Hysteroscopic procedures are getting refined and with the advent of miniature scopes , doing these procedures in he office is getting better and more comfortable.

1. Office
hysteroscopy
Dr Yamal Patel
Consultant OBGYN

2. Definition
• Diagnostic and some operative hysteroscopy
• outside the formal operating theatre setting
• appropriately equipped and staffed
ambulatory situation
• Maintaining patient safety and privacy
• Usually:
• No anaesthesia nor analgesia usually
• No drugs – keep atropine around
• No speculum nor tenaculum
• Operative procedures

3. Indications
• Diagnostic
• AUB
• Peri and post menopausal bleed
• Selected infertility cases
• Abnormal HSG
• Unexplained infertility
• RPL
• Repeated implantation failure
• Pre- IVF

4. Indications
• Operative
• IUD removal
• Biopsy intrauterine lesions
• Hemangioma and A-V malformations
• Resection septum
• Uterine synechiae
• Cannulation tubes
• Sterilization – essure
• Polyps
• Submucous fibroids
• Endometrial ablation

5. Timing
Ideally post menstrual

6. ANESTHESIA
NONE
LOCAL ANESTHESIA
GENERAL
ANESTHESIA

7. Anaesthesia
• Usually not needed
3mm flexible/ rigid
• Parous not needed
• Tenaculum site LA 1% lidocaine
5.5 mm rigid without dilatation
• Tenaculum site LA
• Paracervical block
5.5 mm rigid with dilatation

8. Analgesia
Routine use Opioids NOT
recommended
NSAID around 1hr before
scheduled procedure

9. Conscious sedation
• Not routinely used – no advantage in
terms of pain control or comfort of the
patient.
• Risk of occasional life-threatening
complications
• Appropriate monitoring and staff

10. TYPE OF HYSTEROSCOPE
• Miniature hysteroscope (2.7mm with a 3-
3.5mm sheath) should be used. There is
significant reduction in the discomfort
experienced by the patient.
• Flexible hysteroscopes are associated
with:
o less pain
o the provide better images
o fewer failed procedures
o quicker examination time
o reduced costs

11. DISTENTION MEDIUM
• Can use either CO₂ or normal saline.
• Neither is superior for alleviating pain, however uterine
distension with normal saline reduces the incidence of vaso-
vagal episodes.
• Uterine distention with normal saline improves image quality
• Distention with saline is faster as compared to that of CO₂
• Operative outpatient hysteroscopy, using bipolar requires the
use of normal saline to act as both, the distending and
conducting medium

12. Antibiotics
Not routine
in diagnostic
Used in
operative
hysteroscopy

13. POSITIONING OF THE PATIENT
• DORSAL LITHOTOMY POSITION
“Individual lies on the back with the hips and
knees flexed and the legs spread and raised
above the hips often with the use of stirrups”

14. Cervical
preparation
• Routinely NOT recommended
• Sometimes may need to use misoprostol
• Nulliparous
• Previous cervical surgery
• Routine intracervical or paracervical LA not
indicated to reduce incidence of vasovagal
reactions.

15. Types of hysteroscopes
• Miniature hysteroscope
• 2.7mm with 3-3.5mm sheath
• Microhysteroscope
• 1.9 mm scope
• Flexible hysteroscope
[Rigid hysteroscope – better image, fewer failed procedures, quicker
and reduced cost.]

16. Distension
media
• CO2 or Normal saline
• Discretion of the operator
• Less vasovagal episodes with normal saline
• None superior in reducing pain
• Saline allows improved image quality
• Operative using bipolar energy using saline
• Saline – hydroflotation subtle lesions
• Saline has rinsing effect in case of bleeding

17. Technique
• Vaginoscopic – standard technique
• Enter vagina
• Aim deep in the posterior fornix
• Locate cervix
• Follow external os and into cervical
canal

18. Contra-
indications
Acute PID
Pregnancy
Genital tract malignancy
Lack of informed consent
Poor surgical candidates – medical complications
Poor understanding of equipment
Untrained staff

19. Setup
Spacious
Ergonomic
Detailed protocols and flow charts
Log of all procedures
Dedicated area within the room for drugs
Complete equipment and instrumentation

20. CLEANING
AND DRAPING
Sterile drapes
Avoid all risk of patient to patient transfer of
infection (viral, MRSA, C.Difficile, β
streptococcus
Minimize risk of ascending infection
In outpatient hysteroscopy, it is difficult to
completely sterilize the vagina, but the cervix
should be cleaned

21. TIPS AND TRICKS FOR
SUCCESFUL OFFICE
HYSTEROSCOPY
• Can be considered the gold standard for the
examination of the uterine cavity
COMFORTABLE SETTING
• Organize a relaxed setting, using a protected space
with a comfortable seat
• A plan of care that will help minimize the patient’s
anxiety
• The nurse or resident should provide emotional
support (vocal local)
• Get the patient more involved in the procedure by
inviting her to look at the additional monitor