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Title: EVIDENCE BASED PRACTICAL TIPS FOR OFFICE HYSTEROSCOPY BY DR SHASHWAT JANI


1
Evidence Based Practical Tips For Office
Hysteroscopy
  • Dr. Shashwat Jani.
  • M.S. ( Gynec ).
  • Diploma in Advance Endoscopy ( France ) .
  • Assistant Prof., Smt. N.H.L. Mun. Medical
    College,
  • Ahmedabad, Gujarat.
  • Mobile 91 99099 44160.
  • E- mail drshashwatjani_at_gmail.com

2
Greetings From Ahmedabad . . .
3
What is E.B.M. ...???
  • Evidence Based Medicine? ?
  • Experience Based Medicine? ?
  • Eminence Based Medicine....? ?
  • ?

4
(No Transcript)
5
Sources
  • Cochrane library .
  • Royal College of Obstetricians Gynecologists
    (RCOG) Guidelines.
  • Journal of Evidence Based Obstetrics
    Gynecology.
  • National Guideline Clearinghouse . ( U.S. Govt.
    ).
  • New Zealand Guidelines Group
  • PubMed.
  • Italian Society of Gynecological Endoscopy.
  • International Society Of Gynecology Endoscopy.
  • American Association Of Gynecology Laparoscopist.

6
What is Office Hysteroscopy .???
  • Diagnostic hysteroscopy and some
    operative hysteroscopic procedures should be
    conducted outside of the formal operating theatre
    setting in an appropriately equipped and staffed
    ambulatory situations yet guarantying patients
    safety privacy.

7
  • No Anesthesia nor Analgesia.
  • No drugs ( Atropine only ).
  • No speculum nor Tenaculum.
  • Operative procedures.

8
Prof Bettocchi
  • A pioneer in the field of office
    hysteroscopy,
  • Prof Bettocchi, in 2004 reported on 4863
    operative hysteroscopic procedures where a
    vaginoscopic technique was used without analgesia
    or anesthesia.
  • As technology has further advanced and
    hysteroscopes have reduced in size, office
    procedures have become even more feasible.
  • There have also been improvements in
    energy sources such as bipolar (as opposed to
    monopolar) that have decreased complications
    related to the operative distension media, this
    has made operative hysteroscopy more acceptable.

9
Set Up
SET UP
10
Hysteroscopy Instrumentation
  • Lockable cabinet
  • Telescope
  • Sheath system
  • Hysteroscope
  • - Diagnostic
  • - Operative
  • Resectoscope
  • Distention systems
  • Fluid delivery system
  • Light source and cable
  • Video cameras and monitors

11
Indications
  • DIAGNOSTIC
  • Unexplained abnormal Uterine bleeding (AUB) .
  • Peri and post menopausal bleeding.
  • Selected infertility cases.
  • Abnormal HSG.
  • Unexplained Infertility.
  • Recurrent pregnancy loss.
  • Should be used prudently
  • only after other investigations.

12
INDICATIONS
  • Therapeutic
  • 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.

13
Timing
  • Ideally Post menstrual Period

14
Anesthesia
  • 3 mm Flexible/Rigid
  • Usually not needed
  • 5.5 mm Rigid w/o Dilatation
  • Parous usually not needed
  • Tenaculum site local
  • 1 Lidocaine
  • 5.5 mm Rigid with Dilatation
  • Tenaculum site local
  • Paracervical block

15
Analgesia
  • Routine use of Opiates NOT recommended.
  • Women without contraindications should be
    advised to consider taking standard doses of
    NSAIDs around 1 hour before their scheduled
    outpatient hysteroscopy appointment with the aim
    of reducing pain in the immediate postoperative
    period.

16
Cervical Preparation
  • Routinely NOT recommended
  • See and Treat
  • Cervical dilation usually not needed
  • 3 mm flexible hysteroscope with sheath.
  • Misoprostol
  • Cramping and bleeding
  • Give narcotic pain medication

17
Misoprostol
  • Misoprostol is not required in every
    patient, but should be considered in selective
    patients
  • - Post menopausal patients,
  • - Nulliparous patients,
  • - Patients who have had previous cervical
    surgery or where the procedure is assessed to
    be difficult in dilating cervix.
  • Oral / Vaginal 400 µgm 6-8 hr prior.
  • Sublingual 400 µgm 2-4 hr prior.

18
Types of Hysteroscope
  • Miniature hysteroscopes (2.7mm with a 3
    3.5mm sheath) should be used for diagnostic
    outpatient hysteroscopy as they significantly
    reduce the discomfort experience by the woman.
  • 1.9 mm Microhysteroscope should be
    reserved for special cases like severe cervical
    stenosis.

19
  • There is insufficient evidence to
    recommend 0 or fore-oblique optical lenses (i.e.
    12, 25 or 30 off-set lenses) for routine
    outpatient hysteroscopy.
  • Now ,,,
  • Types Of Hysteroscopes?

20
  • Flexible hysteroscopes are associated
    with less pain during outpatient hysteroscopy
    compared with rigid hysteroscopes.
  • However, Rigid hysteroscopes may
    provide better images, fewer failed procedures,
    quicker examination time and reduced cost.
  • Thus, there is insufficient evidence to
    recommend preferential use of rigid or flexible
    hysteroscopes for diagnostic outpatient
    procedures.
  • Choice of hysteroscope should be left to the
    discretion of the Operator!!! ?

21
Distension Media
OR
  • For routine outpatient hysteroscopy, the
    choice of distension medium between Carbon
    dioxide and Normal Saline should be left to the
    discretion of the operator as neither is superior
    in reducing pain, although uterine distension
    with normal saline appears to reduce the
    incidence of vasovagal episodes.

22
  • Uterine distension with Normal saline
    allows improved image quality and allows
    outpatient diagnostic hysteroscopy to be
    completed more quickly compared with carbon
    dioxide.
  • Operative outpatient hysteroscopy, using
    bipolar electrosurgery, requires the use of
    normal saline to act as both the distension and
    conducting medium.

23
Local Anesthesia Cervical Dilatation
  • Miniaturization of hysteroscopes and
    increasing use of the vaginoscopic technique may
    diminish any advantage of Intracervical or
    paracervical anesthesia.
  • Routine administration of intracervical
    or paracervical local anaesthetic should be used
    where
  • ? larger diameter hysteroscopes are
    being employed (outer diameter greater than 5mm)
  • ? where the need for cervical dilatation
    is anticipated (e.g. cervical stenosis).
  • Routine administration of intracervical
    or paracervical local anesthetic is Not indicated
    to reduce the incidence of vasovagal reactions.

24
Conscious Sedation
  • Conscious sedation should not be
    routinely used in outpatient hysteroscopic
    procedures as it confers No advantage in terms of
    pain control and the womans satisfaction over
    local anaesthesia.
  • Life-threatening complications can
    result from the use of conscious sedation.
  • Appropriate monitoring and staff skills
    are mandatory if procedures are to be undertaken
    using conscious sedation.

25
Antibiotics
  • Routine use of Antibiotic is
  • NOT recommended after Diagnostic Office
    Hysteroscopy.
  • But should be given in Operative
    Hysteroscopy.

26
Vaginoscopy
  • Vaginoscopy should be the standard technique
    for outpatient hysteroscopy, especially where
    successful insertion of a vaginal speculum is
    anticipated to be difficult and where blind
    endometrial biopsy is not required.

27
Tips for the Bettochi vaginoscopic technique
  • Enter into the vagina, aiming for deep in the
    posterior fornix.
  • Initially place the hysteroscope light lead
    at 6 oclock and try to localize the
    cervix.
  • Once through the external os, follow the
    endocervical canal (seen as a Black Hole).
  • At the internal os turn scope on its side
    by turning the light lead 90 degrees as this
    facilitates entry of scope into the uterine
    cavity.

28
  • Role In Infertility

29
As a Screening test
  • Given the low invasiveness and the
    safety of office hysteroscopy and the desire for
    the infertile couple to shorten as much as
    possible the diagnostic period which is often a
    source of anxiety and uncertainty, it is
    reasonable to recommend the evaluation of uterine
    cavity by office hysteroscopy in the diagnostic
    work up of infertile couples.
  • (LEVEL OF EVIDENCE VI,
  • STRENGH OF THE RECOMMENDATION B).

30
Prior to IVF.
  • Hysteroscopy should be recommended for
    women with repeated implantation failure.
  • (LEVEL OF EVIDENCE I ,
  • STRENGH OF THE RECOMMENDATION A).
  • However, a screening office
    hysteroscopy should be performed before including
    patients in an IVF program in order to minimize
    any negative intrauterine influence on IVF
    outcome.
  • (LEVEL OF EVIDENCE VI,
  • STRENGH OF THE RECOMMENDATION B).

31
H/o of Recurrent Miscarriage
  • Diagnosis and treatment by hysteroscopy of
    uterine malformations and intrauterine adhesions
    in such patients may improve live birth rate and
    therefore, their treatment could be recommended.
  • (LEVEL OF EVIDENCE V,
  • STRENGH OF THE RECOMMENDATION B).

32
Role In AUB
  • Hysteroscopy should be always performed in
    women presenting with AUB, in whom other tests
    (Sonohysterography and/or Transvaginal
    ultrasound) have already reported OR have been
    unable to rule out endouterine pathologies.
  • ( LEVEL OF EVIDENCE III ,
  • STRENGHT OF THE RECOMMENDATION B ).

33
Post menopausal Bleeding
  • It is reasonable to recommend evaluation
    of endometrial cavity by hysteroscopy in cases of
    repeated AUB in such women.
  • (LEVEL OF EVIDENCE VI,
  • STRENGH OF THE RECOMMENDATION B).

34
Role in Biopsy
  • Target-eye biopsy is more accurate than
    blind biopsy, and therefore hysteroscopy with
    multiple target biopsies should be used in place
    of blind techniques in the diagnostic work-up for
    atypical lesions.
  • ( LEVEL OF EVIDENCE II,
  • STRENGH OF THE RECOMMENDATION B).

35
  • The possible risk of the spreading
    of neoplastic cells to the abdominal cavity
    should not limit the use of hysteroscopy in
    favour of blind techniques.
  • (LEVEL OF EVIDENCE II,
  • STRENGH OF THE RECOMMENDATION A ) .

36
  • TIPS
  • For
  • Managing Minimizing
  • Operative Complications

37
  • Ignoring contraindications to
    hysteroscopic surgery increases the risk of
    complications and is the single greatest factor
    leading to patient injury and physician
    liability.

38
Contraindications
  • Acute pelvic inflammatory disease
  • Pregnancy
  • Genital tract malignancies
  • Lack of informed consent
  • Inability to dilate the cervix
  • Inability to distend the uterus to obtain
    visualization
  • Poor surgical candidates who may not tolerate
    fluid overload because of renal disease, or
    radiofrequency current when a cardiac pacemaker
    is present.
  • Unfamiliarity with equipment, instruments or
    technique
  • Lack of appropriate equipment or staff familiar
    with the equipment.

39
A False Passage
  • If muscle fibers are visible and the tubal ostea
    are not, assume the passage is false.
  • Slowly remove the hysteroscope and identify the
    true cavity for confirmation.
  • Discontinue the procedureeven if no perforation
    is detectedto prevent distention fluid from
    being absorbed into the circulation through the
    injury. Adequate distention is not possible at
    this time.
  • Delay repeat hysteroscopy for 2 to 3 months.

40
A False Passage
Myometrial fibers signal that a false passage has
been created.
41
To Avoid Creating A False Passage
  • Dilate the cervix with slow, steady pressure
    and stop as soon as the internal os opens do not
    attempt to push the dilator to the uterine
    fundus.
  • Often the external os opens, but the internal
    os cannot be dilated the extra 1 to 2 mm
    necessary to accommodate the 27- French
    resectoscope.
  • Rather than exert more force and risk
    perforation or laceration, simply turn on the
    resectoscopes inflow with the outflow shut off,
    and let the fluid pressure dilate the cervix.
  • Always insert the hysteroscope or
    resectoscope under direct vision rather than use
    an obturator.
  • Keep the dark circle in the center of the
    field and slowly advance the hysteroscope toward
    it until the cavity is reached.

42
Avulsion of the Myometrium
Small bowel visible within the uterine cavity
after avulsion of uterine wall at the time of
myomectomy.
43
To Prevent Myometrial Avulsion
  • Keep the myoma grasper away from the fundus
    when removing myoma segments, and avoid excessive
    traction on what may be a thin segment of
    myometrium.
  • Injuries can occur when the grasper
    perforates the uterus and bowel is inadvertently
    grasped.
  • Large injuries require laparoscopic repair.
  • Perforation is more likely in repeat procedures.

44
Perforation
  • In the AAGL survey, the incidence of
    perforation was 14 per 1,000.
  • It was even higher during transection of
    lateral and fundal adhesions 2 to 3 per 100.
  • Although perforation is more common with
    thermal energy sources, it may occur mechanically
    when scissors are used to transect a uterine
    septum, synechiae, or polyps.

45
Perforation
  • Hysteroscopic view of perforation at the fundus.
  • The small bowel is visible beyond the
    perforation at left.

46
When perforation occurs
  • During the use of thermal energy,
    laparoscopy is necessary to assess the organs
    overlying the site.
  • During setup for laparoscopy, bring the
    hysteroscope near the area of perforation to
    inspect the bowel beyond the uterus.
  • Since the pelvis fills quickly with
    distention fluid, the hysteroscope can even be
    placed through the perforation to yield an
    excellent view of the undersurfaces of the bowel
    immediately adjacent to the injured area.
  • Disconnect the electrosurgical cord before doing
    this..!!!
  • ?

47
Intra operative bleeding
  • Bleeding is unlikely unless vessels are
    lacerated or injured in the cervical canal or
    lower uterine segment during dilation or deep
    ablation or vaporization.
  • Bleeding is more common when endomyometrial
    resection is performed with the wire loop
    electrode or during ablation or vaporization of
    fibroids.

48
To achieve hemostasis
  • 1 ) Insert a Foley catheter with a 30-cc
    balloon into the uterine cavity, inject 15 to 20
    mL (or more for a larger cavity) of fluid into
    the balloon, and observe the patient.
  • 2 ) Pack the uterus.
  • 1/2-inchgauge packing that has been soaked
    in a dilute vasopressin solution.
  • (20 U 1 mL in 60 mL Normal Saline).

49
Benefits of Vasopressin
  • Before balloon tamponade or Packing the
    uterus,
  • Inject very dilute vasopressin
  • (4 U 0.2 mL in 60 mL normal saline)
  • directly into the cervix 2 cm deep,
  • at the 4 and 8 oclock positions.

50
Electrosurgical Gaseous Complications
  • Most electrosurgical complications involve
    activation of an electrode at the time of
    perforation, or current diversion to the outer
    sheath.

51
To Avoid
  • Avoid perforating the uterus by applying
    current only when the electrode is moving toward
    the operator, not the fundus.
  • To avoid return-pad injuries
  • Keep the patients thigh
    completely dry ensure that the pad is flat
    against the skin at application, with no bubbles
    or creases and use only return electrode monitor
    (REM) dispersive pads.

52
Gas Embolism
  • Carbon dioxide is a soluble gas, so these
    emboli generally resolve rapidly.
  • In contrast, room air emboli are more
    likely to be fatal.

53
To reduce risk of gas embolism
  • Avoid Trendelenburg positioning
  • Remove last dilator just before inserting the
    resectoscope
  • Limit repeated removal - reinsertion of the
    resectoscope
  • Vaporizing myomas eliminates the need to
    remove fibroid chips
  • Intracervical injection of vasopressin may
    block gas from entering circulation.

54
Distension Media
  • Continuously record inflow and outflow
    using the electronic monitor with the deficit
    alarm set to 500 mL.
  • Keep distention fluid at room temperature
    and monitor the patients core temperature
    continuously.
  • Significant fluid intravasation will lower
    the patients temperature, and this may be the
    first sign of fluid overload.
  • Perform operative hysteroscopy under spinal
    or epidural anesthesia so the anesthesiologist
    can continually assess the patients sensorium.
  • Confusion and irritability are early signs of
    dilutional hyponatremia.

55
Safety First
  • Hysteroscopy is a technologically dependent
    surgery and before starting surgery every surgeon
    should have reasonably good knowledge of
    Hysteroscopic procedures.
  • Please put a board in your Hospital
  • Your Safety Is Our First Priority.

56
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