Indications and Techniques
Operative hysteroscopy is performed for the treatment of organic disease with one exception. That exception is the operation of endometrial ablation, which is done to treat abnormal uterine bleeding in the absence of organic disease (e.g., endometrial hyperplasia or cancer). Table 107–1 lists the most frequent indications for hysteroscopy and Table 107–2 for abnormal uterine bleeding by age-related diagnosis.
Certain principles prevail for all hysteroscopic surgery. In Chapter 103, the quantification of medium intake and outflow was already mentioned. No hysteroscopic surgery should be performed in an unclear visual field. The best example of the latter is one in which the bleeding is so brisk that it discolors the flushing medium, creating a pink or red field of view. No energy device should be activated on the forward thrust movement of an electrosurgical or laser-energized tool. Power should be applied only during the return stroke, that is, when the device is moving away from the uterine fundus (Fig. 107–1).
Another dictum involves loss of uterine distention and cessation of the surgical procedure. Loss of distention translates into a diminished view of the operative field. A cause for the loss of distention must be identified. Perforation of the uterus must be the first thing ruled out (Fig. 107–2).
Dilation of the cervix is typically required for the insertion of an operative sheath as compared with a diagnostic sheath (Fig. 107–3). The diagnostic sheath’s diameter does not exceed 5 mm, whereas the average operative sheath measures 8 mm. The surgeon must never overdilate the cervix because the fluid medium will leak out retrograde, resulting in the inability to properly distend the uterine cavity.
