Hysteroscopy

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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CHAPTER 2 Hysteroscopy

Diagnostic Indications

Infertility

Hysteroscopy is a reliable method to detect and potentially treat submucous fibroids, endometrial polyps, intrauterine adhesions and endometritis. Congenital anomalies are infrequent but are associated with infertility. Abnormalities of the endometrium and organic intrauterine pathologies are important causes of failed in-vitro fertilization/embryo transfer cycles. A recent meta-analysis has shown potential benefits of performing pretreatment hysteroscopy in patients being referred for IVF (El-Toukhy et al 2008).

Chronic pelvic pain

Patients with chronic pain can pose a difficult challenge to the gynaecologist. Obstructive uterine anomaly may be associated in 40% of these patients (Schifrin et al 1973). Concomitant hysteroscopy may reveal polyps, fibroids, adhesions and septate uterus which may contribute to the patient’s symptoms.

Contraindications

Instrumentation

Inadequate instrumentation resulting in poor visualization and reduced safety is not only dangerous, but will potentially give erroneous results. Good-quality hysteroscopes, cameras and driver units are basic requirements for good visualization of the uterine cavity. Appropriate fluid monitoring systems and energy sources, such as laser or diathermy, are essential for operative hysteroscopy (Figure 2.1).

Before commencing any hysteroscopic procedure, one must ensure that the stack system (Figure 2.2) is fully functional. This includes the telescope, surgical instruments, camera drive unit, camera head, light source, light lead, monitor, electrosurgical generator and image recording equipment. If a simultaneous laparoscopy is required, two stack systems should be made available. It is essential to assemble the equipment to ensure that it works prior to use. The distension medium, suction machine, fluid measurement apparatus and connecting tubing must be checked. Fluid should be allowed to flow through the giving set to remove all air bubbles.

Optical systems

Camera and stack system

The hysteroscopic image is visualized on a monitor with the help of a camera connected to a camera drive unit. The image clarity of a single chip camera is perfectly adequate. Special weighted cameras are available and facilitate orientation, but the same camera as is used for laparoscopy is equally appropriate. It is important to ‘white balance’ the camera system to ensure that the colours are displayed correctly (see Figure 2.2).

Technique of Diagnostic Hysteroscopy

Anaesthesia

In the majority of cases, the smallest modern diagnostic hysteroscopes require no anaesthetic whatsoever. A crucial factor is good communication between the gynaecologist and the patient, with thorough preoperative counselling and the support of a skilled nurse who is able to complement the operator in explaining things to the patient. The role of local anaesthetic gels is open to question. They are inexpensive and certainly lubricate and cause the external os to open. They probably have little anaesthetic effect other than as a psychological adjunct to the gynaecologist’s reassurance.

Where facilities do not exist for outpatient hysteroscopy, the procedure is carried out in the operating theatre. Whilst a 5-mm rigid diagnostic hysteroscope can be passed through the cervix in the majority of women of reproductive age, this can prove extremely difficult in postmenopausal women and cervical dilatation is often needed. This requires a paracervical block, a regional anaesthetic or a general anaesthetic. The choice of anaesthetic method will, of course, be decided in conjunction with the anaesthetist and the patient. The choice will, in part, be determined by the patient’s state of health and whether any additional procedures are planned. It must be remembered, however, that those patients who are at risk of endometrial cancer in the postmenopausal period are often more obese and suffer from cardiovascular and airways disease. These render them at high risk from the anaesthetic point of view. Such patients provided a major stimulus to the establishment of outpatient diagnostic and, in some cases, therapeutic hysteroscopy services.

Procedure

Inpatient/general anaesthetic

A pelvic examination is performed in order to determine the size and direction of the uterus. The vulva and vagina are cleaned with antiseptic solution, and the anterior lip of the cervix is grasped with a vulsellum forceps. The majority of rigid hysteroscopes offer a fore/oblique view ranging from 12 to 90°. By convention, the direction of the view is away from the light post. The camera system is attached to the scope with the camera orientated correctly and the light post either up or down such that the angled view is in the vertical plane. It is easier to follow the cervical canal if the scope is orientated to view along the direction of the canal (i.e. forwards and downwards in a retroverted retroflexed uterus). Crucial to obtaining a thorough hysteroscopic examination is an understanding of how rotation of the hysteroscope allows the area of uterine wall under inspection to be changed. The authors suggest holding the camera in one hand and maintaining the position of the camera fixed in relation to the vertical plane. Rotation of the scope by manipulating the light post with the other hand allows the view to be manipulated appropriately.

Insertion of the hysteroscope through the cervical canal should be performed under direct vision and, in the first instance, without cervical dilatation or the passage of a sound. This allows examination of the cervical canal and inspection of undamaged endometrium. Once instruments have been passed into the uterine cavity, they cause damage to and stripping of the endometrium, which can then give appearances suggestive of polyp formation. The image of the cervical canal during passage of the scope is, of course, dependent on the viewing angle of the scope. A 0° scope requires the cervical canal to be kept in the middle of the field of view during insertion to maintain the direction of travel of the scope parallel to the direction of the cervical canal. When an angled viewing scope is used, the position of the cervical canal in the field of view has to be offset in order to maintain the direction of travel of the hysteroscope parallel with the direction of the cervical canal. This is why orientation of the light post relative to the orientation of the camera is a crucial step in the assembly of the equipment, but it is often overlooked.

Once the cervical canal is passed, a panoramic view of the uterine cavity is obtained. Uterine distension at a flow rate of 40–60 cc/min with pressure between 40 and 80 mmHg achieves good visualization. The scope is advanced towards the fundus and rotated to allow inspection of the tubal ostia. The scope can then be withdrawn and readvanced whilst rotating it to enable systematic inspection of each uterine wall in turn.

Potential problems include blood accumulating in the cavity and obscuring the view. This can occur during diagnosis when the seal between the hysteroscope and the cervix is very tight, preventing outflow of distension medium. The passage of a dilator 1 mm greater than the outer diameter of the hysteroscope allows flow and clearance of the contaminating blood. If a large polyp is present in the endometrial cavity, it is possible to inspect the cavity without realizing that the polyp is there because the polyp fills the cavity and the scope has been passed beyond the tip of the polyp before inspection begins (Figure 2.5). Suspicion should be aroused if the endometrial surfaces are different in colour, and careful inspection of the panoramic view of the cavity during insertion and removal of the scope will avoid missing a large polyp as the tip of it will be seen. A thorough examination of the uterine cavity should allow inspection of both tubal ostia. A record of this in the operation notes demonstrates that the operator has obtained a good view.

Hysteroscopy in outpatients

Provision of hysteroscopy combined with transvaginal ultrasound in outpatients provides a very efficient method of assessing women with pre- and postmenopausal bleeding. As mentioned above, many patients who require a hysteroscopy pose significant risk for general anaesthesia, and are best managed under local or no anaesthetic (Valli et al 1998). In addition, there are many advantages to the patient, including shorter time at the hospital and more rapid return to normal activity. There are also cost advantages to the hospital, as an outpatient clinic is clearly a less expensive environment than an operating theatre (Marsh et al 2004).

Choice of equipment

Choice of equipment will vary with the prior experience of the operator and the facilities available for disinfection/sterilization of the instruments. Rod lens hysteroscopes may be autoclaved, necessitating the provision of an adequate number of scopes for a session of activity. Fibreoptic hysteroscopes, whether rigid or flexible, cannot be autoclaved and must be sterilized with ethylene oxide or closed liquid disinfection systems.

In reality, there are disadvantages and advantages of every system. Rigid autoclavable scopes tend to be of larger diameter, necessitating cervical dilatation in a proportion of cases. The advantage is clarity of view and a fore/oblique view allowing easier examination of the cornua. Flexible scopes are delicate and more expensive, but allow steering through the cervical canal and angulation to allow full inspection of the uterine cavity without any anaesthesia (Kremer et al 1998) (Figure 2.6A). Fibreoptic rigid scopes can be of very small diameter (1.2 mm in a 2.5-mm diagnostic sheath (Figure 2.6B). They are 0° so viewing of the cornua is more difficult, but they are relatively easy to pass through stenosed postmenopausal cervices, leading to a very low failure rate. The Versascope system provides a disposable sheath which can be distended by the passage of a 5 French instrument. This means that a change of sheath is not required to convert a diagnostic procedure into an operative procedure.