the mean arterial pressure.B3- Excessive absorption of hypotonic fluids such as glycine (1.5% orsorbitol 3%) can result in fluid overload and hypotonic hyponatremia,causing permanent neurologic complications or death.13Safety measures in op. Hysterosc.O Warda
  14. 14. AAGL Practice guidelines for the management ofhysteroscopic distending media (2013):B4- The risk of hypotonic encephalopathy is greater inreproductive-aged women than in postmenopausalwomen.B5- When compared with electrolyte free media, saline B5- When compared with electrolyte free media, salineappears to have a safer profileB6- Excessive absorption of isotonic fluids such as salinecan cause severe complications. Continuous andaccurate fluid monitoring is mandatory.B7- The risk of systemic absorption varies with theprocedure and increases when myometrial integrity isbreached (e.g. with myomectomy).14Safety measures in op. Hysterosc.O Warda
  15. 15. AAGL Practice guidelines for the management ofhysteroscopic distending media (2013):B8- Due to the conflicting evidence regarding their impact onthe volume of fluid deficit during resectoscopic surgery, thedecision to use GnRH agonists should be the provider’sdecision.decision.CRecommendations from 9 to 18 are Level C evidence and included :-CO2 use only in diagnostic procedures-Air purge out the system before and during operative procedure-Limiting preoperative oral or iv hydration-Obtain pre-resectoscope base-line electrolyte levels-Use automated fluid managemet systems15Safety measures in op. Hysterosc.O Warda
  16. 16. Hysteroscopic MyomectomyPre-operative evaluation with SIS, or combinedoffice hysteroscopy and TVS to discoverassociated pathology (eg adenomyosis or polypi)associated pathology (eg adenomyosis or polypi)(Lasmar et al 2005)ESH types 0 , I . (Wamsteker K et al 1993), (Lasmar et al 2005).Diameter ≤5cm carries better prognosis.(Hart R et al 1999).Uterine cavity length ≤ 10cm. (Wamsteker et al 1993)16Safety measures in op. Hysterosc.O Warda
  17. 17. Hysteroscopic Myomectomy cont,:Intra-operative sonographic guidance.(Coccia et al,2000)Two-step procedures if large, multiple,type II17Safety measures in op. Hysterosc.O WardaTwo-step procedures if large, multiple,type IIConcomitant polypectomy during hysteroscopicmyomectomy does not increase operative durationor complication.(Linda D Bradly 2012).
  18. 18. Hysteroscopic MetroplastyVarious instruments including semirigid or rigid scissors(7F) or unipolar wire loop(8mm), urologic resectoscope(21-26F), Versapoint® bipolar electrode (1.6; 5mmsheath); or lasers (KTP/532), (Nd:YAG),( argon).sheath); or lasers (KTP/532), (Nd:YAG),( argon).Use of any of them is associated with good success ratesand infrequent complications.Use of micro-scissors or bipolar electrodes decreaseoperative time. (Colacurci et al 2007)18Safety measures in op. Hysterosc.O Warda
  19. 19. Hysteroscopic Adhesiolysis:In severe adhesions :(to avoid perforation)1. Concurrent ultrasound guide cervical dilationavoiding false passage. (Marcelle I Cedars 2012)2. Concurrent laparoscopy (Levine & Neuwirth;1973)3. Concurrent fluoroscopy ( Thomson et al;2007).4. Multi-stage surgery (Zikopoulos et al 2004)19Safety measures in op. Hysterosc.O Warda
  20. 20. Endometrial Ablation1st generation (resectoscopic) : no significantdifference in complications between ablation andresection.(Lethaby et al 2009)resection2nd generation (non-resectoscopic) ; (safer)most of these techniques don’t require hysteroscopy.Requires less experience and less operative time.(Deb et al 2008)20Safety measures in op. Hysterosc.O Warda
  21. 21. The surgeon’s skill remains the bestsafety measure in operativehysteroscopy.Safety measures in op. Hysterosc.O Warda 21hysteroscopy.

×