Liselotte Mettler, M. Parikh, Thoralf Schollmeyer
Hysteroscopy has revolutionized the field of Gynecology and the management of many gynecological conditions. It has now become a standard part of the gynecologic surgeons armamentarium. Cost, convenience, accuracy, and patient acceptability of these procedures are clearly superior to those of traditional surgeries. As gynecologists have grown better acquainted with the benefits and techniques of operative hysteroscopy, it has become the method of choice for treatment of intrauterine pathology.
The acceptance and practical application of hysteroscopy have come about only through a long and arduous struggle. Modern hysteroscopy represents a technological triumph that has built on the trail-and-error research of many scientists. The development of endoscopy may be traced to Phillip Bozzini, who in 1806 originated the idea of illuminating the body cavities by an exterior light source. Desormeaux in 1865 produced the first hysteroscope. It was in 1869, though, that Pantoleoni performed hysteroscopy for the first time, using Desormeaux hysteroscope.1 In 1879, Nitze drew and produced an endoscope using modern beginnings. Duplay and Clado, in 1898; David, in 1908; Heineberg, in 1914; Rubin, in 1925; Seymour, in 1926; Van Mikulicz, in 1927; Gauss, in 1928; Schroeder, in 1934; Segond, in 1937; Fourestier, Gladu and Vulmiere, in 1952; Mohri and Mohri, in 1954; Norment, in 1956; Palmer, in 1957; Silander, in 1962; Marleschki, in 1966; Edstrom and Fernstrom, in 1970; Lindemann and Mohr, in 1971; Porto and Gaujoux, in 1972; Vulmière, in 1972; Iglesias, in 1975; Lindemann, in 1976; Siegler and Kemman, in 1976; Hopkins, in 1976; March, in 1978 and Sugimoto, in1978 all contributed in some way to the technological progress of the method. Hamou, in 1979, idealized the microhysteroscope with panoramic vision and of contact. Since then, the development of hysteroscopy has flourished. During the 1980s and 1990s, gynecology has shifted heavily towards endoscopy as specialty.
Hysteroscopy is generally a low risk technique that uses the endocervical canal, the natural passageway of the body, to gain entry into the uterine cavity. Refinement of optical and fiberoptic light instrumentation and of operative accessories allow high resolution and excellent visual documentation by hysteroscopy. Tremendous advances are still being made.22 Hysteroscopy in 21st century has finally found its niche, and every gynecologist is required to learn skills of hysteroscopy.
The success of hysteroscopy depends on the choice of anesthesia, choice of distention media, the instrumentation, and the experience of the surgeon. As hysteroscopy has increasingly become the method of choice for treatment of intrauterine pathology, the number of complications has also risen. Most of these complications are caused by operator error and inexperience.
CHOICE OF ANAESTHESIA
A great number of diagnostic hysteroscopies and some operative ones can be performed without the need of anaesthesia.2 When anesthesia is required, different anesthetic techniques adapt to the range of interventions and to patient preferences, from local anaesthesia,3 supplemented or not, with sedation to regional or general anaesthesia.4
Minor surgeries are generally office based, with local anesthesia, mild sedation, or without anesthesia. Major hysteroscopies are programmed in a day-surgery facility, under locoregional or general anesthesia. The anesthetic technique depends on several factors: type and duration of surgery, chosen surgical technique and instruments, surgeon’s experience, and patient acceptability.
There are multiple and widespread applications for hysteroscopy, from a quick diagnostic hysteroscopy to extensive intrauterine surgeries. The instruments for hysteroscopy must therefore be completely adapted to the specific indications of the procedure.6
Two main types of hysteroscopes are available and are differentiated by the degree of flexibility of the body of the hysteroscope: rigid and flexible.
The rigid hysteroscope has three parts: the eyepiece, the barrel, and the objective lens. Surrounding the optics are numerous small-diameter incoherent fiberoptic bundles that provide intense cold illumination to the operative field. There are three type of lenses (0,12 and 30), each of which has different applications. Conventionally for diagnostic hysteroscopy a 30 degree for oblique lens with a diameter of 2.9-3 mm and a 4 to 4.5 mm detachable external sheath are used. Minihysteroscopes, introduced recently have a 30-degree lens with a diameter of 1.2 to 1.9 mm and a 2.5 to 3 mm external sheath. Image quality is similar to conventional hysteroscopes. Microhysteroscopes have a diameter less than 2 mm and are made of fiberoptics. These are very fragile and have a poor image quality.
Flexible hysteroscopes are fiber optic hysteroscopes. Those with a diameter of 3.1 to 3.7 mm are used for diagnosis whereas 4.9 to 5.3 mm diameters with a working channel are used for surgery. They are equipped with a mechanism that allows 100-degree guidance of the tip of the hysteroscope so that areas that are not visible with the rigid hysteroscope can be seen (e.g. uterine retroflexion). Since it is optical fiber, the image shown is cellular similar to the honeycomb of bees, and quality is lower.5
Diagnostic and operative sheaths
A diagnostic sheath is required to deliver the distention media into the uterine cavity. The telescope fits into the sheath and is secured by means of a watertight seal that locks into place. The sheath is 4 to 5 mm in diameter, depending on the outer diameter of the telescope, with a 1 mm clearance between the inner wall and the telescope, through which the distention media is transmitted.
Operative sheaths have a larger diameter than diagnostic sheaths. They range from 7 to 10 mm and average 8 mm in diameter. The operative sheaths allow space for instillation of medium, for the telescope, and for the insertion of operating devices.
The resectoscope is a specialized electrosurgical endoscope that consists of an inner sheath and outer sheath. The outer sheath is for medium return. The inner sheath has a common channel for the telescope, medium and electrode. The monopolar or bipolar electrode is fitted to a trigger device that pushes the electrode out beyond the sheath and then pulls it back within the sheath. The operating tools consist of three basic electrodes: a ball, barrel, and a cutting loop.
The standard accessories are 7F alligator grasping forceps, biopsy forceps, and scissors. A variety of monopolar and bipolar electrodes are also available for operative hysteroscopy. Monopolar balls, needles, and loops can be inserted through the large operating channel. Bipolar needles, ball electrodes, and scissors have also been manufactured.
A new bipolar system named VersaPoint™ (Gynecare, Menlo Park, CA) permits cutting, ablation via operative hysteroscopes or via a dedicated bipolar resectoscope. The biggest advantage of this bipolar technology is that saline may be used as distention media.
Hysteroscopic examination is impossible without an adequate light source. Light is effectively conducted through the fiberoptic cable, which is an integral part of the hysteroscope. Two main types of light generators are available: halogen and xenon. The xenon generator provides white light, which gives a superior color and intensity.
The endometrial cavity is a virtual space that is only distended in pathological situations. Under normal circumstances the uterine walls are in close opposition to one another. To achieve panoramic view of the uterus, the walls must be forcibly separated. The thick muscle of uterine walls requires a minimum pressure of 40 mm Hg to distend the cavity sufficiently to see with a hysteroscope.7 There are various types of distention media, but they can be mainly classified as gaseous and liquid distention media. The latter may be further subdivided into high-viscosity and low-viscosity fluids.
Carbon dioxide is a colorless gas that is highly soluble when mixed with blood. It can be safely used to distend the uterus when instilled with proper insufflation apparatus. This distention media is ideal for office hysteroscopy. When CO2 flow is excessive it produces bubbling and obscures the vision. CO2 mixes with blood and produces an obscuring, bubbling foam. CO2 tends to flatten the endometrium, and this can give a wrong visual impression of the endometrium. When instilled improperly it can lead to gas embolism. However the best feature of CO2 is its neatness. It does not foul the instruments, it does not mess up the office or operating room, and it allows entry evaluation of the endocervical canal. CO2 therefore is an excellent diagnostic medium. However, liquid media are superior in most aspects for operative hysteroscopy.
High viscosity fluids
Hyscon was the distention media that was used for diagnostic and operative hysteroscopy frequently in the 1980s. However, due to the high rate of complication and difficulty of use, other media have replaced it.
Low viscosity fluids with electrolytes
Frequently used low viscosity fluids are normal saline and lactated ringer’s solution. The advantage of these media, in addition to their easy availability and low cost, is that they provide a greater margin in fluid intravasation. Nevertheless, pulmonary and cerebral edema cannot be ruled out if too much fluid is lost. Interventions such as targeted biopsies, polypectomies, division of uterine septa, myomectomies, division of intrauterine adhesions, removal of foreign bodies, etc., can be performed using scissors, biopsy forceps, and grasping forceps. These media are also appropriate for bipolar resectoscope, VersaPoint™, and laser surgery.
Low viscosity fluids without electrolytes
In order to practice electrosurgery, particularly with monopolar current, distention media without electrolytes should be used. 1.5 % glycine is the most commonly used medium. It is also the medium with which there is most experience since it has been used in urology in transurethral resections since 1948. It is a hypotonic solution with an osmolarity of 200 mOsm/l. If the inflow outflow deficit is more than 1500 cc, serious complications may arise, including aqueous intoxication.8 In order to prevent complications, it is important to maintain a strict control of the inflow and outflow, respect infusion pressures and flow rates, and limit intervention time to 60 minutes. Other non-electrolyte media that are uncommonly used are 5% glucose and sorbitol/mannitol.
DIAGNOSTIC HYSTEROSCOPY TECHNIQUE
Diagnostic hysteroscopy is an intrauterine examination without the expectation of a therapeutic intervention. Accurate knowledge of the position of the uterus is critical to facilitate the examination. The best time to perform a diagnostic hysteroscopy is during the proliferative phase of the menstrual cycle. The patient is placed in lithotomy position and perineum and vagina prepared with povidone iodine. Sims retractor retracts the posterior vaginal wall and the cervix is visualized. The cervix is grasped with a single toothed tenaculum. The telescope is assembled and checked for clarity of image. The distention media flow is started as the hysteroscope is engaged into the external os of the cervix. Cervical dilatation is not required in multiparous women, whereas some dilatation may be needed in nulliparous women. Excess dilatation is avoided to prevent escape of the media from the sides of the telescope. As the endoscope is advanced through the external os, the distention media separates the wall of the endocervix to allow excellent view of the endocervical folds and crypts. The internal os is identified as a narrow constrictive opening at the end of cervical canal and the hysteroscope is manipulated under vision into the uterine cavity. Flow rate might need adjustment after entering the uterine cavity. Systematic examination of all four walls of the uterine cavity and the tubal openings is carried out with axial movements of the telescope. The endometrium is smooth and pink white in color during the proliferative phase and lush and velvety in the secretory phase. Any abnormal pathology should be documented. This procedure can be done on an outpatient basis with or without anesthesia.
OPERATIVE HSYTEROSCOPY TECHNIQUES
The telescope is inserted into an operative sheath or resectoscope sheath. The sheath is flushed with distention media, and the light cable is attached. The cervical canal is carefully dilated with Pratt or Hegars dilators. Dilatation should be performed until the operative sheath negotiates a tight passage through the cervix. The hysteroscope is inserted into the uterine cavity under direct vision. The cavity is scanned and the landmarks noted i.e. tubal ostia, location and attachment of the lesion, proximity of internal os etc. If the vision is not clear because of debris, the uterine cavity is flushed and the fluid is aspirated until a clear view is obtained. No operative procedure can be performed until an absolutely unobstructed view is obtained. In certain cases, it may be advantageous to perform a simultaneous laparoscopy to permit an assistant to view the serosal surface of the uterus to provide some assurance against inadvertent perforation. Laparoscopy is recommended during septal resections, excision of large myomas, lysis of uterine adhesions and during tubal cannulation.20,21
HYSTEROSCOPY AND INFERTILITY
Reproductive medicine reaps the benefits of hysteroscopy in 2 different ways: (1) in the precise diagnosis of any alteration of the endocervical canal or the uterine cavity in patients with fertility problems or in patients with repeated IVF failures and (2) in patients who have pathology, susceptible to correction and to provide a normal uterine cavity for embryo transfer.
Various pathologies that cause, or are a co-factor in, infertility can be successfully treated with hysteroscopy. Cervical stenosis and synechia can be corrected via hysteroscopic mechanical dilatation. Cervical and uterine polyps can be removed mechanically with scissors or graspers, or using resectoscopes. Hysteroscopy guided tubal cannulation can help to open ostia obstructed with membranes or mucus debris. Diagnostic hysteroscopy helps to detect concealed pathology in women with multiple IVF failures. Large submucous myomas and uterine cavity adhesions are important causes of infertility. Before the advent of hysteroscopy these pathologies required opening of the uterine cavity and subsequent increased complications and morbidity. Hysteroscopic correction of uterine malformation such as septum and T-shaped uterus has not only increased conception rates but also has drastically reduced early pregnancy loss. At present the tendency to use hysteroscopy in fertility is increasing. Hysteroscopy does not only clear some doubts, it can also be therapeutic.
LASER AND ELECTROSURGICAL DEVICES
The Nd:YAG laser, which works by thermal energy, is the preferred laser for hysteroscopic surgery. Electrosurgical devices exert their tissue actions in a similar fashion. Light energy from lasers is transformed to thermal energy by electron flow. The Nd:YAG laser beam can be transmitted equally with any distending medium, whereas monopolar electrosurgical devices operate most effectively in an electrolyte-free medium. Bipolar electrosurgical devices can be used with saline solution as a distension medium. The surgeon must be familiar with the physics governing the actions of lasers or electrosurgical tools and with the tissue actions exerted by these energized devices. Proper selection of wattage depends on disease pathology and location. High power applied for a long period of time is risky, and will inevitably lead to unwanted tissue injury.
THE PROCEDURES OF HYSTEROSCOPIC SURGERY
Uterine anomalies, specifically uterine septum, may cause repetitive abortions in one out of every five women who achieve pregnancy with this condition. The diagnosis of uterine septum is made at hysterosalpingography or during a diagnostic hysteroscopy. A symptomatic uterine septum is best treated with hysteroscopy. The uterine septum may be of different lengths and widths involving only the corporeal portion of the uterus or extending into the cervix and rarely the vagina.9
Hysteroscopic treatment provides a less invasive approach to divide the uterine septum. The treatment offers minimal discomfort to the patient as well as minimal morbidity, as it is performed on an outpatient basis. Because the uterine wall is not divided, a subsequent cesarean section is required only for obstetrical indications. The healing with reepithelialization of the uterine cavity takes only 4 to 5 weeks, and patients are allowed to conceive sooner than with abdominal metroplasty. Hospitalization is not required so expenses are markedly reduced.
Three hysteroscopy methods can be used to divide the uterine septum. The mechanical method using rigid scissors, the resectoscope, and the fiberoptic laser.
The most commonly used method for treatment of the uterine septum is with a monopolar hook using the resectoscope. The fibrotic consistency of the septum permits this division without significant bleeding and the procedure is performed systematically dividing the septum in the middle from its top to its base, having as landmarks both uterotubal junctions and the translucency of the hysteroscopic light is seen by the assistant utilizing a laparoscope with dimmed or no light. Systematic, delicate, shallow cuts should be performed in order to observe at all times the symmetry of the uterine cavity. The use of bipolar cutting devices permits to distention of the uterine cavity with saline solutions.10 Bipolar vaporizing electrodes permit the use of electrolyte containing fluids.
Another method of hysteroscopic division of septum is to use semi rigid hysteroscopic scissors through the working channel of the diagnostic hysteroscope. When using the monopolar hook of the resectoscope only fluids devoid of electrolytes can be used to avoid conduction.11
Finally, fiberoptic lasers can be used also to divide the septum, be it Nd:YAG, KTP or argon lasers. Fluids with electrolyte media can be used as lasers do not produce conductive energy.12
Adhesions form between the anterior and posterior walls of the uterus as a result of trauma or infection in a milieu of estrogen deprivation. Classically, this problem follows abortion or post partum hemorrhage for which a vigorous curettage was performed.13 Most of the women with uterine adhesions complain of oligomenorrhoea or amenorrhea. A hysterosalpingogram may reveal filling defects that vary from minimal to severe. Past treatment of uterine synechia consisted of blind curettage; the results were poor. With the advent of hysteroscopy, treatment has progressed to identification of adhesions and sharp incision of the adhesions with scissors. Hysteroscopic methods used for adhesiolysis are mechanical scissors, resectoscope, fiberoptic lasers and, of late, bipolar vaporizing electrodes.
As intrauterine adhesions are avascular, they can be divided and not removed. The adhesions are divided centrally, allowing the uterine cavity to expand upon division of the adhesions. The most commonly used method is with semi-rigid scissors because of the increased facility in manipulating the scissors. Occasionally, thick connective tissue adhesions are present and it is better to remove rather than divide them.14 To achieve these goals sharp punch biopsy forceps may be more useful. If electrosurgical methods are used, it is preferable to use a thin, sharp electrode through the operating channel of the hysteroscope than through the resectoscope. Filmy and central adhesions should be cut first, marginal and dense adhesions should be tackled last, always cutting from below and moving upwards. Simultaneous laparoscopy is a prudent measure to prevent perforation of the uterus.
If during the above procedures, bleeding ensues, a Foleys catheter is inserted into the endometrial cavity and inflated to 5 to 6 ml saline. The Foleys catheter is also introduced for a short while of up to 6 hours or an IUD can be placed for 1 month. The catheter may be deflated and removed 6 to 12 hours postoperatively. Antibiotics are not routinely administered. Women are usually advised to take 2.5 mg estrogen daily for 30 days after surgery to help re-epithelization. Placement of IUCD is not based on scientific fact but has been used for many years. Recently we have applied Sprayshield™, a Poly Ethinyl Glycol gel for adhesion prevention.
Endometrial polyps are benign growths appearing to originate from localized hyperplasia of the endometrium. Polyps are generally solitary, but in 20% of cases are multiple. They can be sessile or pedunculated and originate anywhere in the uterine cavity. They usually present as abnormal uterine bleeding, but are also implicated as a possible cause of infertility. Large polyps that extend into the cervix and dilate the internal os can cause endometritis. In general, polyps are benign growths with no malignant potential. Diagnosis is usually made using ultrasonography. HSG and sonosalpingography are other modes of detecting the size and location of polyps.
Hysteroscopic polypectomy is a minimally invasive operation and allows complete removal of polyps under direct vision. Most of the polyps can be removed using an operative hysteroscope with scissors. The extraction is possible with the use of an endoscopic grasper or endoscopic basket. Alternatively, it can also be removed by a simple curettage. Other methods of hysteroscopic polypectomy involve usage of an electric snare loop of a resectoscope. A resectoscope loop can be used with electric current. Larger polyps need piecemeal removal with the help of resectoscope. After the procedure is completed, the site of removal is inspected again. If any bleeding is observed, a 3 mm ball electrode is applied to the site for coagulation (roller ball).
CANNULATION OF FALLOPIAN TUBE
Novy et al. described a technique for passing a special catheter into the tubal ostium and through the obstructed interstitial portion of the tube.15 This procedure was successful in 92% of cases. This technique is useful for treating interstitial obstruction secondary to cellular debris and tubal spasm. The obvious advantage of this cannulation technique is its usefulness in treating cases that might otherwise require tubocornual anastomosis.
The technique in case of cornual obstructions involves introduction of 5.5 F Teflon cannula with a metal obturator through the operating channel of hysteroscopic sheath. The obturator is removed and a 3 F cannula with a guide cannula wire is introduced in the 5.5 F cannula. The cannula is then negotiated to enter the tubal cornua. The guide wire is then removed and methylene blue dye is injected into the cannula. The spill through the fimbrial end is visualized via laparoscopy. In some case this technique represents a simple surgical procedure.
Uterine myomas are benign encapsulated tumors that originate from the muscle tissue of the uterus. Depending upon their location, they can be classified as subserosal, intramural and submucous. Intramural and submucous myomas are usually symptomatic and may present as abnormal uterine bleeding, infertility, pain or pressure symptoms. Diagnosis is with the help of ultrasonography or detected as a filling defect on a hysterogram. In the past, a diagnosis of submucous myoma was usually followed by a recommendation for hysterectomy. Today, hysteroscopic surgery offers a therapeutic alternative to that radical approach. The treatment methods used with the multichannel hysteroscope are Nd:YAG laser, monopolar loop, monopolar needle, bipolar needle or scissors.16 Submucous intramural myomas are divided into 3 types depending on their myometrial invasion.
The most common method of submucous myoma excision is with a resectoscope using a monopolar loop and glycine as distention media. Before beginning with the resection, large vessels on the surface of the myoma are coagulated in order to prevent bleeding that obstructs the vision. The electrode is always moved in the forward direction from behind the myoma rather than in the opposite direction. Resection begins from the surface of the free intracavitatory portion of the myoma and proceeds towards the base. The fragments of myoma produced should be removed as they may obstruct vision. This can be done with the help of the resectoscope itself or using a fenestrated curette or an ovum forceps. After resecting the entire intracavitatory portion of the myoma, it is advisory to wait for a few seconds, allowing time so that the uterine contractions cause the intramural portion of the myoma to protrude into the cavity. A reduction of intrauterine pressure may reveal persisting bleeders, which then can be coagulated. Expulsion of this portion can also be favored by administration uterotonics. Constant checking of the distention media loss has to be maintained. Any procedure lasting for more than 60 min and associated with more than 1500 cc fluid loss may lead to severe complications. For extremely large myomas it is safe to complete the resection in a second sitting 2 to 3 weeks later.17
The technique of myoma removal with bipolar resectoscope is the same as above, except that saline solution can be used as distention media rather than glycine. The complication rate is lower with such a technique. In pedunculated myomas, Nd:YAG laser can be used to cut the base. In myomas with an intramural portion, the laser facilitates vaporization of the myoma with no need for cutting. The major disadvantage is its high cost and the lack of material for histological analysis. Other methods involve use of VersaPoint™ and bipolar needles to perform myolysis. The Wolf resectoscope facilitates continuous suction of resected chips of tissue.
Bleeding can be controlled by ball cautery or by inflating Foleys balloon inside the uterine cavity. Simultaneous laparoscopy may be beneficial in cases with large partially intramural myoma where the risk of perforation is high.
The introduction of hysteroscopic ablation in the field of hysteroscopy has significantly reduced the rate of hysterectomies, thereby decreasing overall cost and morbidity for the women. Nowadays, endometrial ablation has replaced hysterectomy as a treatment for abnormal uterine bleeding of benign origin. Since the first practical method of hysteroscopic ablation was described in 1981, the success rate has increased and complication rate has gone down. Adequate preoperative counseling is a must before endometrial ablation. Women need to be aware that the usual result after ablation is hypomenorrhea and not amenorrhea. Chances of success and a rare need for hysterectomy in the future should be explained in addition to the normal complications that can occur during hysteroscopic surgery. The need for contraceptive use after the surgery should be emphasized and as well as the fact that this surgery does not protect against occurrence of endometrial cancer. With a careful selection of patients the success rate is excellent.
A preoperative diagnostic hysteroscopy, endometrial sampling, or both should be performed to exclude endometrial carcinoma or hyperplasia. Pretreatment of the endometrium with progesterone, danazol or GnRH analogues 6 weeks prior to surgery is advisable. The distention media used commonly is 1.5% glycine. The resectoscope with a monopolar loop electrode is inserted into the uterine cavity, and the blood and debris are cleared by suction. The cavity is inspected and resection is started. Resection is performed systematically, completing one uterine wall followed by another, to ensure all areas are adequately resected. All the time the loop should be moved towards the resectoscope sheath, as an active loop pushed away from the sheath can easily perforate the uterus. It is always better to ablate the fundal and corneal endometrium with a ball electrode.18 This decreases the chance of perforation and bleeding as this area is very thin and vascular. Power settings for the electrosurgical unit range from 50 to 150 watts, depending on the size of the ball, barrel, or loop electrode. Alternatively, the entire procedure can be done by lased or bipolar resectoscope.
The goal of ablation is to destroy the visible endometrium, including the corneal endometrium, to the depth of 1 to 2 mm. The conduction heat will actually spread deeper to 3 to 5 mm. This penetration causes extensive superficial myometrial destruction and coagulation of radial branches of the uterine artery. The endometrium sloughs and regeneration is prevented. Over a period of 6 weeks the uterine walls scar and shrink.
There are many non-hysteroscopic methods of second-generation endometrial ablation that are commonly used nowadays. If there is thermal destruction by using hot water, balloons, cryo-destruction of microwave ablation, the principle remains the same.
Hysteroscopy can also be used for certain other intrauterine procedures than those mentioned above. Hysteroscopic guided removal of impacted IUCD, biopsy of suspicious endometrium, hysteroscopy guided tubal sterilization and treatment of hemangiomas and arteriovenous malformations to mention a few.
Unfortunately, accurate data concerning complication are hard to obtain, but over the years the complication rate has been decreasing. This has been demonstrated by improvements in equipment and experience of the surgeons. In two multicentric interviews of the American Association of Gynaecologic Laparoscopists performed by Hulka the severe complication rate decreased from 1% to 0.2 % in 3 years.19 These indices can further be reduced if a series of precautions are taken before, during, and after the procedure. The patients should be aware of the risks and provided with an informed consent.
Intraoperative and postoperative bleeding
Intra and postoperative bleeding is the most common complication inherent to hysteroscopy. Hemorrhage is more common in procedures like endometrial resection and submucous myoma resection. There are various methods to control the bleeding. An immediate measure to reduce bleeding and clear the field of vision is to aspirate the blood and increase the pressure of distention media above the mean arterial pressure. This compresses the wall of the uterus sufficiently to stop bleeding. Then the bleeding vessel can be coagulated with a 3 mm ball electrode. If the counter pressure of the media is relaxed at the end of procedure and the bleeding still continues, it is best controlled by inserting a Foleys balloon and inflating it to 3 to 5 ml. The balloon can be kept in situ and removed 6 to 12 hours after the surgery. More distention may be required in case of larger uteri. In very rare cases when the bleeding is arterial and is not controlled by the above techniques, uterine artery embolization or even hysterectomy may be needed. Delayed postoperative bleeding is associated with endometrial slough, chronic endometritis or spontaneous expulsion of intramural portion of previously resected submucous myoma.
Uterine perforation most commonly occurs during septal resection, myomectomy surgery and adhesiolysis. However it can occur even in a simple diagnostic hysteroscopy. With appropriate care, this sort of perforation should not happen, because the cervix, internal os, and cavity should be negotiated under direct vision. The most dangerous perforations are those with lasers and electrosurgical devices. The incidence of injury can be reduced by not activating the energy device during thrusting forward movement. If a perforation does happen with laser or electrosurgical electrode, then laparotomy is required to ensure no injury has been inflicted to bladder, bowel, or ureter. The operator knows that perforation has occurred as it becomes difficult to maintain the distention. Simultaneous laparoscopy while performing operative hysteroscopy acts as a safeguard against risk of uterine perforation. If perforation is suspected due to a non-energy instrument, strict observation of the women postoperatively is mandatory. Rarely, vessel injury can occur when uterus is perforated, unexplained falling blood pressure along with inability to maintain distention should alert the operator. Women who have uterine perforation during operative hysteroscopy are at increased risk of uterine rupture during pregnancy. If any patient feels miserable after 10–20 hours with constant blood pressure, a bowel lesion may be suspected and an immediate laparoscopy must follow.
Infection is rare complication associated with hysteroscopy. Hysteroscopy should be avoided in presence of gross cervical infection, suspected uterine infection, or salpingitis. Prophylactic antibiotics should be administered only in cases of suspected chronic endometritis, large submucous myoma, embedded IUD, or in women with underlying rheumatic carditis or congenital heart defect.
Complications due to distention media
Inappropriate methods to infuse CO2 during diagnostic or operative hysteroscopy can lead to gas embolus. The diagnosis is made by presence of cogwheel murmur accompanied by rapid fall in expired CO2. Air embolism is extremely dangerous and can be avoided by purging air from the tubing before the procedure, careful dilatation to avoid opening venous channels, avoiding steep head low.
Spread of electric current and thermal damage using a resectoscope with unipolar cautery in a conductive media (electrolyte media) can cause thermal injury to the bowel/bladder. Use of low viscosity non-electrolyte media can avoid spreading of current.
The principal hazard of non-electrolyte media that are commonly used in operative hysteroscopy is creation of acute hyponatremic state. A fluid deficit equal or greater than 500 ml should alert a surgeon to a likelihood of hyponatremia and hypoosmolality, which can furthur lead to cerebral edema an CNS abnormality. Close monitoring of inflow and outflow and thereby the deficit can avoid these complications. Certain principles need to be followed: to stop the surgery if the fluid deficit is more than 1500 ml or the patient starts showing signs of hyponatremia, restrict the time of the procedure to less than 60 min and use an automated electronically controlled irrigation suction pump. Postoperative strict monitoring of the vital parameters as well as serum sodium concentration can help early diagnosis. Similar complication can also occur with electrolyte media but are rare compared to non-electrolyte media.
Injury to adjacent organs
Injury to organs such as bowel, bladder or ureter can go unnoticed during the procedure and present postoperatively with pain, fever, abdominal distention or diminished urine output. Vascular injury may present with falling blood pressure with rapid thread pulse. It is best to maintain a constant vigilance at the time of surgery to detect these complications, as they are best treated if diagnosed early. Cases involving injury recognized at the time of surgery and correctly managed do not usually become medico-legal cases. A late diagnosis (after 24 hours of surgery) should not occur, as the patients have symptoms. If she is an outpatient she will have come back with pain, shock, collapse, high fever or abdominal distension. If she calls saying she is not well, let her come immediately.
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