Diagnostic Hysteroscopy Presented by Dr.Narayan M.Patel M.D.,D.G.O. FICS Emeritus Professor Muni. Medical college Postal address-- Mahalaxmi Institute of medical teaching, 3, Shantiniketan park, Naranpura, Nr.Sardar Patel Colony, AHMEDABAD- 380 014 (Gujarat) INDIA T.N.(079) 27682572, Mobile;- 98252 95530 E mail:- email@example.com
Historical aspect of Hysteroscopy 1869 :-- Pantaleon visualize polypoidal tumor in uterus 1925:---Rubin used cysto urethroscope to look into uterus. Used water to distend Uterus and to wash ` lense. He also used carbon dioxide
Historical aspect of Hysteroscopy 1971:- Lindeman used Carbon Dioxide.50 to 100 cc/ minute . Pressure should be 100 mm of Hg . Co2 is easy to get, does not wet surgeons cloths as fluid does, or mix with blood and has good visibility. Co2 is popular for office diagnostic hysteroscopy. Hysteroflator is a special instrument for using Co2 as distending media as shown below..
Historical aspect of Hysteroscopy 1960-70 low viscosity fluids like saline or ringer lactate, with pressure of 50 to 100 mm of Hg, is popularly used in diagnostic hysteroscopy. It is cheap and easily available. Fluid bottle is suspended high over a stand, as shown. Some people used blood pressure cuff wrapped in collapsible bottle,to raise pressure in bottle. Disadvantage is poor visibility if bleeding occurs. It may wet surgeons cloths.
Historical aspect of Hysteroscopy HYSCON 1971:--Menken used high viscosity fluid HYSCON It is 30% Dextran in 10% glucose Molecular Wt. 7000 Fern storm Viscosity- 220 centipoises Retractile index 1.39 Costly and not available in India, Caramelizing effect on Instruments if not washed immediately after use.
K-Y Jelly is also used by some doctors in India as a distending media. It is cheap, easily available and does not mix with blood Late Dr.Khandwala in India used 50% glucose as a distending media for dignostic hysteroscopy .
5 mm telescope Obturator 6 mm Sheath for Diagnostic hysteroscopy Sheath for Operating Hysteroscopy Instruments required for Diagnostic Hysteroscopy
Diagnostic Hysteroscopy <ul><li>Hysteroscopy is technically quite different from Laparoscopy and expertise with the laparoscopy is no guarantee of success with hysteroscopy. </li></ul><ul><li>Co2 insufflators used for laparoscopy, should never be used for Hysteroscopy. </li></ul><ul><li>In laparoscopy the flow of Co2 is in litters, while in hysteroscopy it is in ccs, with 100mm pressure to distend, uterine cavity. Patients have died in past due to wrong use of instruments. </li></ul>
For hysteroscopy one is sitting on a low level stool while operation table Is to be raised, for the surgeon to be comfortable, as shown in picture. For introduction of Hysteroscope with sheath, one may need occasionaly cervix to be dilated up to 7 Hegar. Be very gentle in dilating Cx. as any bleeding will interfere in your vision. If you are using saline or ringer lactate, let fluid run from proximal end of scope, before you introduce it, in the cavity. Once in uterine cavity, one should pause momentarily until mucus bubbles have dissipated and vision is clear. Never advance scope blindly, as it may leads to perforation.
Diagnostic Hysteroscopy <ul><li>To look into endocervix </li></ul><ul><li>To look Into uterine cavity </li></ul><ul><li>To look at endometrium </li></ul><ul><li>To look at tubal osteium </li></ul>
With more and more use of carbon dioxide as a distending media and avabilty of sophisticated instrument like Hysterflator,Dignostic hysteroscopy has almost become an office procedure. which can be done without anesthesia or some times with local anesthesia. This slide shows Endocervix as you are advancing scope in the uterine cavity. Unless pressure is enough to distend cavity, you can not see interior of cavity
1 2 Picture No-1 of hysterosalpingo graphy, shows a septate uterus. Picture No-2 shows the same septum at Hysteroscopy. Some times diagnostic hysteroscopy has to be converted in to operative hysteroscopy, in the same sitting
1 2 Picture No-1 shows tubal osteam from a distance. Uterine cavity looks quite red and healthy. Picture No-2 shows tubal osteam at a closer view. It looks normal.
Hysterosalpingography shows a filling defect in uterine cavity. This can be due to submucous fibroid sessile myoma. It does not look like Synechia or an air bubble Diagnostic hysteroscopy is the indication. During procedure, it may have to be converted to Operative one. Keep things ready. Filling defect at H.S.G.
Diagnostic Hysteroscopy <ul><li>It is most important to insure prevention of complications and their recognition, and their management, if they occur. </li></ul><ul><li>Complication may occur due to </li></ul><ul><li>Instrumental procedure </li></ul><ul><li>Distension media. </li></ul><ul><li>Inadequate visualization </li></ul><ul><li>Anesthetic agent </li></ul>
Diagnostic Hysteroscopy <ul><li>The Hysteroscope should never be advanced into the uterine cavity without adequate visibility. </li></ul><ul><li>Otherwise, it can cause:-- </li></ul><ul><li>False passage </li></ul><ul><li>Perforation </li></ul><ul><li>Bleeding </li></ul>
Diagnostic Hysteroscopy The out flow stopcock must never be closed completely, as this will eliminate the liquid flow. which is most important aspect of the C F principle
Contra indications of Hysteroscopy <ul><li>Acute and chronic upper genital tract infection. </li></ul><ul><li>Recent uterine perforation. </li></ul><ul><li>Pregnancy. </li></ul>
Operative Hysteroscopy Operative Hysteroscopy is not for the novice, but should be an extension of basic skill learnt at diagnostic hysteroscopy. It is recommended by one author that unless you have done 500 diagnostic hysteroscopy, you should not venture operative hysteroscopy.