EVIDENCE BASED PRACTICAL TIPS FOR OFFICE HYSTEROSCOPY BY DR SHASHWAT JANI

Evidence Based Practical Tips
For
Office Hysteroscopy
Dr. Shashwat Jani.
M.S. ( Gynec ).
Diploma in Advance Endoscopy ( France ) .
Assistant Prof., Smt. N.H.L. Mun. Medical College,
Ahmedabad, Gujarat.
Mobile : +91 99099 44160.
E- mail : drshashwatjani@gmail.com

Greetings From Ahmedabad . . .
27-Nov-14 Dr Shashwat Jani. 9909944160 2

What is E.B.M. ...???
 Evidence Based Medicine…? 
 Experience Based Medicine…? 
 Eminence Based Medicine....? 


Sources
Cochrane library .
Royal College of Obstetricians &Gynecologists
(RCOG) Guidelines.
Journal of Evidence Based Obstetrics & Gynecology.
National Guideline Clearinghouse . ( U.S. Govt. ).
New Zealand Guidelines Group
PubMed.
 Italian Society of Gynecological Endoscopy.
International Society Of Gynecology Endoscopy.
American Association Of Gynecology Laparoscopist.

What is Office Hysteroscopy .???
“ Diagnostic hysteroscopy and some
operative hysteroscopic procedures
should be conducted outside of the
formal operating theatre setting in an
appropriately equipped and staffed
ambulatory situations & yet guarantying
patient’s safety & privacy. “

 No Anesthesia nor Analgesia.
 No drugs ( Atropine only ).
 No speculum nor Tenaculum.
 Operative procedures.

Prof Bettocchi
 A pioneer in the field of office hysteroscopy,
Prof Bettocchi, in 2004 reported on 4863
operative hysteroscopic procedures where a
vaginoscopic technique was used without analgesia or
anesthesia.
 As technology has further advanced and
hysteroscopes have reduced in size, office procedures
have become even more feasible.
 There have also been improvements in energy
sources such as bipolar (as opposed to monopolar)
that have decreased complications related to the
operative distension media, this has made operative
hysteroscopy more acceptable.

SET UP
Set Up

Hysteroscopy Instrumentation
 Lockable cabinet
 Telescope
 Sheath system
 Hysteroscope
- Diagnostic
- Operative
Resectoscope
 Distention systems
Fluid delivery system
 Light source and cable
 Video cameras and monitors

Indications…
DIAGNOSTIC :
 Unexplained abnormal Uterine bleeding (AUB) .
 Peri and post menopausal bleeding.
 Selected infertility cases.
 Abnormal HSG.
 Unexplained Infertility.
 Recurrent pregnancy loss.
 Should be used prudently
only after other investigations.

INDICATIONS…
Therapeutic:
 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.

Timing…
Ideally Post menstrual Period

Anesthesia…
3 mm Flexible/Rigid
• Usually not needed
5.5 mm Rigid w/o Dilatation
• Parous usually not needed
• Tenaculum site local
• 1% Lidocaine
5.5 mm Rigid with Dilatation
• Tenaculum site local
• Paracervical block

Analgesia…
 Routine use of Opiates NOT recommended.
 Women without contraindications should
be advised to consider taking standard doses
of NSAIDs around 1 hour before their
scheduled outpatient hysteroscopy
appointment with the aim of reducing pain in
the immediate postoperative period.

Cervical Preparation…
Routinely NOT recommended…
See and Treat
• Cervical dilation usually not needed
• 3 mm flexible hysteroscope with sheath.
Misoprostol
• Cramping and bleeding
• Give narcotic pain medication

Misoprostol
 Misoprostol is not required in every patient,
but should be considered in selective patients :
- Post menopausal patients,
- Nulliparous patients,
- Patients who have had previous cervical surgery
or where the procedure is assessed to be difficult in
dilating cervix.
 Oral / Vaginal 400 μgm 6-8 hr prior.
 Sublingual 400 μgm 2-4 hr prior.

Types of Hysteroscope
 Miniature hysteroscopes (2.7mm with a 3 –
3.5mm sheath) should be used for diagnostic
outpatient hysteroscopy as they significantly reduce
the discomfort experience by the woman.
 1.9 mm Microhysteroscope should be reserved
for special cases like severe cervical stenosis.

 There is insufficient evidence to recommend
0° or fore-oblique optical lenses (i.e. 12°, 25° or 30°
off-set lenses) for routine outpatient hysteroscopy.
Now ,,,
Types Of Hysteroscopes?

 Flexible hysteroscopes are associated with
less pain during outpatient hysteroscopy compared
with rigid hysteroscopes.
 However, Rigid hysteroscopes may provide
better images, fewer failed procedures, quicker
examination time and reduced cost.
 Thus, there is insufficient evidence to
recommend preferential use of rigid or flexible
hysteroscopes for diagnostic outpatient procedures.
Choice of hysteroscope should be left to the
discretion of the Operator…!!!


Distension Media
OR
 For routine outpatient hysteroscopy, the
choice of distension medium between Carbon
dioxide and Normal Saline should be left to the
discretion of the operator as neither is superior in
reducing pain, although uterine distension with
normal saline appears to reduce the incidence of
vasovagal episodes.

 Uterine distension with Normal saline
allows improved image quality and allows
outpatient diagnostic hysteroscopy to be
completed more quickly compared with
carbon dioxide.
 Operative outpatient hysteroscopy, using
bipolar electrosurgery, requires the use of
normal saline to act as both the distension
and conducting medium.

Local Anesthesia & Cervical Dilatation
 Miniaturization of hysteroscopes and increasing use
of the vaginoscopic technique may diminish any advantage
of Intracervical or paracervical anesthesia.
 Routine administration of intracervical or paracervical
local anaesthetic should be used where :
 larger diameter hysteroscopes are being employed
(outer diameter greater than 5mm) &
 where the need for cervical dilatation is anticipated
(e.g. cervical stenosis).
 Routine administration of intracervical or paracervical
local anesthetic is Not indicated to reduce the incidence of
vasovagal reactions.

Conscious Sedation
 Conscious sedation should not be routinely
used in outpatient hysteroscopic procedures as it
confers No advantage in terms of pain control and
the woman’s satisfaction over local anaesthesia.
 Life-threatening complications can result from
the use of conscious sedation.
 Appropriate monitoring and staff skills are
mandatory if procedures are to be undertaken using
conscious sedation.

Antibiotics
 Routine use of Antibiotic is
NOT recommended after Diagnostic
Office Hysteroscopy.
 But should be given in Operative
Hysteroscopy.

Vaginoscopy
 Vaginoscopy should be
the standard technique
for outpatient
hysteroscopy, especially
where successful
insertion of a vaginal
speculum is anticipated
to be difficult and where
blind endometrial biopsy
is not required.

Tips for the Bettochi vaginoscopic
technique :
 Enter into the vagina, aiming for deep in the
posterior fornix.
 Initially place the hysteroscope light lead at
6 o’clock and try to localize the cervix.
 Once through the external os, follow the
endocervical canal (seen as a ‘Black Hole’).
 At the internal os turn scope on its side by
turning the light lead 90 degrees as this facilitates
entry of scope into the uterine cavity.

Role In Infertility

As a Screening test…
 Given the low invasiveness and the safety of
office hysteroscopy and the desire for the infertile
couple to shorten as much as possible the
diagnostic period which is often a source of anxiety
and uncertainty, it is reasonable to recommend the
evaluation of uterine cavity by office hysteroscopy
in the diagnostic work up of infertile couples.
(LEVEL OF EVIDENCE VI,
STRENGH OF THE RECOMMENDATION B).

Prior to IVF….
 Hysteroscopy should be recommended for
women with repeated implantation failure.
(LEVEL OF EVIDENCE I ,
STRENGH OF THE RECOMMENDATION A).
 However, a “screening” office hysteroscopy
should be performed before including patients in an
IVF program in order to minimize any negative
intrauterine influence on IVF outcome.

H/o of Recurrent Miscarriage…
 Diagnosis and treatment by hysteroscopy of
uterine malformations and intrauterine
adhesions in such patients may improve live birth
rate and therefore, their treatment could be
recommended.
(LEVEL OF EVIDENCE V,

Role In AUB…
 Hysteroscopy should be always performed in
women presenting with AUB, in whom other tests
(Sonohysterography and/or Transvaginal
ultrasound) have already reported OR have been
unable to rule out endouterine pathologies.
( LEVEL OF EVIDENCE III ,
STRENGHT OF THE RECOMMENDATION B ).

Post menopausal Bleeding…
 It is reasonable to recommend evaluation of
endometrial cavity by hysteroscopy in cases of
repeated AUB in such women.

Role in Biopsy…
 Target-eye biopsy is more accurate than
blind biopsy, and therefore hysteroscopy with
multiple target biopsies should be used in
place of blind techniques in the diagnostic
work-up for atypical lesions.
( LEVEL OF EVIDENCE II,

 The possible risk of the spreading of
neoplastic cells to the abdominal cavity should
not limit the use of hysteroscopy in favour of
blind techniques.
(LEVEL OF EVIDENCE II,
STRENGH OF THE RECOMMENDATION A ) .

TIPS
For
Managing & Minimizing
Operative Complications

“ Ignoring contraindications to
hysteroscopic surgery increases
the risk of complications and is
the single greatest factor leading
to patient injury and physician
liability. “

Contraindications
 Acute pelvic inflammatory disease
 Pregnancy
 Genital tract malignancies
 Lack of informed consent
 Inability to dilate the cervix
 Inability to distend the uterus to obtain visualization
 Poor surgical candidates who may not tolerate fluid
overload because of renal disease, or radiofrequency
current when a cardiac pacemaker is present.
 Unfamiliarity with equipment, instruments or
technique
 Lack of appropriate equipment or staff familiar with
the equipment.

A False Passage…
 If muscle fibers are visible and the tubal ostea are
not, assume the passage is false.
 Slowly remove the hysteroscope and identify the
true cavity for confirmation.
Discontinue the procedure—even if no perforation
is detected—to prevent distention fluid from being
absorbed into the circulation through the injury.
Adequate distention is not possible at this time.
Delay repeat hysteroscopy for 2 to 3 months.

A False Passage…
Myometrial
fibers signal
that a false
passage has
been created.

To Avoid Creating A False Passage…
 Dilate the cervix with slow, steady pressure and stop as
soon as the internal os opens; do not attempt to push the
dilator to the uterine fundus.
 Often the external os opens, but the internal os cannot be
dilated the extra 1 to 2 mm necessary to accommodate the
27- French resectoscope.
Rather than exert more force and risk perforation or
laceration, simply turn on the resectoscope’s inflow with the
outflow shut off, and let the fluid pressure dilate the cervix.
 Always insert the hysteroscope or resectoscope under
direct vision rather than use an obturator.
 Keep the “dark circle” in the center of the field and slowly
advance the hysteroscope toward it until the cavity is
reached.

Avulsion of the Myometrium
Small bowel visible
within the uterine
cavity after avulsion
of uterine wall at
the time of
myomectomy.

To Prevent Myometrial Avulsion…
 Keep the myoma grasper away from the fundus
when removing myoma segments, and avoid
excessive traction on what may be a thin segment
of myometrium.
 Injuries can occur when the grasper perforates
the uterus and bowel is inadvertently grasped.
 Large injuries require laparoscopic repair.
 Perforation is more likely in repeat procedures.

Perforation…
 In the AAGL survey, the incidence of perforation
was 14 per 1,000.
 It was even higher during transection of lateral
and fundal adhesions: 2 to 3 per 100.
 Although perforation is more common with
thermal energy sources, it may occur mechanically
when scissors are used to transect a uterine
septum, synechiae, or polyps.

Perforation…
 Hysteroscopic view of
perforation at the fundus.
 The small bowel is
visible beyond the
perforation at left.

When perforation occurs…
 During the use of thermal energy, laparoscopy is
necessary to assess the organs overlying the site.
 During setup for laparoscopy, bring the hysteroscope
near the area of perforation to inspect the bowel beyond the
uterus.
 Since the pelvis fills quickly with distention fluid, the
hysteroscope can even be placed through the perforation to
yield an excellent view of the undersurfaces of the bowel
immediately adjacent to the injured area.
Disconnect the electrosurgical cord before doing this..!!!


Intra operative bleeding…
 Bleeding is unlikely unless vessels are
lacerated or injured in the cervical canal or
lower uterine segment during dilation or deep
ablation or vaporization.
 Bleeding is more common when
endomyometrial resection is performed with
the wire loop electrode or during ablation or
vaporization of fibroids.

To achieve hemostasis
1 ) Insert a Foley catheter with a 30-cc balloon into
the uterine cavity, inject 15 to 20 mL (or more for a
larger cavity) of fluid into the balloon, and observe
the patient.
2 ) Pack the uterus.
1/2-inch–gauge packing that has been soaked in a
dilute vasopressin solution.
(20 U [1 mL] in 60 mL Normal Saline).

Benefits of Vasopressin :
Before balloon tamponade or Packing the uterus,
Inject very dilute vasopressin :
(4 U [0.2 mL] in 60 mL normal saline)
directly into the cervix 2 cm deep,
at the 4 and 8 o’clock positions.

Electrosurgical & Gaseous Complications
 Most electrosurgical complications involve
activation of an electrode at the time of
perforation, or current diversion to the outer
sheath.

To Avoid…
 Avoid perforating the uterus by applying current
only when the electrode is moving toward the
operator, not the fundus.
 To avoid return-pad injuries :
Keep the patient’s thigh completely dry;
ensure that the pad is flat against the skin at
application, with no bubbles or creases; and use
only return electrode monitor (REM) dispersive
pads.

Gas Embolism :
 Carbon dioxide is a soluble gas, so these
emboli generally resolve rapidly.
 In contrast, room air emboli are more
likely to be fatal.

To reduce risk of gas embolism :
 Avoid Trendelenburg positioning
 Remove last dilator just before inserting the
resectoscope
 Limit repeated removal - reinsertion of the
resectoscope
 Vaporizing myomas eliminates the need to
remove fibroid chips
 Intracervical injection of vasopressin may
block gas from entering circulation.

Distension Media :
 Continuously record inflow and outflow using the
electronic monitor with the deficit alarm set to 500 mL.
 Keep distention fluid at room temperature and monitor
the patient’s core temperature continuously.
 Significant fluid intravasation will lower the patient’s
temperature, and this may be the first sign of fluid overload.
 Perform operative hysteroscopy under spinal or epidural
anesthesia so the anesthesiologist can continually assess the
patient’s sensorium.
 Confusion and irritability are early signs of dilutional
hyponatremia.

Safety First…
 Hysteroscopy is a technologically dependent
surgery and before starting surgery every
surgeon should have reasonably good
knowledge of Hysteroscopic procedures.
 Please put a board in your Hospital :
“ Your Safety Is Our First Priority. “
drshashwatjani@gmail.com 55

Thank you

EVIDENCE BASED PRACTICAL TIPS FOR OFFICE HYSTEROSCOPY BY DR SHASHWAT JANI

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EVIDENCE BASED PRACTICAL TIPS FOR OFFICE HYSTEROSCOPY BY DR SHASHWAT JANI