starting with hysteroscopy can be quite a challenge. Discover ways of handling and preventing some of these.

1. Challenges during
hysteroscopy
DR YAMAL PATEL
Consultant OBGYN,
Nairobi

2. Types
CHALLENGES OF
DIFFICULT CERVICAL
ENTRY
FALSE PASSAGE VISION CHALLENGES BLEEDING COMPLICATIONS -
PERFORATION

3. Difficult entry
Cervical stenosis – conization,
LLETZ, curettage and ashermans,
trauma to cervix, Manchester
repair
Adhesions and fixed direction of
cervix

4. Pharmacologic
dilatation
• Misoprostol before hysteroscopy
• No benefit in postmenopausal
women
• 400 mcg vaginally 6-8h prior

5. Mechanical
dilatation
• Hegars dilatation
• Risk of false passage
• Entry under direct vision safer than blind
dilatation

6. Hygroscopic
dilatation
• Laminaria tents
• Hygroscopic rods of dried seaweed [24h], though there
are synthetic versions that act more quickly [ 4h]

7. hydrodilatation
• Under direct vision using the
hysteroscope
• Safer as instrument advanced
under direct vision
• Less risk of false passage
• Using the pressure of fluid
• Direction of the scope – with 0 and 30
degree scopes

8. Dilatation with
scissors
• Put scissors in the operative port and
advance scope while opening ahead
using scissors under vision

9. Ultrasound
guidance
With a sound or scope through
a difficult-to-define os
Patient needs a full bladder for
this

10. Operating during menstruation
Follow the blood
trail and mucus
Disadvantage –
poor view of the
cavity once inside

11. Cruciate incision
• In severe stenosis
• Cut down through the cervix – cruciate incision, to find the cervical
canal and internal os

12. False passage
Muscle fibres visible and
tubal ostia not
1
Slowly remove the scope
and try identify the true
cavity
2
Discontinue – to prevent
fluid from being absorbed
throught the injury and
since adequate distension
not possible
3
Delay repeat procedure 2-3
months
4

13. Prevention
false passage
Dilate cervix slowly and stop as
soon as internal os reached
Put scope into external os with
inflow open and outflow shut and
let the fluid pressure dilate the
cervix.
Insert the scope under direct vision
with correct orientation

14. Vision
challenge
• Reduced IUP or flow or fluid over
• More bleeding than can be
removed by outflow
Japanese flag
• Look at fluid
• Check IUP
• Check for bleeding
STOP !

15. Bleeding
• More common when endomyometrial
junction breached
• Myomectomy
• TCRE
• Management:
• Foleys with 15-20 ml balloon
• Pack with gauze soaked in dilute
vasopressin
• Bipolar cauterization

16. perforation
14/1000 – AAGL
survey
Higher in resection
of lateral and fundal
adhesions – 2-3/100
Diagnosis:
Cavity collapse
Rapid inflow of fluid
Bowel or omentum
seen
Scope goes far in.

17. What next!

18. management
• Depends on what perforated the uterus
• Energy – laparoscopy needed to check
• Cold instrument – can observe

19. Prevention
perforation
• Resection –
• Apply current only when electrode moving
towards operator, not away.
• Simultaneous Ultrasound
• Simultaneous laparoscopy

20. Gas embolism

21. Embolism
CO2 SOLUBLE, SO THESE EMBOLI
GENERALLY RESOLVE RAPIDLY
ROOM AIR EMBOLI – MORE
LIKELY TO BE FATAL

22. Prevention
embolism
Purge all air from the tubings before introducing scope
Avoid trendelenberg
Remove last dilator just before inserting the scope
Limit repeated removal-reinsertion
Intracervical vasopressin
Right equipment and settings

23. Safety first!
HYSTEROSCOPY IS
TECHNOLOGICALLY DEPENDENT
POTENTIALLY DANGEROUS PROCEED ONLY WITH GOOD
KNOWLEDGE OF EQUIPMENT