Outpatient hysteroscopy
- Is the use of miniature hysteroscope without formal theatre facilities and need of local or regional
anaesthesia. - Some operative procedures can also be done (polypectomy, ablation, fibroid resection and removal of lost
instruments) - Advantages – successful, safe and well tolerated, rapid recovery, early mobilization, less cost, ↑ satisfaction
- Disadvantages – pain, anxiety and embarrassment
Equipment
- Dedicated outpatient room, with trained staff
- Patient friendly room and staff (relieve anxiety)
- Miniature hysteroscopy
o 2.7mm with 3-3.5mm sheath for diagnostic hysteroscopy
o Choice of hysteroscope (0/300
) depends on operator
0 – Easy entry into cavity, ↓ need of cervical dilatation, ↓ trauma
30 – Easy view of cornual recesses of ostia with minimum external movement of the scope
o Vaginoscopy reduces pain during diagnostic rigid hysteroscopy – - Standard technique in OP hysteroscopy RCOG – DOES NOT ↑ failure rate
- Flexible vs rigid – also operator preference
o Flexible causes less pain but expensive, difficult to maintain
o Rigid has good image quality, less failed procedures, quick examination times, cheap, easy to clean and maintain - Distension medium
o CO2 vs Normal saline
▪ Neither is superior in pain
▪ Normal saline has better image quality, Less vasovagal attacks
▪ Operative procedures – Normal saline for bipolar and Glycine for monopolar - Pressure
o Hysteromat
Method - Communication
o Substantial level of anxiety during OP-hysteroscopy
o Reduced by providing PIL prior to procedure, calm and comfortable room, adjoining changing room
and toilet, female nurse and assistant, operator and assistant communicating and reassuring the
woman throughout procedure, adjoining recovery area with refreshments - Analgesia
o Routine use not needed
o Communication with the patient while operating is necessary
o NSAIDs 1 hour prior to procedure
▪ Mefenamic acid 500mg (reduce pain in 30 and 60 mins)
▪ Ketorolac 30mg IM
▪ PCM 1g, Ibuprofen 400mg
Diclofenac 50mg – No effect
o If tenaculum used – Apply LA to ectocervix RCOG – 5% lignocaine spray
o Transcervical gel – DOES NOT REDUCE PAIN but REDUCES vasovagal attacks
o Intracervical/ paracervical blocks
▪ Reduces pain – NO evidence on significance
▪ Routine use to reduce vasovagal reactions – NOT RECOMMENDED
▪ Consider routine use in - Post-menopausal women RCOG
- If dilatation required – Cervical stenosis, Large scope >5.5mm)
- Conscious sedation with midazolam – No benefit over local anesthesia + Life threatening complications – NOT RECOMMENDED
- Cervical preparation – NOT routinely needed
- Cervical dilatation NOT routinely required – Cause pain, vasovagal attacks, uterine trauma RCOG
o Use of vaginoscopy – NON-touch technique – Less pain, trauma and vasovagal attacks
o If cervical dilatation needed – Use local anaesthesia RCOG
Complications - Pain
- Anxiety and embarrassment
- Uterine trauma (perforation 0.002-1.7%)
o Risk is increased with
▪ Need for blind dilatation
▪ Cervical stenosis (atrophy, cervical surgery, past LSCS, nulliparity)
▪ Tortious canal (associated with fibroids)
▪ Deviated uterine cavity (anteflexion, pelvic masses and adhesions)
o Use of prostaglandins before surgery is NOT recommended, however, reduced pain shown in some studies but no reduction in lacerations etc
PGs NOT useful for postmenopausal uterus – No reduction in failure rates
o CI to PGs
Uncontrolled severe asthma, CRF, Renal or hepatic impairment, Acute porphyria, BF - Fluid overload
- Air-embolism – rare, cause sudden desaturation and CVS collapse
Isotonic media preferred to hypotonic to avoid serious hypervolemia, but need careful deficit monitoring for both
- Hypertonic Dextran 32% now not used due to serious complications (anaphylaxis, and cardiac failure with even small absorption)
- Gas CO2 is NOT used for operative hysteroscopy
- Saline
Less vasovagal episodes compared to CO2, Lavage the cavity from blood + mucous, Better view, Less time, Can do operative procedures
Fluid overload
Risk factors for fluid overload
o High distension pressure
o Low MAP
o Large uterine cavity
o Resection surface area
o Deep myometrial invasion
o Prolonged surgery
Management
o Catheterize and monitor IP/OP
o Serum electrolytes
o If cardiac failure suspected – Chest X-ray, 2D Echo
o Asymptomatic women
▪ Fluid restriction +/- diuretics
o Symptomatic women
▪ MDT care
▪ ICU care
▪ Correct electrolytes (3% hypertonic sodium chloride), but avoid rapid correction
Measures to reduce
o Develop technical skills to minimize operative time
o Pre-operative administration of GnRH agonists
o Intracervical vasopressin before dilatation
o Use of local anaesthesia preferred to GA – Monitor symptoms
o Maintaining low distension pressure as possible (<100mmHg) and use of automated devices
(hysteromat)
Failed hysteroscopy management
Failures are due to
- Technical failures
o Most common reason is cervical stenosis, anatomical factors and difficult entry (60% internal os and
24% external os)
o More than ½ of other complications are also related to difficult entry - Patient factors
o Vasovagal episodes and intolerance
Risk factors for stenosis - Nulliparous
- Post-menopausal
- Women who had past cervical procedures
Overcoming cervical stenosis - Pharmacological dilatation
o Misoprostol 400ug 1 hour prior to procedure in pre-menopausal women
▪ Less need of dilatation, force for dilatation, Less pain
o No benefit in literature for post-menopausal women (only anecdotal)
o Complications
▪ Fever, Nausea, Gastric irritation
▪ Increased risk of perforation through soft cervix - Mechanical dilatation
o Local anaesthesia – Paracervical block
o Pull gently on Vulsellum – Straighten cavity
o Hagar dilators or Sims sounds (3-10mm) with lubricant gel coating
o Consider USS guidance – Risk of false passages with small diameter scopes
o If dilator NOT applicable – Use a Pipelle, lacrimal duct probe, spinal needle under US-guidance
o Entry under direct vision – With a 2mm hysteroscope if available
o Position the cervical os at center vs 6 o’ clock position
False passage causes increased risk of perforation and damage to surrounding organs
o - Hygroscopic dilatation
o Laminaria tents with hygroscopic rods (seaweed or synthetic)
o Absorb water and swell to soften the cervix
o Seaweed in 24 hours, Synthetic in 4 hours
o 3-4mm – Expand 3x - Hydro dilatation
o Use of pressure from normal saline once the external os passed
o Dilated under direct vision
o See pictures for 0 and 30 degree scopes
- USS guidance
o With TAS probe for sounding - Miscellaneous entry techniques
o Operating during menstruation
▪ Allows following blood but vision impaired
o If external os not visible – making a cruciate incision to find the os
Alternatives when failed - Investigation depending on original indication
o CT/MRI or USS - Spinal needle through canal and SIS
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