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DR PAWAN JHALTA
DR NISHI SOOD
HYSTEROSCOPY IS A PROCEDURE THAT
INVOLVES DIRECT VISUAL INSPECTION OF
CERVICAL CANAL AND UTERINE CAVITY.
First described by Panteleoni in 1969 and done
as an office procedure only .
1st optical hysteroscopy was introduced by David
First distension media used was CO2.
In 1980s hysteroscopy replaced blind D&C as a
standard procedure for precise diagnosis of
Diagnostic and Operative sheaths
3 parts –
a) eye piece
c) objective lens
Available in various diameters-
a) 4mm standard – gives high quality sharpest image
b) 3 mm diameter – inferior to 4mm but gives
satisfactory image clearity.
a) straight on i.e. 0 degree, distant panoramic view
b) fore oblique i.e. 30 degree – has an advantage that
just by rotating it all walls and cornual ends can be
Usually 4 – 5 mm in diameter
Required to deliver the distending media into
Telescope fits into the sheath and there is
1mm gap between sheath and scope through
which distending media is transmitted and is
controlled by external stopcock.
Imprecise or loose coupling telescope and
sheath results in leakage of distending
It has channels for
a) 3 - 4 mm telescope
b) instillation of medium
c) operating instruments
A) STANDARD OPERATING SHEATH
Single cavity for medium,telescope and
Disadvantage of not being able to flush the
cavity with distending medium and operating
tool manipulation within the cavity is difficult.
B) ISOLATED MULTIPLE CHANNEL OPERATING
Double flushing sheath that allows media
instillation by inner sheath and return by
perforated outer sheath, constant flow of
medium leads to very clear operative field.
Inner sheath - which has a common channel for
telescope, distending media and electrode
Outer sheath - for the return of distending
Lens is angled towards the electrode for clear
Electrode can be ball, barrel, knife, or cutting
KARL STORZ (BETTOCHI HYSTEROSCOPE)
• External diameter of 2.9 mm and can be used
both as panoramic hysteroscope and micro
• Flexible telescope made up of 50,000 fused
• External diameter of 1.8 mm and length of 28
• It has a disposable sheath too.
• Quality depends upon
b) remote light generator
c) structural integrity of light cable
• Wattage – 175 W for routine procedures and
300 W for special interventions
• Light generator
– tungsten orange yellow light
– metal halide bluish colouration
- xenon white light
- LED source
• The camera consists of a camera head, cable
and camera control.
• -Camera head attaches to the eye piece of
• -The basis cameras is solid state silicon
computer chip or charged coupled device.
• -Each silicon element contributes one pixel to
the image produced.
• Gaseous CO2
• Liquid –
High viscosity – hyskon
Low viscosity –
Ionic/electrolyte NS,RL,5%D,10%D,4% and 6%
Non ionic 1.5% glycine , 3%sorbitol,
5% mannitol and cmbination of
2.8%sorbitol and 0.5% mannitol.
CO2 AS DISTENDING MEDIA
Used in office hysteroscopy
Rate of flow 30-40 ml/min( should be < 100 ml/min)
Intrauterine Pressure 60-70mmHg
Provides clean media
Allows entry evaluation of endocervical canal
Doesn’t flush the cavity of debris
Mixes with blood to form foam obscuring the view
Flatten the endometrium
Emboli can form causing gas embolism and death
LOW VISCOSITY DISTENDING MEDIA
Delivered fluid must be circulated out and clear
fluid added in order to maintain view and
distension of cavity
Delivery systems used are
Gravity fall system
Electronic suction irrigation pump
Proper monitoring of infused volume is important
and infusion is stopped positive infusion
500 cc for hypo-smolar solution and
1000 cc for iso-osmolar solution
0.9% Normal Saline is commonly used
Low operative cost
Physiological disposal by peritoneal absorption
Efficient conductor of electrons so electrosurgery
with monopolar devices is not possible.
Not suitable for office hysteroscopy.
Fluid overload and pulm oedema risk
Glycine (1.5%) and Sorbitol (3%)
Inexpensive and readily available
Media of choice for monopolar cautery
Hypo-osmolar solution causing dilutional
hyponatremia and hypervolemia
Interferes with oxygenation and coagulation
Cerebral oedema,cardiac and skeletal muscle
MANNITOL (5%) AND GLYCINE (2.2%)
Can be used with electrosurgical instruments
Decreased risk of fluid overload and
HIGH VISCOSITY MEDIA -HYSKON
High viscosity liquid distending media
32% high molecular weight dextran solution
Colourless viscid medium
Usual volume required-
Diagnostic – 100 ml
Operative 200 – 500 ml
Upper safe limit 500 ml.
1ml of hyskon withdraws 20 ml of water in
Being highly viscous small quantities are
required for examination.
Provides excellent visualization due to its high
refractive index and as does not mix with
Caramalize on instruments and may freeze the
stopcocks of the instruments making them
Morbidities ocaused are
• Pulmonary edema
• Electrolyte imbalance
• Anaphylactic reaction
Mechanical pump is necessary to deliver these
• Mechanical energy
• Bipolar standard electrode.
• Bipolar versapoint .
STERILIZATION OF INSTRUMENTS
• Standard : gas sterilization with ethylene
• Cidex OPA(0.55% ortho phthaldehyde)
• 12 min soak at 20Ċ and 5 min at 25Ċ in an
automatic endoscope reprocessor.
• Require 3 one minute rinses to remove
INDICATIONS OF HYSTEROSCOPY
Evaluation of abnormal uterine bleeding
Infertility workup along with laparoscopy
Prior to IVF
Diagnosis of polyps, fibroids and uterine
• Endometrial ablation
• Resection of septae, myomas and polyps
• Extraction of lost IUCD
• Targetted biopsy
• Treat AV malformations and hemangiomas
• Gamete transfer in ART
• Tubal cannulation of proximal tubal
• Recent history of PID as it may precipitate
• Acute cervicovaginal infections
• Extreme bleeding
TIMING - proliferative phase 6th to 10th day of
- isthmus is hypotonic
-proliferative endometrium has better
endoscopic view and
-no risk of unexpected pregnancy
Timing of cycle not important in emergency
cases or OCP users.
Distension media normal saline
-abnormal uterine bleeding not responding to
-recurrent endometrial hyperplasia
-high risk for surgery
• Pre-operative preparation – danazol or GnRH
analogue treatment for endometrial thinning
• EXCLUDE ENDOMETRIAL CARCINOMA
ROLLERBALL ENDOMETRIAL ABLATION
• Ball electrode is used and start from fundus
then anterior and lateral walls and posterior
wall is ablated at last
• Isthmus is spared
• Power 50-150 W
• Depth of 1-2 mm is targetted and heat
actually reaches 3-5 mm depth also
depending on time of contact
• Endometrium sloughs and regeneration is
prevented because basal and spiral arterioles
donot survive 100 degree centigrate heat.
Uterine walls scar in 6-8 weeks and shrink.
Easier to learn and perform than resection.
Shorter operating time than laser ablation
Less risk of uterine perforation and hemorrhage
No tissue for histology
Cannot treat submucus fibroids
Use of mnonopolar energy and nonphysiologic
TRANSCERVICAL RESECTION OF
• Loop shaped electrode is used
Continuos flow resectoscope provides efficient resection
of endometrium and myometrium(2.5-3 mm).
Provides tissue for histopathology
Suitable for thick endometrium
Submucus fibroids and polyps can be excised at the same
• Most skill dependent hysteroscopic procedure
• Greatest risk of uterine perforation.
• Use of electrolyte free media with monopolar
HYSTEROSCOPIC LASER ENDOMETRIAL
Tissue coagulation upto 5-6 mm
Perforation is less likely than resection
Small fibroids and polyps can be vapourised
Expensive capital and running cost
Slowest of all techniques
Greater risk of fluid overload
Need for special laser safety procedures and
SECOND GENERATION ENDOMETRIAL ABLATION
The HydroThermAblator System
A single-use 3 mm hysteroscope coated with polycarbonate
is inserted into the endometrial cavity. Saline is instilled at
low intrauterine pressures of <45 mm Hg and then heated
to 90°C. This low pressure is used to prevent flow of heated
saline through the fallopian tubes.
After the treatment is complete, cool saline is used to
replace the heated saline prior to removal of the device
from the cavity.
Endomyometrial necrosis to a depth of 2-4 mm is achieved
after 10 minutes of treatment. The endometrial cavity is
uniformly ablated with this method, including both cornua.
• Flexible or semi-rigid scissors or
resectoscope with Nd-YAG laser is used
• TECHNIQUE –
Flimsy and central adhesions are cut first
then marginal and dense adhesions are
start cutting from below and move up
maintain the hysteroscope in midchannel
- numerous vascular channels are
opened so risk of intravascular absorption of
media is high
- anatomy is disturbed so risk of
perforation is more.
• POST OPERATIVE CARE-
-Pediatric foley’s catheter can be inflated for 7-10
-Conjugated estrogens 2.5 mg daily for 2-3
• Multichannel operating hysteroscope is used
• Retractable electric snare is inserted which
encompasses the base of polyp and is then
• Cutting current of 30-40 W is applied
• Snare removed and polyp is grasped with
aligator jaw forceps
• Site of removal is inspected and if any
bleeding observed it is coagulated with ball
Hysteroscope is drawn to the level just above the
internal os and septum is cut from below
upwards with simultaneous laparoscopy.
Stop dissecting when both tubal ostia are clearly
visible in panoramic view and signal from
laparoscopist that fundus is approaching
Post op care-
-conjugated estrogens and
- HSG after 6-8 weeks
• With the Essure system, a 5-mm hysteroscope is
used to introduce a delivery catheter that contains a
3.85 cm flexible coil called a microinsert into the
proximal portion of the fallopian tube.
• The inserts are made of a stainless steel inner coil
wound in polyethylene fibers and an outer coil of nickel
titanium. After a microinsert is placed at the uterotubal
junction, the delivery catheter is removed and the
outer coil of the insert expands.
• Three to eight trailing coils of the insert should remain
visible at the tubal ostia.
• The inner polyethylene fibers induce tissue in-growth
into the insert, facilitating occlusion of the tubal lumen
by 12 weeks.
Hysteroscopic tubal cannulation
a) interstitial obstruction
b) transfer of gametes.
c) tubal sterilisation
• TECHNIQUE –
• In interstitial obstruction 5.5 F teflon cannula with
metal obturator is introduced, obturator removed and
a 3F catheyer with guide wire is withdrawn and dye
injected, dye spilling can be seen via laparoscope.
• Gamete transfer is done by 1 mm catheter cannulation.
Uterine distension media are toxic to gametes so CO2
is preffered that too at low flow rates and gas flow is
shut off when catheter enters the tube.
• Multichannel hysteroscope with alligator
forceps is inserted and string is grasped and
drawn along with hysteroscope.
• If embedded IUCD is there rigid grasping
forceps are used and jaws grab the extruded
portion of IUCD and taken out by strong force
• Leiomyomas appear as white spherical masses
covered by network of thin fragile vessles
• PRE OPERATIVE ASSESSMENT-
EUROPEAN SOCIETY OF HYSTEROSCOPY
CLASSIFICATION OF INTRAUTERINE MYOMAS
• GRADE ‘0’ – Myoma with development limited
to uterine cavity, pedunculated or with limited
• GRADE ‘1’ – Myoma with partial intramural
development having an endocavitary
component >50% with angle of protrusion
between myoma and uterine wall <90*
• GRADE ‘2’ – Myoma with predominantly
intramural development, <50% endocavitary
component and angle of protrusion between
myoma and uterine wall >90*
Pedunculated leiomyoma Partially intramural myoma
Myoma with predominantly intramural
Factors For GnRH analogues
•Type of myoma.
•Residual distance to
•No. of Myoma
•Ability of the surgeon.
None or Mild
Gr. 0 or 1
Anterior, posterior or
lateral pelvic wall
In Favour Pretreatment
> 4 cms
< 8 mm
Fundus, close to tubal ostium
Technique of myoma resection
• MECHANICAL - Progressive shaving of myomas and
harvesting tissue for HPE eveluation
• ELECTRODE – Straight electrode for fundal myomas and
angulated for myomas on anterior and posterior walls.
Electrode must be activated only while returning towards
hysteroscope and never while advancing from lens.
• LASER –
A) 1mm laser fibre cuts myoma across.
B) 1mm ball is drawn over myoma multiple times for ablation.
C) Layer by layer by layer myoma is sliced until its base is
D) Myoma is devascularised by making multiple punctures
into its substance and then extracted piece by piece.
Hemangioma and Arterio-venus
• Can be diagnosed by their characteristic hysteroscopic appearance
and H/O unresponsive bleeding
• Women usually young and low parity.
• Hysteroscopy shows endometrial surface covered with irregular
bluish purple vessels but form an abnormal tangle of distended
channels which differ markedly from normal fine capillary net
• Management – Nd: YAG or Holmium YAG laser is discharged
touching the vessels or surface of epithelium.
• Laser energy causes vessels to collapse, coagulate and the surface
to blench white
COMPLICATIONS OF HYSTEROSCOPY
• Incidence 1-9%
• Commonest complication
• Usually occurs during –
-lasers and electrosurgical devices.
Always do simultaneous laparoscopy with these procedures
to avoid it
• If perforation occurs –
procedure is postponed,
vital monitoring of patient,
antibiotics and iv oxytocin
Second most common complication
Coagulation of bleeding vessel.
Foley’s catheter is inflated with 15-30 ml of fluid and
Vasopressin and misoprostol.
Embolisation of uterine artery.
Hystrectomy in case of intractable bleeding
MEDIA RELATED COMPLICATIONS
• Gas embolism – most common with CO2 and
can cause circulatory collapse and death of
• Intravasation of media – more risk if
-prolonged operative procedures,
-large volumes of low viscosity media,
-procedures which lead to open venous chanels
- if intrauterine pressure exeeds mean arterial
pressure of the patient.
• For every liter of hypotonic media absorbed, the
patient's serum sodium decreases by 10 mEq/L. If
the patient's sodium level is less than 120 mEq/L,
she is at increased risk for having devastating
complications. Hyponatremia can occur rapidly,
resulting in generalized cerebral edema, seizures,
and even death.
• In general, if a fluid deficit is greater than 1500
mL or if the sodium level is less than 125 mEq/L,
the procedure should be terminated.
• Out of all nonelectrolyte media, 5% mannitol has
the safest adverse-effect profile because it can
maintain a patient's osmolality despite
hyponatremia, improving neurologic outcomes.
• Allergic reactions – most common with
• Others - Derangement of coagulation profile,
water intoxication, hyponatremia and cerebral
• Haemorrhage usually is a sequelae to
unrecognised bleeding during the operative
procedures, infection, deranged coagulation
• Infections not a common complication usually
seen in patients with pre existing infections or
PID or in case proper asepsis is not
• Thermal damage if unrecognised may cause
peritonitis, sepsis and even death. In case of
severe burns hystrectomy is the only option.