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Refers to the inspection of the uterine cavity by endoscopy with access through the cervix.
It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention.
A hysteroscope is an endoscope that carries optical and light channels or fibers.
It has an inflow and outflow channel for insufflation of the uterine cavity, and an operative channel may be present to introduce scissors, graspers or biopsy instruments.
A hysteroscopic resectoscope allows entry of an electric loop to shave off tissue, for instance to eliminate a fibroid.
Hysteroscopy is performed when the endometrium is relatively thin, that is after a menstruation.
Only 15% of US gynecologists perform office hysteroscopy.
Local anesthesia can be employed.
Analgesics are not always necessary.
The patient is in a lithotomy position during the procedure, and a paracervical block may be used in the upper part of the cervix.
The procedure can also be done under general anesthesia.
Prophylactic antibiotics are not necessary.
Cervical dilation is performed prior to insertion, and this is facilitated with misoprostol in premenopausal women.
The technique proceeds with the hysterosope sheath inserted transvaginally guided into the uterine cavity, the cavity insufflated, and an inspection is performed.
Either fluids or CO2 gas is introduced to expand the cavity, with the choice dependent on the procedure, the patient’s condition, and the physician’s preference.
Fluids can be used for both diagnostic and operative procedures.
The use of CO2 gas does not allow the clearing of blood and endometrial debris during the procedure, making visualization difficult.
Gas embolism may also arise as a complication when using CO2.
Current recommendation is to use electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used, but since they conduct electricity, these fluids should not be used with monopolar electrosurgical devices.
Non-electrolytic fluids eliminate problems with electrical conductivity, but can increase the risk of hyponatremia.
When fluids are used to distend the cavity, inflow and outflow to prevent fluid overload and intoxication of the patient is required.
If abnormalities are found, an operative hysteroscope is used to perform endometrial ablation, submucosal fibroid resection, and endometrial polypectomy.
Hysteroscopy also used to apply the Nd:YAG laser treatment to the inside of the uterus.
Tissue removal methods include electrocautery bipolar loop resection, and morcellation.
Hysteroscopy is useful in a number of uterine conditions:
Asherman’s syndrome
Endometrial polyp. Polypectomy.
Abnormal uterine bleeding
Adenomyosis
Endometrial ablation
Myomectomy for uterine fibroids.
Congenital uterine malformations.
Evacuation of retained products of conception in selected cases.
Removal of embedded IUDs.
The use of hysteroscopy in endometrial cancer is not established.
Allows direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result in Asherman’s syndrome.
Hysteroscopy allows access to the utero-tubal junction for entry into the fallopian tube.
Uterine perforation with the hysteroscope itself or one of its operative instruments breaches the wall of the uterus it can lead to bleeding and damage to other organs.
Cervical laceration, intrauterine infection, electrical and laser injuries, and complications caused by the distention media can be encountered.
Insufflation media can lead to complications due to embolism or fluid overload with electrolyte imbalances, and even death.
Electrolyte-free insufflation media increase the risk of fluid overload with electrolyte imbalances, particularly hyponatremia, heart failure as well as pulmonary and cerebral edema.
Factors contributing to fluid overload in hysteroscopy are:[
Hydrostatic pressure of the insufflation media
Amount of exposed blood vessels,
Duration of the hysteroscopy procedure.
The overall complication rate is 2%, with serious complications occurring in less than 1% of cases using older methods.