GYNECOLOGY LECTURE #4 |MIDTERMS

DIAGNOSTIC PROCEDURE (HYSTEROSCOPY AND LAPAROSCOPY) DATE LECTURED:

OUTLINE in the setting of retained IUD or products of

I. HYSTEROSCOPY conception removal.
II. LAPAROSCOPY
EQUIPMENT
 Hysteroscope can either be rigid or flexible.
HYSTEROSCOPY
 Hysteroscopy is the direct visualization of the Rigid Hysteroscope
endometrial cavity via the cervix using an endoscope  Small Caliber Scope
and a light source. It is a simple technique that most o 3-5 mm diameter, used for diagnostic
gynecologist are trained to perform. purpose.
 Office and operating room hysteroscopy requires o Angle Views 0 to 70 degrees but 12 to 30
knowledge of instrumentation, techniques, indications, degrees are most commonly used.
o Outer sleeve contains several channels that
contraindications, and complication management.
extend the full length of the instrumen
 Inserting a hysteroscope for diagnostic purposes only
is a low-risk procedure.  4-mm telescope with 7-mm outer sheath
 Office hysteroscopy saves time for both the patient o For office hysteroscopy
and physician, saves money, and is convenient. o There is a channel for seven French flexible
or semirigid instruments such as scissors, or
INDICATIONS biopsy or grasping forceps.
 Abnormal uterine bleeding- most common indication o The outer sheath also allows for inflow of the
o Premenopausal distending media
o Postmenopausal  Large scopes
 Persistent abnormal uterine bleeding after negative o 8 to 10 mm
endometrial biopsy o may be used for high flow of distending
 Postmenopausal endometrial thickening and negative media and have a second channel for
endometrial biopsy
outflow of blood and fluid.
 Endometrial polyp
o These are used for moderate to complex
 Submucosal myoma or possibly <50% intramural
procedures.
 Uterine septum
 Uterine synechiae Flexible Minihysteroscopic Instrument and
 Retained IUD Microadenoscopes
 Sterilization  Convenient and well tolerated in the office for
 Endocervical lesions. diagnostic and simple operative procedures such as
directed biopsies.
CONTRAINDICATIONS
 There is generally less pain with the small flexible
Absolute Contraindication Relative Contraindication
hysteroscopes, but the visual quality is poorer.
 Acute Pelvic/ vaginal  Active bleeding
 They do allow more ease when lysing intrauterine
infection (Exception:  Extensive adhesion
adhesions in difficult locations
Retrieval of IUD if the  Leiomyomata (>50%)
pelvic infection is related intramyometrial Distending Media
to the device.
 The success of hysteroscopy depends on the media
 Cervical and Uterine
used to expand the uterine space.
Cancer
 For operative hysteroscopy, it is necessary to
carefully and frequently monitor intake and outflow of
 Pregnancy (not indicated whether absolute/ relative) distention media.
is also a contraindication to hysteroscopy unless used
 Non-electrolyte media
o Cutoff is 1000 to 1500 mL

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  Electrolyte Medium -
note the size of the uterus and direction of
o Cutoff is 2500 mL the uterine fundus.
 For operative procedures with electrocautery, saline - Knowing whether the uterus is anteverted or
or isotonic solutions cannot be used because they retroverted is important to avoid uterine
conduct electricity (except bipolar cautery). perforation.
 HYSTEROSCOPIC DISTENTION MEDIUM o Rectovaginal exam
1. 32% dextran 70 - Determines position
- Highly viscous, biodegradable, nontoxic,  Laboratory tests
nonconductive, good optical qualities o Pap smear,
- Importantly, immiscible with blood which o Pregnancy test,
helps the field clear during surgery. o Hgb and hct,
- Drawback: Antigenic and anaphylactic. o Gonorrhea and Chlamydia testing
Rapidly crystallizes.
2. 5% dextrose and water (D5W)
- Has low viscosity
- Precaution: always monitor total fluid intake
to avoid water intoxication.
3. 1.5% glycine
4. Ringer’s lactate and Normal saline
- Common in office hysteroscopy
- Eay to use, less pain, avoid risk of electrolyte
and osmolar imbalance.
5. Carbon dioxide gas
- Maintained at 60-70 mmHg
- Can cause diaphragmatic discomfort and
iiritation.

 Procedure:
1. Explain to the patient that she will experience
discomfort if cervical dilation is needed and
uterine cramping during the short time that the
hysteroscope is inside the uterus.
2. A single-toothed tenaculum may be used to
secure the anterior cervical lip.
3. Gentle traction on the tenaculum straightens out
the uterine axis to facilitate endocervical passage
of the instruments.
o Small scope diameter does not utilize
tenaculum
4. The exocervix is then cleaned of mucus and
HYSTEROSCOPY TECHNIQUE bacteria using iodine solution
 Fairly similar whether performed as an office 5. When inserting the hysteroscope, it is useful to
wait a few seconds to let the distending media
procedure or in an operating room
open the internal cervical os
 Hysteroscopy can be performed at any time during
6. Secure good visualization before advancing the
the menstrual cycle, but it is best scheduled in the hysteroscope to avoid perforation.
early to middle proliferative phase. 7. As the hysteroscope is advanced, it is rotated
 Endometrial pretreatment with hormonal agents clockwise and counterclockwise to see the
o may be considered prior to hysteroscopic cornua and tubal ostia.
sterilization procedures, hysteroscopic 8. On removal, endocervix is viewed.
myomectomies, resectoscopic ablations, and
nonresectoscopic ablations.  Cervical stenosis or spasm
o Thins out the endometrium that facilitates o The most frequent problem in performing
visualization and may aid in tissue destruction hysteroscopy.
during an ablation. o The optimal method to relieve pain and
overcome resistance is a Paracervical
Office Hysteroscopy block with 1% Lidocaine.
 Complete History  Vaginal and oral misoprostol (prostaglandin E1)
o Confirm allergies and medications o given the night before the procedure, in
 Physical exam dosages of 200 to 800 mcg can
o Bimanual examination o aid in the transcervical passage of the
hysteroscope.

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 o This can be useful for women at risk for 5. Microwave endometrial ablation
cervical stenosis such as those with prior
cervical surgery and nulliparous women.  Hysteroscopic sterilization may be accomplished
with insertion of coils in the tubal ostia. This is
desirable, as no incision is needed as for laparoscopic
sterilization, and it can be performed in the office.

COMPLICATIONS
 Complications of hysteroscopy are rare and are noted
in less than 2% of the procedures.
 Complications include:
1. Uterine perforation (0.12%)
2. Pelvic infection (0.01%)
3. Bleeding (0.03%)
4. Fluid overload from absorption of distending
media (0.06%)
5. Bladder or bowel injury (0.02%)
 Diagnostic hysteroscopy has a significantly lower
complication rate than operative hysteroscopy
(0.95%).
 The major complication of diagnostic hysteroscopy is
uterine perforation, and office hysteroscopy has an
incidence of 1 or 2 cases per 1000.
o Midline perforation
Operative Hysteroscopy - rarely results in significant complications
 Operative hysteroscopy may be performed with unless electrocautery or laser energy is
mechanical devices such as small operating scissors, used.
electrocautery, and modified resectoscopes and
o Lateral perforation into the broad ligament
lasers.
can cause bleeding complications.
 Women with repetitive miscarriages should have a
diagnostic hysteroscopic procedure, which often leads o Suspect uterine perforation if the operative
to an operative procedure. view suddenly disappears, the fluid deficit
 Congenital abnormalities that interfere with the suddenly increases, or the hysteroscope
success of early pregnancies, such as septa of the suddenly inserts farther than the fundus
uterus, may be seen and removed
 Often endometrial polyps or submucous myomas are
discovered and may be removed with a resectoscope
wire.
 Simultaneous laparoscopy guidance is often used to
avoid perforation when cutting the intrauterine
adhesions.
 Hysteroscopic metroplasty of intrauterine septa has
replaced abdominal metroplasty, as it is safer and has
fewer complications than laparotomy.
 Hysteroscopy is superior to hysterosalpingogram
(HSG) in discovering intrauterine disease.
 Women with amenorrhea and a history of curettage
who do not respond to a hormonal challenge should
have an HSG or hysteroscopy. LAPAROSCOPY
 In women with a history of recurrent abortions or  Provides a window to directly visualize pelvic anatomy
infertility with a uterine abnormality seen on as well as a technique for performing many
ultrasound, sonohysterography (SHG) is comparable operations with less morbidity than laparotomy
to HSG and hysteroscopy in detecting uterine  The advantages of less postoperative pain, shorter
anomalies, especially septate and bicornuate uterus recovery time, and shorter hospital stays are obvious
o SHG has the benefit of being noninvasive, when laparoscopy is compared with laparotomy.
cost effective, and does not expose the  Laparoscopic visualization is excellent because the
patient to radiation. video camera and endoscope magnify the image.
 Five global endometrial ablation devices:
o Endometrial ablation techniques offer a less
invasive alternative to hysterectomies INDICATIONS
1. Thermal balloon endometrial ablation  Removal of ectopic pregnancies
2. Rediofrequency endometrial ablation  Resection or ablation of endometriosis
3. Hydrothermal endometrial ablation
 Ovarian cystectomy or salpingo-oophorectomy
4. Cryoablation
 Myomectomy

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  Hysterectomy
 Lysis of adhesions
 Removal of intraperitoneal intrauterine device,
 Lymph node dissections,
 Urogynecologic procedures.
 Laparoscopic ovarian bipsy

CONTRAINDICATIONS
Absolute Contraindication Relative Contraindication
 Intestinal Obstruction  Morbid Obesity
 Hemoperitoneum that  Large hiatal hernia
provides hemodynamic  Advanced malignancy
instability  generalized peritonitis
 Severe Cardiovascular/ or peritonitis following
Pulmonary disease previous surgery
 Tuberculous peritonitis  Inflammatory bowel
disease,
 Extensive
intraabdominal scarring.

Laparoscopic Gases
LAPAROSCOPIC EQUIPMENT AND TECHNIQUES  The choice of gas to develop the pneumoperitoneum
Anesthesia depends on the choice of anesthesia.
 Laparoscopy may be performed under local, regional,  Nitrous Oxide
or general anesthesia. o Preferable with local anesthesia
 Local anesthesia- for simple procedure o Nonflammable but supports combustion
 Regional anesthesia- is possible, but the  Carbon Dioxide
Trendelenburg position needed for gravity to keep o Preferred with general anesthesia
the bowels in the upper abdomen can be bothersome o Quickly forms carbonic acid on the moist
to the patient and restrict respiration. parietal peritoneal surface, which results in
 General anesthesia- very risky and hazardous but considerable discomfort to a patient without
when operative laparoscopy is contemplated, general regional or general anesthesia.
anesthesia is recommended.
Veress Needle
Laparoscope  Has a retractable cutting point that is used for entry
 Vary in sizes (2-20 mm) but the standard is 10 mm in into the abdominal cavity for the purpose of
diameter. insufflating the abdomen with gas for laparoscopy.
 Microlaparoscopes are used primarily for diagnostic
Trocar
evaluation. The 5-mm and 10-mm forms are widely
 A trocar is a blunt, bladed, or optical device for
utilized.
entering the abdominal cavity for laparoscopy and is
 Laparoscopic telescopes come in 0-degree to 30- the cannula for holding the laparoscope or
degree lens angles, but the 0-degree type is most laparoscopic instruments.
commonly used.
 Most laparoscopes are 30 cm long and provide a field Laparoscopic Technique
of vision of 60 to 75 degrees.  There are three techniques to access the abdomen.
1. Veress needle insertion is used to create a
Site of Insertion pneumoperitoneum followed by trocar placement.
 The inferior margin of the umbilicus is the preferred 2. Direct trocar placement in noninsufflated
site of entry, as this is the thinnest area of the abdomen
abdominal wall. 3. Open or Hasson technique used when adhesions
 Alternative sites are are expected, particularly under the umbilicus.
1. Infraumbilical fold,
2. Supraumbilical fold, LAPAROSCOPIC PROCEDURES
3. Left costal margin,  Sterilization: Laparoscopy has made outpatient
4. Midway between umbilicus and pubis sterilization available to women throughout the world.
5. Left McBurney’s point. Sterilization is accomplished with electrocautery,
titanium, or spring-loaded clips.
 Infertility investigation: Laparoscopy is a more
sophisticated and accurate method of diagnosing
tubal problems during an infertility investigation than
HSG.

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  Pelvic Disorder: Laparoscopy is able to confirm or LAPAROSCOPIC COMPLICATIONS
rule out intrinsic pelvic disorders, such as
endometriosis or chronic pelvic inflammatory disease
with adhesions. It is possible not only to describe and
stage the extent of endometriosis or pelvic adhesions
but also to treat them.
 Acute pelvic infection: Laparoscopy may be used in
the management of acute pelvic infection, taking
direct bacterial cultures of purulent material from the
tubes, draining a tubo-ovarian abscess, or removing a
tubo-ovarian abscess complex with unilateral
salpingo-oophorectomy.
 Ectopic pregnancy: Laparoscopic treatment of
ectopic pregnancy most often involves salpingotomy
but also may include salpingectomy
 Hysterectomy: Laparoscopic hysterectomy is one  The major categories of complications with
area of considerable research. If vaginal laparoscopy are laceration of blood vessels,
hysterectomy cannot be done (which has lower  Intestinal and urinary tract injuries, including trocar
complication rates, lower costs, and better outcomes), and thermal injuries,
then laparoscopic hysterectomy should be considered  incisional hernias,
over abdominal hysterectomy.
 cardiorespiratory problems arising from the
 Myomectomy: This can be technically challenging pneumoperitoneum
laparoscopically because of the dissection and
suturing required. The laparoscopic approach resulted
in less blood loss, reduced length of postoperative
ileus, shorter hospital stay, reduced use of pain
medications, and more rapid return to normal
activities, but a longer operative time.
 Operative laparoscopy has additionally been used for
laparoscopic- assisted hysterectomy, salpingo-
oophorectomy, salpingostomy and fimbrioplasty, tubal
reanastomosis, appendectomy, uterosacral ligament
transection, presacral neurectomy, retropubic bladder
neck suspensions, and complex urogynecologic
procedures. Laparoscopy may be used for major
cancer staging, including paraaortic and pelvic
lymphadenectomy.

LAPAROSCOPY IN PREGNANCY
 Laparoscopic surgery can sometimes be safely
performed on the pregnant patient. The benefits to
this approach over an open procedure are the same
as in the nonpregnant patient.
 In addition, laparoscopic surgery may provide better
visualization and less manipulation of the gravid
uterus.
 Indications for laparoscopy in pregnancy include,
o suspected appendicitis,
o ovarian torsion, and
o gallbladder disease.

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Proverbs 3:5-6 Trust in the LORD with all your heart and lean not on your own understanding; in all your ways submit to him, and he will make your paths straight.