HYSTEROSCOPY

DR.GURURAJ DESHPANDE
MS(OBG)
ASSOCIATE PROFESSOR DEPT.OF.OBG
KAMINENI INSTITUTE OF MEDICAL SCIENCES
NARKETPALLY
Contents

 HISTORY
 INDICATIONS
 COUNSELLING
 ANAESTHESIA
 POSITION
 EQUIPMENTS
 DISTENDING MEDIA
 PROCEDURE
 COMPLICATIONS
 CONCLUSION
HISTORY:PANTALEONI 1869 T0 1970
A LONG GAP
INDICATIONS

DIAGNOSTIC
• Unexplained abnormal uterine bleeding(AUB)
• Pre and post menopausal
• Selected infertility cases
• Abnormal HSG
• Unexplained infertility
• Recurrent pregnancy loss
• Should be used prudently only after other
investigations
THERAPEUTIC INDICATIONS

 IUD removal
 Biopsy of intrauterine lesions
 Hemangioma and A-V malformations
 Resection of uterine septum
 Uterine synechiae
 Cannulation of fallopian tubes
 Sterilization
 Uterine polyps
 Submucous myomas
 Endometrial ablation
PATIENT COUNSELLING

 Benefits Vs Risks
 Other treatment options
 Realistic success rate
 Informed written consent
ANAESTHESIA

 Patient anxiety
 Cervix status
 Procedure
 Paracervical block and IV sedation
 Transcervical topical anesthesia
 Spinal/epidural
 GA
POSITION
EQUIPMENTS:TELESCOPES
VIEW
DIAGNOSTIC CONTINOUS FLOW
HYSTEROSCOPE
Operative sheaths and working
channel for accessory instruments
OFFICE HYSTEROSCOPE (BETTOCCHI
HYSTEROSCOPES)
Unipolar resectoscope consisting of
working element, 8mm resectoscope
sheath,4mm telescope
UNIPOLAR LOOP ELECTRODE FOR END
ABLATION,MYOMA,POLYP
UNIPOLAR ELECTRODES
(LOOP,NEEDLE,ROLLER,BALL)
DISTENDING MEDIA

 Need to distend uterus to view as uterus is

almost closed structure.
 Minimum 45mm of Hg for diagnostic
 Upto 70mm of Hg for operative
 If more than MAP ,more chances of overload
 Gaseous and liquid
 High and low viscosity medium
Carbon dioxide

 Neatness
 Doesn't damage instruments
 Doesn't mess up office/OR
 CO2 and bleeding incompatible
 CO2 and blood form obscuring bubbling
foam
 Cannot flush debris
 CO2 embolism rarely
CO2

 Insufflation should not exceed 100ml/min

 Unlike laparoscopy which are in litres/min
 Use only hysteroinsufflator
 Ideal for diagnostic office hysteroscopy
HYSKON

 32 percent dextran 70 in dextrose

 Immiscibility with blood
 Excellent visualization even in active bleeding
 Compatible with electrosurgery and lasers
 Outflow less due to high viscosity
 Hyskon allergic reaction 0.05% treat like
anaphylaxis
 Pulmonary edema 0.11% due to overload as it
pulls water into intravascular space.
HYSKON

 Fibrinoplastic action leading to bleeding

diathesis
 Clogs instruments if instruments are not
washed immediately with hot water
 Remains in bloodstream for 4-6 weeks
LOW VISCOCITY LIQUID MEDIA
MEDIUM OSMOLALITY mosm/kg SODIUM IN mEq/L
of water

SERUM 290 135-145

GLYCINE 1.5% 200

SORBITOL 3% 178

MANNITOL 5% 280

GLYCINE 2.2% 280

NS 308 154

RL 273 130
NORMAL SALINE

 Safest
 Instilled with 2-3 litres bag from 6-8 feet
 Continuous high flow required
 Cannot use monopolar cautery as it contains
electrolytes, bipolar can be used.
 Still overload can occur which can be treated
with diuretics
 Stop if deficit is 1.5 litres
1.5%GLYCINE AND 3%SORBITOL

 Taken from urology

 Hypotonic
 Metabolized to CO2 and free water
 Female brain cells cannot pump cations due to
progesterone action so more prone for cerebral
edema.
 Check osmolality and sodium minimum pre op
intra op and 4 hr post op
 Stop if >500ml deficit,
 Can use monopolar
5%MANNITOL AND 2.2%GLYCINE

 Both are safer and isoosmolar

 Mannitol is diuretic also
 Studies have shown that glycine2.2% is very
safe upto 1000ml deficit
 Can use monopolar
 Keep strict inflow and outflow
 Take into account the fluids infused by
anesthesiologist as RL commonly given is
hypoosmolar
CONTRAINDICATIONS

 Active PID
 Active profuse bleeding
 Recent perforation
 Pregnancy
 Cancer cervix
 Systemic disorders affecting fluid and
electrolytes
PROCEDURE

 Cervical priming and dilatation if needed

 Per vaginal examination to know the position
of uterus
 Vaginoscopic technique
 Systematic examination
 Operations with correct use of electrosurgery
and lasers
Panoramic view
Tubal ostium
Cu-T
DENSE ADHESIONS
SUBMUCOUS FIBROID
EXCISION WITH LOOP
EXCISION OF UTERINE SEPTUM
COMPLICATIONS

 Due to position
 Anaesthetic complications
 Due to distending media
 Uterine perforation
 Bleeding
 Bowel and bladder injury
 Septicemia
 Death
Bipolar resectoscopes
Hysteromat E.A.S.I
Intrauterine BIGATTI shaver
CONCLUSION

 Hysteroscopy is a part of every gynecological

surgeon’s armamentarium
 Generally a low risk technique using natural
pathway.
 Supersedes laparoscopy in philosophy of MIS
THANK YOU