Title: EVIDENCE BASED PRACTICAL TIPS FOR OFFICE HYSTEROSCOPY BY DR SHASHWAT JANI
1Evidence 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 . . .
3What is E.B.M. ...???
- Evidence Based Medicine? ?
- Experience Based Medicine? ?
- Eminence Based Medicine....? ?
- ?
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5Sources
- 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.
6What 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.
8Prof 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.
9Set Up
SET UP
10Hysteroscopy Instrumentation
- Lockable cabinet
- Telescope
- Sheath system
- Hysteroscope
- - Diagnostic
- - Operative
- Resectoscope
- Distention systems
- Fluid delivery system
- Light source and cable
- Video cameras and monitors
11Indications
- 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.
12INDICATIONS
- 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.
13Timing
- Ideally Post menstrual Period
14Anesthesia
- 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
15Analgesia
- 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.
16Cervical 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
17Misoprostol
- 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.
18Types 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!!! ?
21Distension 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.
23Local 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.
24Conscious 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.
25Antibiotics
- Routine use of Antibiotic is
- NOT recommended after Diagnostic Office
Hysteroscopy. - But should be given in Operative
Hysteroscopy.
26Vaginoscopy
- 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.
27Tips 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 29As 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).
30Prior 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).
31H/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).
32Role 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 ).
33Post 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).
34Role 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.
38Contraindications
- 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.
39A 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.
40A False Passage
Myometrial fibers signal that a false passage has
been created.
41To 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.
42Avulsion of the Myometrium
Small bowel visible within the uterine cavity
after avulsion of uterine wall at the time of
myomectomy.
43To 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.
44Perforation
- 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.
45Perforation
- Hysteroscopic view of perforation at the fundus.
- The small bowel is visible beyond the
perforation at left.
46When 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..!!! - ?
47Intra 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.
48To 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).
49Benefits 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.
50Electrosurgical Gaseous Complications
- Most electrosurgical complications involve
activation of an electrode at the time of
perforation, or current diversion to the outer
sheath.
51To 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.
52Gas Embolism
- Carbon dioxide is a soluble gas, so these
emboli generally resolve rapidly. - In contrast, room air emboli are more
likely to be fatal.
53To 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.
54Distension 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.
55Safety 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.
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58Thank you