Basics of hysterolaparoscopy in gynecology

1. BASICS OF LAPAROSCOPY &
HYSTEROSCOPY IN GYNECOLOGY
 Dr. VIVEK KAKKAD

2. BASICS OF LAPAROSCOPY
Laparoscopy literally means, "to look inside the abdomen".

3. History
 1805, Bozzini, an obstetrician, using candlelight through
a tube attempted to examine urethra and vagina
 1910, Jacobaeus, performed laparoscopy using a
cystoscope
 1920s & 1930s, Kalk, a gastroenterologist, popularised
diagnostic laparoscopy
 Origin of modern laparoscopic surgery- Kiel School in
Germany, headed by Semm, a gynaecologist.
 Dr. Camran Nezhat - “FATHER OF MODERN
LAPROSCOPIC SURGERY” introduce video
laparoscopy
Litynski G.S. JSLS 1997; 1(2): 185-188
1901: George Kelling, Dresden,
Saxony (Germany) performed 1st
experimental laparoscopy on dog,
calling it ‘Celioscopy’

4. ADVANTAGES
 Reduced postoperative morbidity - pain, chest & wound
complications
Ellstrom M. Acta Obstet Gynecol Scand 1998;77: 923-928
 Accelerated recovery ACOG 2009, Cochrane Database Syst Rev. 2009
8;(3):CD003677
 Lesser adhesion formation Audebert AJ. Fertil
Steril. 2000;73(3):631-5.
 Better cosmesis
 Reduced contact with body fluids & disease
transmission
 Reduced incidence of ventral hernia-
 11% in midline vs 4.7% in transverse scar vs 0.7% after laparoscopy.
Le Huu Nho R. J Visc Surg. 2012;149:3-14
MAGNIFICATION PRECISION DOCUMENT-
ATION

5. DISADVANTAGE
 Expensive equipment
 Learning curve
 Limitation of intact organ retrieval(tumours)
 Trocar related injuries to vessels and viscera
 Counter-intuitive motion
 Diathermy burns
 Hemostasis more difficult
 Insufflation related postoperative pain Williams Gynecology 2nd Edition A guide to laparoscopic
surgery

6. Indications CONTRAINDICATIONS
Diagnostic-
 Infertility
 Acute and chronic pelvic pain
Therapeutic-
 Ectopic pregnancy
 Endometriosis & infertility
 Ovarian cyst, adnexal torsion
 Hysterectomy
 Myomectomy
 Prolapse repair
 Mullerian anomalies
 Oncosurgery
 Contraindications to GA/
pneumoperitoneum-
 Cardio-respiratory
 Uncorrected
coagulopathy
 Major haemorrhage requiring
rapid control
 Intestinal obstruction(severe
distension)
 Acute glaucoma
 Increased intracranial pressure,
peritoneal shunts

7. IMAGING SYSTEM
TRIPLE CHIP CAMERA (HD)
CAMERA 3D
LIGHT CORD(fibre-optic)
Xenon (300 watt)
500 hrs (Best illumination by powerful sources)
Minimum heat conduction to the telescope body- “cold light”
MONITOR &
RECORDING
SYSTEM

8. INSUFFLATOR
 Initially low flow & then increased, preferably to 3-6 L/ min.
 Throughout insufflation, vitals are closely monitored.
 Pressure 12-15mmHg
 Pressure gauge automatically stops gas flow on reaching pre-selected
pressure
 Rapid insufflation- dysrhythmias & post-operative pain
Total
Volume of
Gas
Flow
RateAbdomina
l
Pressure
Cylinder
Pressure

9. SURGICAL INSTRUMENTATION
LAPAROSCOPE : Two channels
a) Optical viewing channel
b) Light channel
Head on
0°
in careful
study of
adhesions &
ovarian
surfaces
30°
Endocameleon
0-120°

10. SURGICAL INSTRUMENTATION
Most commonly
used for operative
as well as
diagnostic
purpose
10 mm
Mainly used for
diagnostic
purpose , can be
used for operative
purpose
5mm
Very delicate
MINIlaproscopy
As a fetoscope
Diagnostic purpose
Also in operative
< 5 mm
 LAPAROSCOPE OPERATING
LAPAROSCOPE
• Used in sterilisation
procedures
• Single incision
• Restricted view

11. MINILAPAROSCOPY
 O'Donovan defined these miniature
scopes as-
Minilaparoscope – Diameter < 5mm
 Conventional minilaparoscopy: 5-
3.5mm
 Modern minilaparoscopy: 3.4-2mm
 Microlaparoscopy: <2mm
 Smaller incisions mean lesser pain
and faster recovery & less chances of
hernia.
Conventional minilaparoscopy
(5mm) when compared with
modern minilaparoscopy(2.9mm),
diagnostic accuracy, operative
difficulty, operating time, intra-
op complications, post-op pain,
hospital stay, patients'
acceptance are comparable
except quality of image and size
of projected image on screen,
which were better in 5mm
Group.
Roy K.K et al., BJOG 2013

12. Basic Instruments
 Trocar & Cannula
 Tissue Holding Forceps
 Non-tooth
 Tooth
 Scissors
 Suction & Irrigation devices
 Needle Holder
 Energy sources
Bowel clampBabcock
Non tooth graspers
Claw
Needle Holder
Suction
Scissors
Ports

13. Trocars & Cannulas
 Pyramidal-
 Less force; better cutting
 Lesser visceral injury
 Increased abdominal wall vessel injury &
incisional hernia
Woolcott R. Aust N Z J Obstet Gynaecol.
1997;37:216
 Conical-
 Greater force required
 Lesser vessel injury & hernias
 Increases risk of visceral injury
 Blunt-
 Open technique
 Re-introduction of displaced cannula

14. ENERGY SOURCES
MONOPOLAR BIPOLAR
 Hand piece (Active electrode) is
at the surgical site
 Ground pad (Return electrode)
is elsewhere on body
 Current passes through large
amount of tissue
 DISADVANTAGES
 Large volumes of tissues are
injured
 Distant burns can occur
 Interferes with pace makers
 Active & return electrode are
located in same instrument
 More limited area of thermal
spread
 Useful for coagulation only
 Separate instrument for
cutting
e.g. Robi, Bipolar grasping
forceps(Kleppinger)
Brill A.I. Obstet Gynecol Clin N Am 2011;38:687-702

15. Energy Sources
Electrosurgi
cal
Monopolar Bipolar
Advanced
Bipolar Devices
Ligasure
EnSeal
PKS
Ultrasonic
Harmonic
Thunderbeat
Lasers

16. Ligasure Vessel Sealing System (LVSS)
 The Ligasure System (Valleylab,
Boulder, Colorado) (coviedion)
 Higher current and lower voltage (180 V)
 Melt vessel collagen and elastin to form a
translucent seal
 Vessels as large as 7 mm in diameter can
be sealed
 The need to use scissors greatly
slows the speed, especially compared
to the ultrasonic coagulator

17. En-seal
 SurgRx Enseal handpiece
 The gold I-blade - When the handpiece handle is
squeezed, the I-blade advances simultaneously with
energy delivery, so it close the bipolar jaws and cut the
sealed tissue .“one-step process” which greatly speeds
up the seal–divide cycle
 NANOPARTICLE acts as thermostatic switch to
regulate amount of current passing in the tissues with
which it is in contact.
 When temp rises to damaging levels, the conductive
nanoparticle interrupts the flow, also when temp dips
below optimal level it switches back on
the gold I-blade

18. Ultrasonic Energy Source
Harmonic
 Cutting is achieved mechanically
by blade(Active) which oscillates at
55,000 Hz
 Active blade pushes the tissue
against the tissue pad; tissue is
sheared between the two
 “MAX” setting- rapid transection
 “MIN” setting- vessel sealing
 Available as Harmonic Ace,
Scalpel
Lyons S.J Minim Invasive Gynecol.2013;301-307

19. COMPARISON OF ADVANCE ENERGY SOURCES
Device
Safety:
Minimal
thermal
spread
Reliability
: Efficacy
on
vessels
≤7 mm
Residual
tip
temperat
ure
Efficiency
:
Treatment
time
Consistenc
y:
Independen
t of user
Utility:
Multiple
uses
Harmonic Excellent Poor(3-5) Poor Excellent Poor Excellent
Gyrus PK Poor Poor Good Excellent Fair Fair
LigaSure V Good Excellent Excellent Good Excellent Fair
EnSeal Fair Excellent Excellent Poor Excellent Poor
•THUNDERBEAT – uses bipolar & ultrasonic energy simultaneously . minimal
lateral spread like harmonic & vessels sealing capacity like bipolar with good
residual tip temperature
Newcomb WL, et al.. Surg Endosc. 2009;23:90–96.

20. PKS
OMNI

21. Lateral Thermal Spread
 Greatest with Monopolar diathermy- 1 cm
 Least with ultrasonic devices
 0.6mm to 1.5 mm with Harmonic for arteries & veins
respectively
 4.5 mm to 6.3 mm with Ligasure, for arteries & veins
respectively
 Thunderbeat similar to Harmonic
 Similar for PKS system & Ligasure
Kenneth S.K.Law. J Minim Invasive Gynecol 2013; 308-318
Sutton P A. Br J Surg 2010;97:428-433
Hruby GW. J Urol. 2007;178:2689-2693

22.  CDC recommends Sterilisation or High Level Disinfection
 Steps involved-
1. Dismantling- To remove debris from crevices
2. Decontamination- visible blood & tissue is wiped off, then
soaked in 0.5% chlorine for 10 minutes
3. Pre-cleaning- with an enzymatic product viz. protease
recommended
4. Cleaning- with soft brush, detergent & water
5. Rinsing- under running water
6. Drying
CDC guidelines 2008
Comprehensive laparoscopic Surgery 2nd edition, IAGES
Maintenance Of Instruments

23. 6. Sterilisation- 2 methods are commonly used
a) Steam Sterilisation-
 Autoclaving at 134° for 30 minutes
 All insulated instruments, tubings, cords should be doubly wrapped in
cloth
b) Ethylene Oxide Gas Sterilisation-
 Non-corrosive to optics
 Permeates porous material
 High cost
 Longer process
c) Low Temperature Plasma Sterilizer
 heat & moisture sensitive equipment
 25-50min cycle
 Keep the instrument in it after plastic covering CDC guidelines 2008
Comprehensive laparoscopic Surgery 2nd edition, IAGES
Maintenance Of Instruments

24.  High Level Disinfection with 2% Glutaraldehyde (Cidex Plus)
for 20-30 minutes
 Good alternative to sterilisation in case of telescopes, and fibre-
optic light cords; as easily damaged
 The length of time that commercially available glutaraldehyde
solutions may be used varies, usually from 14-30 days. It ought to
be tested daily with the manufacturer’s test strip
 Solutions should be replaced any time they become cloudy
 Use of sterile drapes over camera and cord is another
alternative CDC guidelines 2008
Comprehensive laparoscopic Surgery 2nd edition, IAGES
Maintenance Of Instruments

25. PRE-OPERATIVE BOWEL PREPARATION
 Restrict use in cases requiring recto-sigmoid dissection with suspected
adhesions
 Bowel preparation provides statistical improvement in surgical view and
bowel handling; but not clinically significant
 Given the significant discomfort caused , fasting only is a preferable
alternative
Won H. Obstet Gynecol. 2013; 121(3):538-46
 Sodium phospate more effective than polyethylene glycol
Itani KM. Am J Surg. 2007;193(2):190-4
 NaP enema equally effective, less side effects compared to NaP solution
Yang LC. J Minim Invasive Gynecol. 2011;18(2):149-56

26. ANESTHESIA
 GA preffered with endo tracheal tubing
 GA after SPA – for radical surgery
 IV SEDATION + LA – Sterilization procedure, for diagnostic laparoscopy
(pain scoring)
POSITIONING
 Steep, head-down (15-20°) (Trendelenburg position) – bowel displaced
up
 Low lithotomy position of legs
 Adequate padding (avoid common peroneal nerve injury)
 Knees in slight flexion(<90°)
(avoid sciatic nerve stretching)
 Hips in slight abduction(<45°)(avoid femoral nerve injury)
 Left arm by side of patient(avoid brachial nerve injury)
Post operative intraperitoneal bupivacaine administration is beneficial
for patients undergoing diagnostic minilaparoscopy.
KK Roy et al., Arch Gynecol Obstet (2014) 289:337–340

27. VERESS DIRECT OPEN
• Held in a pen holding manner
• Non- dominant hand elevates the
abdomen
• First perpendicularly- resistance
followed by a give felt(1st click), as
passes through sheath
• Then at 45°- click is felt as passes
• Trocar grasped against thenar
eminence
• Index/middle finger extended over
sheath & acts as a guard (like holding
a gun)
• Non-dominant hand elevates the ant
abd wall
• Initially perpendicular, then downward
twisting force
Indication:
Previous lower abd surgery,
pregnancy, children, obesity

28. Mean intra abdominal pressure – 6.5mmHg (0.2-
10)1
After lifting of abdomen – negative
Pre set pressure – 12-15mmHg
VERESS INSERTION TESTS
The double click test
Manometer test
Syringe aspiration
Instillation & aspiration of saline
Syringe barrel flow test
The hanging drop test
Percussion test- loss of liver dullness
Free movement test- (not recommended)
Manometer test- (Most reliable test)
• Insufflation pressure should be low -<10mm Hg
•Incorrect if pressure high & flow low
•If pressure rises initially or vigorously; pre-peritoneal dissection
Teoh B et al. J Minim Invasive Gynecol 2005;12:153-8
1Sanchez NC et al., Am Surg. 2001 Mar;67(3):243-8

29. ADEQUATE PNEUMOPERITONEUM
 HIP (20-25mm Hg) till primary & secondary trocar insertion
followed by decreasing to 12-15 mm Hg RCOG green top
guidelines 2008
 HIP increases gas bubble, splinting of ant abdo wall &
increases distance b/w umbilicus & aortic bifurcation from .6
cm to 5.6 cm
 Volume = 1-4 lt
 Thin built = 1-2 lt
 Mod obese with relaxed abd walls = 5-6 lt

30.  FAILED ENTRY- 2 attempts
 Open laparoscopy
 Entry from palmer’s point
 SCARRED ABDOMEN
• Alternate sites of entry, Direction almost 90°
 PALMER’S POINT
 3 cm below left subcostal border in mid-clavicular line
 Stomach emptied, Exclude splenomegaly or gastric surgery
 OPTICAL TROCAR/VISUAL ENTRY SYSTEM
 Abdominal layers entered under laparoscopic vision
 Hollow trocar with transparent tip
 Allows clear optical entry
 Minimise size of entry wound and reducing force
 Non-superior to other, do not avoid visceral and vascular injury
RCOG Green Top Guidelines 2008

31. “No evidence that they
decrease entry-related
vascular or visceral
complications”
A systematic Review. Vilos GA. J Obstet
Gynaecol Can. 2007;433-65.
Shielded Trocars
 With a shield that partially retracts & exposes a sharp tip as
it encounters resistance
 As it enters the cavity, shield springs forward & covers the
tip.
Health devices 1998;27:376-98

32. RADIALLY EXPANDING ACCESS SYSTEM
 Rapidly expanding access system (STEP TM)
 Uses pneumoperitoneum needle with
expandable sleeve
 Post insufflation, needle removed, outer
sleeve left
 Direct dilatation of sleeve results in creation
of port
 Separates rather than cuts muscle fibres
Not recommended over traditional trocars.
Have blunt tips, may provide some protection from injuries,
Force required for entry is significantly greater than with disposable trocars.
(SOGC I-A)

33. • 28 RCT with 4860 individual evaluated 14
comparisons.
• Using an OPEN-ENTRY technique compared to a
Veress Needle demonstrated a reduction in the
incidence of failed entry, Peto OR 0.12
• DIRECT-TROCAR ENTRY when compared with
Veress Needle entry
lower rates of failed entry (OR 0.2)
extraperitoneal insufflation (OR 0.18)
omental injury (OR 0.28).
• Studies excluding patients with previous abdominal
surgery and women with a raised body mass index
CHOCHRANE
REVIEW 2013
LAPROSCOPIC ENTRY

34. - NITROUS OXIDE pneumoperitoneum - decrease
post‐operative pain in patients with low anaesthetic
risk.
- HELIUM pneumoperitoneum - decreases
cardiopulmonary changes
- No advantage over CO2
- Safety of NO & He has yet to be established.
- Future trials should include more patients with high
anaesthetic risk.
CHOCHRANE
REVIEW 2013
PNEUMOPERITONEUM
CO2 - most commonly used
Safe, rapidly cleared by the
lungs
No optical distortion
Supresses combustion
Readily available & inexpensive

35. SECONDARY PUNCTURE
 INCISION SITE-
 Lower side port-
 2 cm above & medial ASIS(5cm above, 8cm
lateral to PS)
 15cm from operative site
 Upper side port-
 At intersection of vertical line from left lower port &
horizontal line from umbilicus or
 At level of umbilicus, >6cm away from midline
 Forming 30-60º angle with operative site
 Triangulation- Instruments provide opposing action
 Non-midline incision more than 7mm & midline more than
10 mm requires deep sheath closure

36. PORT POSITIONS
 One of the most common cause of stressful surgery is wrong port position
 “BASEBALL DIAMOND CONCEPT” of port position
 Define : Target site
 Primary Port – should be away from TARGET SITE
 In cases of enlarged uteri where the fundus approaches the level of the umbilicus, it
may be necessary to place the ports higher on the abdominal wall to ensure proper
distance for visualization and instrument operation
 Secondary port in diamond/ baseball ground fashion
 INSTRUMENT ELEVATION ANGLE from surface -15-30º
 Half of the instrument in & half out (Type 1 liver mech.)

37. Laparoendoscopic Single-site Surgery
(LESS)
 Single Incision Laparoscopic Surgery (SILS)
 Single intra-umbilical 20-25 mm incision
 Trocar insertion by open method
 Reduced post-operative pain, improved cosmesis
 Special instruments & ports required
 Disadv- Learning curve, swording, increased chances of
capacitative coupling
Sobolewski C. Obstet Gynecol Clin N Am 2011; 741-755
 Comparable in the efficacy and safety
 No advantage in cosmesis or pain compared to
conventional
 May have longer operative time for adnexal surgery, but
not for hysterectomy.
Meta- analysis. Song T. Am J Obstet Gynecol. 2013 Jul 13
A systematic Review & Meta-analysis. Murji A. Obstet Gynecol
2013;121:819–28
Elbert Khiangte. Indian J Surg 2011 73(2):142–145

38. DIAGNOSTIC LAPAROSCOPY
 SYSTEMIC APPROCH NEEDED WITH PRE OPERATIVE CHECK LIST
1. EXAMINE THE TROCAR / VERRES INSERTION SITE & CHECK FOR ANY BOWEL / VASCULAR
INJURY
2. UTERUS FROM ANT, POST ASPECTS & POD
3. UTEROSACRAL LIGAMENT & BROAD LIGAMENT
4. OVARIES ( GLOBAL VIEW INCLUDING UNDERSURFACE)
5. URETER WHEN OVARY IS LIFTED UP
6. FALLOPIAN TUBE WITH T-O RELATIONSHIP
7. APPENDIX
8. UPPER ABDOMEN
9. CHROMOPERTUBATION

39. COMPLICATIONS OF LAPAROSCOPY
In Finland, 256 complications in 70 607 laparoscopic procedures -
3.6/1000
Major complications 1.4/1000
In Netherlands 145 complications from 25 764 laparoscopies - 5.7/1000
84 women (3.3/1000) – need of Laparotomy
57% - laparoscopic entry
Laparoscopy having similar surgical outcome & less complication but
more cost in comparison to laparotomy
Jansen Fwet al.; Br J Obstet Gynaecol 1997;104:5
Harkki-Siren P et al.; Obstet Gynecol
Lee M et al.; Int J Gynecol Cancer. 2011 F

40. LAPROSCOPY & OBESITY
 Anaesthesia risks
 Thick abdominal wall-
• Difficulty in trocar-cannula insertion
• Impedes port movement
• Requires higher insufflation pressures
 Thick omentum & mesentry-impairs visibilty and manipulation
• Wound infection decreases by 70-80% by laparoscopy
Meta-Analysis- Shabanzadeh DM. Ann Surg 2012;256(6):934-45
• Laparoscopic surgery associated with lower complication rate, lower
SSI, postoperative hospitalization than laparotomy
Tinelli R et al. , Anticancer Res. 2014 May;34(5):2497-502

41.  50% of major complications due to access, prior to intended surgery.
Jansen FW. Am J Obstet Gynecol.2004;190:634–8
 Overall rate of major complications: 1.1 to 1.4 per 1000
A meta-analysis. Molloy D. Aust N Z J Obstet Gynaecol. 2002;42:246-254
 Intestinal injuries : 0.6 to 4.4/1,000 procedures
 Urological injuries : 0.3/1,000 procedures
 Vascular injuries :0.9 to 3.1/1,000 procedures in various studies
 30-50% of bowel injuries & 13-50% of vascular injuries undiagnosed
Jansen FW et al., Am J Obstet Gynecol 2004; 190:634.
J Gynecol Endosc Surg 2009;1:4-11.
Harkki-Siren P. Obstet Gynecol. 1997;89:108–112.
ENTRY COMPLICATIONS

42. VASCULAR INJURIES
 Mortality rate of 12-23% Baggish MS.J Gynecol Surg. 2003;19:63–7; Chapron CM. J AmColl Surg.1997;185:461–465.
 Majority occur during veress or primary trocar entry
 Distal aorta, right common iliac & IVC particularly prone
 Minor- inferior epigastric vessels, during placement of secondary cannulas
 Injuries can be hidden behind omentum or retroperitoneum
 Major vessel injury
 First goal is to obtain pressure – laparotomy
 Skilled vascular surgeon called
 Inferior epigastric injury-
 Cautery less useful
 Foley’s catheter or suture ligation done-
 removed after 12-24 hours
COG 2009

43. Bowel Injuries
 Rate- 0.2-1.5/1000 in diagnostic to 1.5-
2.4/1000 in advanced surgery
 Half occur during entry- small intestine
mostly
 Recto-sigmoid common site, if injury is
during surgery
 Diagnosis often delayed in electrosurgical
injuries- 2-7 days
 Patient presents with peritonitis
 Small perforations may be repaired
laparoscopically, larger may require
laparotomy or colostomy
Brosens I. Gynaecol Endosc. 2001;10:141–145.
COG 2009

44. UROLOGICAL INJURIES
 To avoid- bladder drained pre- procedure
 Bladder injury- during bladder dissection at cervico-vaginal junction
 Ureteric injury- near infundibulo-pelvic ligament or uterine artery
 Pre operative stenting- helps to identify ureter easily & decreases
incidence of injury, Limit to high risk cases with distorted anatomy
 To detect- 5 ml indigocarmine dye injected i.v. & cystoscopy done intra-op
 Bladder injuries: <5mm heal spontaneously with continuous drainage
Larger require suturing
Makai G. COG 2009
 Combined incidence after laparoscopic hysterectomies- 4.3-4.8%
Obstet gynecol 2009;113(1):6-10, AJOG 2005:1599-1604
 Ureteral injuries- 3.4 per 1000
 Bladder injuries- 3.4 per 1000 Finnish cohort study- Hum Reprod. 2008;23(4):840-845
 Ureter injuries : 1.2%(range 0.6%–4%)- 70 % diagnosed post operatively
P. F. Janssen, MD; JMIG 2011

45. ELECTROSURGICAL COMPLICATIONS
 Direct thermal burns
› Due to accidental pressing of foot pedal
 Current diversion injuries-
occurs mainly with monopolar
› Insulation Defects
› Direct Coupling
› Capacitative Coupling
 Insulation Defects-
› Zone of high current density created
› To prevent instrument should be kept fully visible
› Away from vital structures
INSULATION DEFECTS

46.  Direct Coupling-
 Activated electrode touches
another uninsulated metal
conductor like laparoscope or
cannula
 Eliminated by avoiding use of
noninsulated & monopolar
instruments together
 Capacitative Coupling-
 Monopolar electrodes emit a
surrounding charge
 Generally, it dissipates to
abdominal wall
 If dispersion blocked due to
plastic cannula, then couples to
bowel or conductive cannula
DIRECT COUPLING
CAPACITATIVE COUPLING

47. Injury Prevention
 Use the lowest possible voltage (interrupted preferred, lesser coagulation
mode)
 Never use 2 energy sources simultaneously
 Keep activated electrode in operative field at all times
 Refrain use till instrument blade has cooled (remove when not using)
 Manually pulse device or irrigate pedicle to prevent thermal spread
 Monitor the quality of the insulation of instruments
 Whenever possible use bipolar energy sources over the monopolar
 When desired tissue effect is not accomplished, check ground pad or for
coupling
Lipscomb G.H. Obstet Gynecol Clin N Am 2010;37:369-377

48. BASICS OF HYSTEROSCOPY

49. HISTORY
 First attemt for visualisation of abdominal organ-
Bozzini 1806 – illumination of urethra by candle
 Pantaleoni 1869 introduced hysteroscopy for diagnosis of intrauterine
ds.
 Rubin 1925 : used cystourethroscope to look into uterus. Used water to
distend Uterus and to wash lense, used carbondioxide
 1990s : Hysteroscopic surgical procedures became popular ,
demonstrated equivalent or better results than traditional laparoscopic
surgery of uterus

50. High cost
Flexible Fragility
 Endoscopes problem in sterilization
Rigid Oº , 12º, 30º..
Diagnostic
Operative
Resectoscope
HYSTEROSCOPE

51. TYPES
 Rigid hysteroscope
 4-mm scope offers the sharpest and
clearest view
 Narrow, 3.5 mm - minimal dilation of
the cervix.
 Ideal for office hysteroscopy
Flexible hysteroscope
• Can deflect over a range of 120-160°
• New equipment replaces image fiber
bundle with a video chip, eliminating
unwanted ground glass artifact (Moire
effect)
• Directed biopsies,transcervical
tubocornual recanalization, chorionic
villus sampling, IUD retrieval

52. DISTENSION MEDIA
Gas Liquid
CO2
HMW LMW
32% dextran
Electrolyte Non electrolyte
- Normal Saline - 2.2%,1.5%
Glycine
- Ringer lactate - 3%Sorbitol
- 5%Mannitol,
5%dextrose
Easily available
Physiological resorption by
peritoneum
Osmolality similar to blood
Disadv . Mixes with blood
Constant perfusion
Intravasation syndrome
Nontoxic
Transmits light
Good view
Does not mix with blood
Not used Commonly

53. TYPE ADVANTAGES DISADVANTAGES AND
SAFETY PRECAUTIONS
Carbon dioxide gas Ease of cleaning and
maintaining equipment
Clear view of cavity
Risk of air embolization
, To minimize it keep flow rate
100ml/min & IU pressure
<100mmhg with Hysteroscopic
Insufflator.(Laproscopic Insufflator
not used)
Electrolyte-poor fluid
(eg, glycine, 1.5%;
sorbitol, 3%; and
mannitol, 5%)
Used with Monopolar
devices
Excessive absorbtion leads to
hyponatremia, hyperammonemia
& decreased osmolality, cerebral
edema,
Electrolyte-containing
fluid
(0.9% NaCl)
Readily available, isotonic
Media of choice during
diagnostic hysteroscopy &
Operative cases where
mechanical & Bipolar energy
Chances of pulmonary edema &
CHF reduced with this media but
still possible.
ACOG 2011

54. MEDIA DELIVERING & CONTROL SYSTEM
Gravity fall system Pressure cuff Electronic
Suction +
irrigation pump
1 to 1.5 m above the uterus
= 70 to 100 mm Hg
app. 80-110mmHg
No precise pressure
control
Violation of the integrity
of the myometrium
Excessive extravasation
Flow Rate= 50-200ml/min
Inflow pressure = <150mmhg
Suction pressure= 0.2-0.4bar
HYSTEROMAT
Flow Rate
Pressure
Suction
Infusion pump

55. Best time- 1st half of menstrual cycle
Isthmus hypotonic
Endometrium proliferative
Less cervical mucus
Less risk of unexpected pregnancy
Positioning : low dorsolithotomy
Preparation of cervix : for cervical stenosis
 Misoprostol 200-400mcg sl/pv 30min - 6 hrs before procedure
 Laminaria tent intarcervical 2-h
 Inj. Vasopressin Intracervical 0.05 U/mL, 4 cc at 4 and 8 o'clock
Phillips DR et al, J Am Assoc Gynecol Laparosc, 1996
Cooper NAM et al., A systematic review and meta-analysis.
2010

56. HYSTEROSCOPY
o Hysteroscopy is considered the gold standard for diagnosis of intrauterine lesions
o Transvaginal sonography / HSG and are most commonly used for UTERINE CAVITY
ABNORMALITY
 INDICATIONS :
 Abnormal uterine bleeding
 Post Menopausal bleeding
 Abnormal HSG/USG
 Uterine abnormalities (septae)
 Suspected intra- uterine pathology (polyps,
myomas,adhesions,foreignnbodies)
 Recurrent Pregnancy loss
 Before IVF
 Unexplained infertility
CONTRAINDICATIONS
• Acute PID
• Active herpes infection
• Pregnency
• Medically Unstable
patient
Endometrial polyp
Cystic endometrial
changes

57. OFFICE HYSTEROSCOPY
 Hysteroscopy done at outpatient basis without anaesthesia/
analgesia & cervical dilatation
 Vaginoscopical approach (no-touch) : Most popular approach: first
proposed by BETTOCCHI AND SELVEGGI in 1996
 <3.5mm rigid hysteroscope / flexible hysteroscope
 Patient can herself observe normal and abnormal findings
 Routine prophylactic antibiotic not recommended
 Vaginoscopic approach, preserves integrity of hymen
No need for use of speculum and tenaculum
Vaginal cavity distended using distension media
Decreased patient discomfort (99.1%)
No assistants required
ACOG 2011 ; Kerkvoorde et al 20

58. OUTPATIENT HYSTEROSCOPY
 NSAIDs 1 hour before hysteroscopy: reduce pain in immediate postoperative
period
 Routine cervical preparation before outpatient hysteroscopy: not be used
 Miniature hysteroscopes (2.7mm with 3–3.5mm sheath) should be used for
diagnostic outpatient hysteroscopy, significantly reduce discomfort
experienced
 Flexible hysteroscopes : less pain during outpatient hysteroscopy
 Rigid hysteroscopes may provide better images, fewer failed procedures,
quicker examination time and reduced cost
 Uterine distension with normal saline appears to reduce incidence of
vasovagal episodes, improved images, completed more quickly compared
with carbon dioxide
 Operative outpatient hysteroscopy, using bipolar electrosurgery, requires use
of normal saline to act as both distension and conducting medium
RCOG Green-top Guideline No. 59 (2011)
LOR
B
A
A
B
A
GPPAvailable evidence fails to show whether paracervical block is inferior, equivalent, or
superior to alternative analgesic techniques in terms of efficacy and safety for women
undergoing cervical dilatation and uterine interventions

59. OUTPATIENT HYSTEROSCOPY
 Topical application of local anaesthetic to ectocervix where
application of a cervical tenaculum is necessary
 Local anaesthetic into or around cervix reduces pain during
hysteroscopy. Routine administration of intracervical or
paracervical LA recommended in postmenopausal women
 Conscious sedation should not be routinely used in outpatient
hysteroscopic procedures, it confers no advantage in terms of
pain control and satisfaction over LA.
 Vaginoscopy reduces pain during diagnostic rigid outpatient
hysteroscopy
 Routine cervical dilatation is associated with pain, vasovagal
reactions and uterine trauma and should be avoided
LOR
A
A
A
A
C
RCOG Green-top Guideline No. 59 (2011)

60. OPERATIVE HYSTEROSCOPY
60
INDICACTIONS
 POLYP
 SUBMUCOUS LEIOMYOMA
 UTERINE SEPTA
 INTRAUTERINE ADHESIONS
 MISPLASED / IMBEDED IUD
 TUBAL CANNULATION & FALLOPOSCOPY
 TUBAL STERILIZATION

61. OPERATIVE HYSTEROSCOPE
 Used for minor surgery (Small endometrial polyp or pedunculated
fibroid)
 Telescope passes through external sheath
 Diameter of extension sheath ranges between 3.5 and 7mm
 Extension sheath allows passage of both operative instrument and
liquid distension media

62. RESECTOSOCPE
 Telescope (12º or 30º)
 Inner sheath
 Outer sheath
 Cautery lead
 Inflow and outflow connection
 Light source
BIPOLAR ENERGY (NORMAL
SALINE )
UNIPOLAR ENERGY (1.5%
GLYCINE)
CONVENTIONAL
- 4mm Telescope
- 9mm with Outer sheath
MINI RESECTOSCOPE
2.9mm telescope
5mm with Outer sheath

63. FERTILITY ENHANCING SURGERIES
UTERINE SEPTUM SUBMUCOUS MYOMA
ADHESIOLYSIS CANNULATION

64. Meta-analysis-Submucous fibroid
 Pritts et al. 2009 - studies regarding the effect of
fibroids on fertility and of myomectomy in improving
outcomes.
 They concluded that fertility outcomes are decreased
in women with submucosal fibroids
 Removal seems to confer benefit in terms of
pregnancy rates.
64

65. Cochrane review
 Hysteroscopic myomectomy might increase the odds of
clinical pregnancy in women with unexplained subfertility
and submucous fibroids, but the evidence is at present
not conclusive.
 Hysteroscopic removal of endometrial polyps suspected
on ultrasound in women prior to IUI might increase the
clinical pregnancy rate J. Bosteels, “Hysteroscopy for
treating subfertility associated with suspected major uterine
cavity abnormalities,” Cochrane Database of Systematic
Reviews, no. 1, Article ID CD009461, 2013
65

66. Metroplasty
 Most studies of metroplasty for a septate uterus
combine women with recurrent miscarriage and
infertility, and no study has been published that
randomizes infertile women to treatment versus no
treatment. For this reason controversy exists as to
whether infertile women should undergo metroplasty
C. R. Kowalik, M. Goddijn, M. H. Emanuel et al., “Metroplasty
versus expectant management for women with recurrent
miscarriage and a septate uterus,” Cochrane Database of
Systematic Reviews, no. 6, Article ID
66

67.  Reproductive Outcome following Hysteroscopic
Monopolar Metroplasty: An Analysis of 203 Cases
Ensieh Shahrokh Tehraninejad
Int J Fertil Steril. 2013 Oct-Dec; 7(3): 175–180.
Evaluate the reproductive outcome of women with
history of infertility or recurrent miscarriage following
hysteroscopic septum resection
 Term deliveries increased significantly from 2.5 to
33.5%.
67

68. HYSTEROSCOPY & ENDOMETRIAL CANCER
 Total of 756 studied patients, 79 presented a positive peritoneal
cytology. The diagnostic hysteroscopy did not signifi cantly increase
the risk of abdominal dissemination of tumor cells. The peritoneal
cytology was positive among 38 patients in the group who underwent
this intervention versus 41 patients in the control group (odds ratio
[OR], 1.64; 95% confi dence interval [CI], 0.96-2.80). Thus, no formal
evidence is currently available concerning the role of diagnostic
hysteroscopy on the frequency of peritoneal dissemination of tumor
cells or on the vital prognosis of the patients presenting with
endometrial carcinoma.
 Hysteroscopy appears to be associated with an increased rate of
malignant cytology after controlling for confounders of stage and
grade. Further, there appears to be an association between
hysteroscopy and upstaging patients due to cytology alone(II-2)

69. OPERATIVE OFFICE HYSTEROSCOPY

70. Perforation
Bleeding
Fluid overload
Infection
Hematometra
Hysteroscopic Complications
Intraoperative
• Pain
• Air embolism
• Fluid overload
• Hemorrhage
• Perforation
• Thermal injuries
Postoperative
• Hemorrhage ,infection, hematometra ,adhesion
Others
• Non-resolution of symptoms
• Spread of malignancy
• Complications of pregnancy
Viscous: Pul. oedema, anaphylaxis
Coagulopathy, renal failure
Hypotonic: Electrolyte imbalance,
encephalopathy &
consequences,
Transient blindness

71. Hysteroscopic Complications
 2.7% to 3.8% of all hysteroscopies
 A multicenter study in the Netherlands
 0.13% - diagnostic hysteroscopy
 0.96% - operative hysteroscopy
 Highest rate of complications seen with hysteroscopic
adhesiolysis (4.5%)
Propst AM, et al. Obstet Gynecol 2008
Jansen FW, et al. Obstet Gynecol 2007
Hulka JF, et al. J Am Assoc Gynecol Laparosc 2

72. PERFORATION
 Midline uterine - no significant morbidity
 Lateral uterine - retroperitoneal hematoma
 Cervical perforations - significant immediate or
delayed bleeding
 Recognition of perforation
 Loss of uterine distension
 Rapid increasing in fluid deficit
 Sudden uterine bleeding
 MANAGMENT
 With small dilator little risk to surrounding organ or major bleeding – conservative
management
 With large dilator or electrical energy - laparoscopy needed
 Perforation has occurred , abandoned procedure and repeat hysteroscopy after 4- 6
weeks
 Prevention:
• pelvic examination to determine uterine
position
• Pink myometrium becomes visible
• Resection to be done till both ostia seen
simultaneously
• Laparoscopic guidance or USG guidance

73. COMPLICATIONS(cont.)
 Vasovagal attack
 Proper evaluation particularly to rule
out preexisting heart disease
 Instillation of LA in cervical canal
may reduce incidence
 Routine administration of intracervical
or paracervical LA is not indicated to
reduce incidence
(Level A) RCOG 2011
 Air Embolism
 OT assistant must keep a watch on
Fluid bottle and inform surgeon before
changing it to prevent entry of air
bubble into uterus
 Mx - Left lateral decubitus position with the
head tilted downward 5 degrees f/b IJV
catheter
 False passage
 Vaginal misoprostol 400ug 2-3 hrs
before procedure
 Office hysteroscopy
Cooper NAM et al., A systematic review and meta-analysis.
2010

74. FLUID OVERLOAD
 Appropriate delivery system -
Hysteromet
infusion pressure < mean arterial
pressure
 Absorption pressure ratio (APR) < 1.
 Avoid entering into vascular channels
 Keep operating time minimal, < 45
minutes.
 Monitor fluid deficit at an extremely close interval
 automated fluid monitoring system facilitates early
recognition
 Preoperative use of GnRH agonists : reduced fluid
deficit among premenopausal women
 Intracervical Vasopressin 8ml (0.05U/L)- dec. fluid
absorption & also force of dilatation
Incidence 0.38%-3.3%
Hypoosmolarity and hyponatremia---
cerebral edema and death
Pulmonary edema & Coagulopathy
ACOG 2011, AAGL 2007
 Correctional of Hyponatremia –
• < 48hrs : hypertonic saline + loop diuretics
1–2 mEq/L/h, but by no more than12 mEq/L
in the first 24 hours
• > 48hrs : rapid correction not recommended
TERMINATE PROCEDURE when fluid
deficit of :
 Electrolyte-poor fluids 750 mL -
 elderly
 with cardiovascular or renal
compromise
 Electrolyte poor fluid 1,000–1,500 mL
 Electrolyte solution - 2,500 mL
 Outpatient setting - discontinuing
procedures at a lower fluid deficit

75. TAKE HOME MESSAGE
 Laparoscopy has grown rapidly & become technique of choice
 Basic knowledge of instruments & energy sources is necessary before any surgery
 Primary incision for laparoscopy should be vertical from base of umbilicus
 Manometer test : most reliable test for veress entry
 Direct trocar entry : less minor complication & failed entry
 For failed entry/ scarred abdomen – open technique / palmer point entry
 Non-midline incision ≥ 7mm & midline ≥10 mm requires deep sheath closure
 Harmonic : poor maintenance of residual tip temperature & minimal thermal spread
 Ligasure : adequate maintenance of residual tip temperature but more lateral thermal spread
 Whenever possible use bipolar energy sources over mono-polar in lowest possible voltage

76. TAKE HOME MESSAGE
 Hysteroscopy done in 1st half of menstrual cycle
 For outpatient hysteroscopy vaginoscopic approach is preferred
 Miniature hysteroscopes (2.7mm with 3–3.5mm sheath) - significantly reduce patient discomfort
 Local Anaesthesia
 Intra cervical - reduces vasovagal symptoms, decreases the pain
 Para cervical - significantly decreases the pain, not reduces vasovagal symptoms
 Distension media
 Normal saline 0.9% – diagnostic, operative hysteroscopy with instrument / with bipolar
 Glycine 1.5% - monopolar energy

77. THANK YOU