OPERATIVE HYSTEROSCOPY

1. OPERATIVE HYSTEROSCOPY
Dr. Khushbu Agrawal

2. THERAPEUTIC INDICATIONS
• Resection of uterine septum
• Uterine synechiae
• Cannulation of fallopian tubes
• Uterine polyps
• Submucous myomas
• Endometrial ablation
• Sterilization - ESSURE
• IUD removal
• Biopsy of intrauterine lesions
• Hemangioma and A-V malformations
• Foreign body removal

3. INSTRUMENTS
• OPERATING SHEATH
The sheath outer diameter ranging between 7 – 10 mm
•to permit the passage of surgical instruments and
•to provide adequate uterine distention using liquid media.

4. Operating instruments
• RESECTOSCOPE
•2 DIAMETERS
•22 Fr – for less dilated cervix
•26 Fr – for bulky uterus
•ENDOSCOPE – 12o viewing angle
•2 SHEATH
•For continuous irrigation
•Suction of distension medium
•A passive spring mechanism for
•CUTTING LOOP
•MICROKNIVES
•ELECTRODES

5. VARIOUS OPERATING ELEMENTS
• CUTTING LOOP
• COLLINS KNIFE
• BALL ELECTRODE

6. Accessory instruments
BIOPSY AND GRASPING FORCEPS
SCISSORS
PUNCH
BIOPSY SPOON FORCEPS
SCISSORS
TENACULUM GRASPING FORCEPS

7. COMPLETE SET FOR OPERATIVE
RESECTOSCOPY
• A RESECTOSCOPE
• THE VIDEO-CAMERA SYSTEM
• THE COLD LIGHT SOURCE
• THE ELECTROSURGICAL UNIT
WITH AUTOMATIC POWER
SUPPLY CONTROL AND
ALARM FUNCTION

9. SPECIFIC PROCEDURES IN
HYSTEROSCOPIC SURGERIES

10. Septate Uterus
• Problem –
– 1st & 2nd trimester losses
– Premature labour
– Primary Infertility
• Concurrent hysteroscopy and laparoscopy:
gold standard for diagnosis
• Laparoscopy needed to r/o bicornuate uterus
Pregnancy wastage

11. Hysteroscopic Meteroplasty
• Anesthesia- GA/SA
• Method
– Microscissors
– Nd-YAG Laser
– Electrosurgery
• Guidance Under
– Laparoscopy
– Ultrasonography

12. Technique
• Panoramic view
• Tubal ostium indentification in each chamber
• Septum is cut from below upwards till fundus
• WHEN TO STOP
– Light transmission via fundus laparoscopically
– Both ostia are visualized in panoramic view.
• To incise – excision is not necessary to avoid
undue myometrial invasion, bleeding and
rupture.

13. • Resect at midpoint
• Avoid to drift posteriorly to prevent bleeding
• Clip the septum squarely in the middle
• At thicker septa – cut from periphery inward
to center.

14. •Follow-up  1-2 months postop
 HSG or hysteroscopy
SCAR

15. Uterine Synechiae
• Asherman Syndrome – adhesions formed
between anterior and posterior wall
• Insult – trauma eg curettage, infection eg GTB
• C/F : Hypomennorhea/ Amenorrhea/Infertile
• Diagnosis: HSG, Hysteroscopy.

16. ADHESIOLYSIS
• Most difficult of all hysteroscopic surgeries
• Methods:-
– Scissors
– Resectoscope
– Nd-YAG laser
• Lysis opens many vascular channels
– high risk of Intravascular Absorption Syndrome.

17. Technique
• Thorough cavity assessment for degree of
adhesions.
• Filmy and central adhesions
– Cut first
– Use Microscissors
• Marginal and dense adhesions
– Cut last
– Use Bipolar electrode
• Post op – use of IUDs prevents readhesions

18. Catheterization of Fallopian Tubes
• Indications
– Unblocking of the ostium and proximal tract
– Application of intratubal contraception devices
• ESSURE
• ADIANA

19. Cannulation in Tubal obstruction
• Proximal tube – 10- 20% cases
• PID
• ENDOMETRIOSIS
Diagnosis – HSG, Chromopertubation.
• Tubal plugs – non anatomical blockage:
resolve after diagnostic procedures
• True anatomical occlusion – 50%

20. Technique –
Modified Novy cannulation set
• Introducing catheter - 5Fr - 35 CM
• Inner Catheter - 3 Fr – 50 CM
• Guide wire - 0.18’’ – 80 CM

22. SUBMUCOSAL MYOMATA
• Complaints:
– HMB, infertility, recurrent pregnancy loss
• Diagnosis:
– Hysteroscopy with combination of
• MRI
• SIS
• TVUS

23. CLASSIFICATION
EUROPEAN SOCIETY OF GYNE ENDOSCOPY
GRADE 0(G0)
Development limited to
uterine cavity.
Pedunculated
GRADE 1(G1)
Partial intramural
component.
>50% endocavitary.
Angle of protrusion<90o
GRADE 2(G2)
Predominantly intamural
development.
<50% endocavitary
Angle of protrusion >90o

24. MYOMECTOMY
• ROUTE OF MYOMECTOMY
– Desire for future fertility
– Size of myoma
– Number of myoma
– Locations of myoma
– Type 2 lesions – relationship with uterine serosa
– Presence of other coexisting pelvic disease
– Availability of appropriate equipment

25. Transcervical Myomectomy
• Preferred due to
– Higher efficacy
– Reduction in surgical morbidity
– Absence of abdominal scar
• Methods of hysteroscopic myomectomy
– Cutting using electrosurgical loop
– Vaporization
– Morcellation – Mechanical (FDA Approved)

26. Preprocedural Preparation
• Use of suppressive medical therapy
– Reduction of volume
– Amenorrhea to built up hemoglobin and iron store
– Facilitation of procedure including improved
visualization
– Reduced systemic absorption of the distending
media
– Complete resection of large myomas in one
setting
GnRH administration 2 months before TCRM resulted in 35% reduction of size.

27. Cervical preparation
• Misoprostol – PGE1 analogue
– 200-400 mcg PO/PV, 12-24 hrs before surgery
• Intracervical vasopressin
– 4 U in 80ml : use 10 ml to inject at 4:00, 8:00 of
the cervix at the time of hysteroscopy.
– Significant reduction in force for dilation of cervix
– Decrease risk for absorption syndrome, bleeding.

28. Technique
• LOOP ELECTROSURGICAL RESECTION
– Activation of electrode with low voltage(cutting)
current  strips of myoma created  removal of
the fragmented tissue
• BULK ELECTROSURGICAL VAPORIZATION
– Activated large surface area electrode with low
voltage applied over large volumes of tissue 
volume reduction of tumor  removal of residual
tissue with grasping forceps

29. • Results in AUB treatment
– EA + TCRM : In women who do not desire fertility,
it improves the success rate to decrease HMB.
TCRM TCRM + EA EA
Completely resected
myomas
84.4% 96.7%
Incompletely resected
myomas
70.4% 92.3%
REPEAT SURGERY RATE 34.6% 39.6%
Loffer FD. Improving results of hysteroscopic submucosal
mymoectomy. J Minimum Invasive Gynecol. 2005;12:254-260(II-3).
SUCCESS RATE
PROCEDURE

30. • Results in INFERTILITY treatment
STUDY- 108 TYPE 0 TYPE 1 TYPE 2
FERTILITY
RATE
49% 36% 33%
STUDY - 215 TCRE DHL & BIOPSY
FERTILITY RATE 63% 28%
RCT – FertilSteril. 2010;94:724-729(I)
Italian study- ObstetGynecol.1999;94:341-347(II-2)
• Results in RECURRENT PREG LOSSES
•Less evidence to support the benefit.
•Mostly 1st trimester losses due to natural risk
DHL: DIAGNOSTIC
HYSTEROLAPAROSCOPY

31. ENDOMETRIAL POLYP
• Hyperplasia: single/multiple; sessile/
pedunculated
• Causes:- AUB/ Infertility/ Endometritis
• DIAGNOSIS: USG/SIS/Hysteroscopy
• Treatment:
– Operative hysteroscope with scissors
• Extraction using grasper or endobasket or simple
curettage.
– Resectoscope electric snare loop – for larger polyp
in piecemeal

32. ENDOMETRIAL ABLATION in AUB
• Described first in 1981.
• Decreased cost , morbidity
• Adequate preoperative counseling
– Hypomenorrhea.
– Rare need for hysterectomy
– Not a method of contraception
– No protection - endometrial Ca.

33. Preoperative preparation
• EB – R/O endometrial Ca and hyperplasia
• Pretreatment :6 wks with GnRH
• Haemogram, Coagulogram.
• Consent
• 1.5% Glycine: distention media.
• No need of simultaneous laparoscopy

34. AIM & ACTION OF ABLATION
• AIM – To destroy the visible endometrium
including the cornual endometrium
• Depth – 1-2 mm.
• ACTION – Heat penetrates 3-5 mm deeper, burns
the superficial myometrium and coagulates the
radial branches of the cavity.
• No regeneration due to loss of basal and spiral
arterioles.
• 6-8 weeks later the uterine walls scar and shrinks

35. Technique
• RESECTOSCOPE WITH MONOPOLAR LOOP
ELECTRODE.
• Remove the debris and blood.
• Never use cutting loop over fundus and cornu

36. Technique contd.
• Next – anterior and lateral walls
• Last – posterior wall
• Never- below the internal os into cervix
• AVOID –
– Prolong contact time to reduce risk of deeper
injuries and perforation.

37. Views during Ablation

38. Failure of endometrial ablation
• Adenomyosis
• Bulky uterus
• Curettage immediately prior to the procedure
• No premedication with GnRH analogues

39. MISCELLANEOUS PROCEDURES
• MISSING IUD REMOVAL
– String grasped with – Alligator-jaw forceps
– Embedded IUDs – Rigid grasping forceps used

40. COMPLICATIONS OF
HYSTEROSCOPY

41. • INCIDENCE : 0.2%
• 10% with major operative surgeries
• SPECTRUM
– Perioperative complications
– Postoperative complications

42. Perioperative
• Patient positioning
• Anesthesia
• Access to the endometrial cavity
– Cervical trauma
– Uterine perforation.
• Gas emboli
• Intraoperative bleed
• Absorption of distention media syndrome.
• Lower genital tract injuries, burns.

43. Post operative
• EARLY
– Infection
– Postop bleeding
• LATE – sequelea
– Intrauterine adhesions
– Uterine rupture during pregnancy

44. PATIENT POSITIONING
• Nerve trauma
• Direct trauma
• Compartment syndrome
• VARIOUS POSITIONS
– Lithotomy position
– Modified lithotomy position – Ideal position
IN ALL PATIENTS WITH
GENERAL ANESTHESIA – AS
THEY CANT REPORT OF
THEIR DISCOMFORT.

45. Dorsal lithotomy position
Compartment syndrome in the lower legs.
• Pathophysiology – ischemia + reperfusion injury
• Sequelae
– Rhabdomyolysis
– Permanent disability
• Events facilitating it
– Leg holders
– Pneumatic compression stockings
– Any direct pressure

46. NERVE INJURY
Femoral neuropathy
Excessive hip flexion
abductionext hip
rotation extreme
angulation of FEMORAL
nerve- compression injury.
Temporary – needs intensive
physical therapy to resolve

47. • Sciatic nerve injury-
– At sciatic notch
• Common peroneal injury
– At neck of fibula – FOOT DROP/ LOWER LATERAL
PARAESTHESIA

48. RISK REDUCTION & MANAGEMENT
• Ideal lithotomy position- moderate flexion
with limited abduction and ext rotation
• Avoid pressure on injury prone areas
• Avoid leaning on the thigh of the patient.
• Early identification and t/t of complication
Compartment syn & Neuropathy

49. ANESTHESIA RELATED
• Local anesthesia related
– Allergic reactions
– Cardiovascular complications
• Awareness and avoiding
– Fluid overload
– Electrolyte disturbance
– Signs of gas embolization

50. INTRAOP/POSTOP BLEEDING
• Most common complication.
• Mostly in myoma resection.
• Immediate :aspirate the blood and increase the
pressure of distention media above the mean
arterial pressure.
• Coagulate with 3mm ball electrode.
• Foleys balloon compression with 3-5ml saline –
kept for 6-12 hrs.
• Rare – UAE/ Hysterectomy

51. Uterine perforation
• Most common during
– septal resection- approaching the fundus
• Dangerous – lasers and electrosurgical
devices.
• Clue - difficult to maintain the distention.
• Safeguard – simultaneous laparoscopy – alerts
the assistant against impending perforation

52. Management
• Non-energy instrument
– Strict observation in postop period
– Any hemodynamic deterioration – immediate
laparotomy.
• Energy instrument
– Laparotomy to ensue adjacent organs injury
• High risk for uterine rupture during future
pregnancy

53. Prevention
• Activate the foot pedal only during the return
phase of electrode towards the sheath.
• Never activate the device during a forward
movement.
• Use roller-ball based
device at the cornu.

54. INTRAVASCULAR ABSORPTION SYNDROME
(OHIA)
• Low viscosity Liquid distention media
• Incidence < 1%.
• More in premenopausal women
– Female sex steriods – inhibits Na-K+/ATPase pump
thus water and sodium not thrown out of cells.
– GnRH agonists inhibits such hormones action –
may prevent this complication to occur.

55. 1.5% Glycine
Low Viscosity Fluid
Hypoosmolar in nature – when delivered by high
pressure infusion pump – excess vascular absorption
 sudden onset Acute Hyponatremia, hypo-osmolar
state IN BLOOD

56. Women’s brain
deficient in such
mechanisms.
Circulatory absorption
creates a gradient
between blood and the
brain cells
Can be overcome by
pumping cations
out of the cell into
blood
Results
CEREBRAL
EDEMA
BRAIN
CELLS
VESSEL
Na/K
ATPase

57. • NORMAL SALINE
– SAFEST
– EXCESSIVE VASCULAR ABSORPTION  FLUID
OVERLOAD  PULMONARY EDEMA.
– NOT SUITABLE FOR MONOPOLAR SYSTEM : good
conductor of electrons.

58. Media Delivery & Management
• Delivery system
– Simple gravity – 10mm tubing – 70-100 mmHg –
height 1-1.5 m above uterus.
– Automated pumps
– Insufflators – for CO2 gaseous media
• Volume estimation
– Vol infused– Vol coming out = Vol absorbed
– Measured manually by capturing & measuring.

59. DEVICES

60. PREVENTION & TREATMENT
• Preprocedure
– Use of GnRH analogs
– Use of Vasopressin
• Intraop
– Work at lowest effective pressure(50-80mmHg)
– Complete as quickly as possible
– Baseline electrolyte
– Cautious in cardiopulmonary disease

61. PREVENTION & TREATMENT
• Deficit – 750ml  check electrolytes & give
Inj Lasix 10-40mg
• Deficit > 1500 ml  stop the procedure
• If Na <125mEq/L  terminate the procedure.
• Post op care of such cases in HDU.
• Look for CEREBRAL OR PUL EDEMA, RHF, need
for VENTILATOR support, use of diuretics.
• May require use of hypertonic solutions.

62. Gas Embolus
• Faulty methods
– Use of laparoscopic insufflator to infuse CO2 in
uterus.
• Diagnosis:
– Tachycardia , desaturation & Hypotension
– Cog-wheel murmur (10% cases) – disappearance
once the hysteroscopy stops
– Rapid fall in expired CO2.

63. Precautions to prevent 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

64. MANAGEMENT
• DURANT Maneuver – left lateral with head
low position with tredelenberg position
• 100% oxygen
• CVC insertion or direct needle in right atrium
to remove the air
• May require CPR.

65. INFECTION
• Avoid hysteroscopy in gross cervical infection,
uterine infection & salpingitis.
• Role of antibiotics controversial
– Supportive studies in cases with RHD, CHD, MVP.
– Suspected chronic endometritis
– Submucous myomas procedure
– Imbedded IUDs.
ACOG guidelines do not recommend routine prophylactic
antibiotics for hysteroscopy.

66. CONTRAINDICATIONS of
Operative Hysteroscopy
• Acute pelvic inflammatory disease
• Pregnancy
• Genital tract malignancies
• Inability to dilate the cervix
• Inability to distend the uterus to obtain visualization
• Renal disease – fluid overload risk
• Patient with pacemaker – avoid radiofrequency current
• The patient desires and expects complete amenorrhea