Anatomy

The uterus is a muscular organ that is partially covered by peritoneum. The cavity of the uterus is lined by the endometrium. The uterus resembles a flattened pear in shape and consists of two major but unequal parts: an upper triangular shaped portion referred to as the body or corpus and a lower fusiform or cylindrical portion, the cervix. The demarcation line of these two portions is known as the isthmus. The anterior surface of the uterus is practically flat while the posterior surface is distinctly convex. The fallopian tubes emerge from the cornua of the uterus at the junction of the superior and lateral margins. The visible openings of the fallopian tubes are referred to as ostia. The upper or “top” portion of the uterus between the points of insertion of the fallopian tubes is called the uterine fundus. The cervical canal openings are called the external os and the internal os. The external os protrudes into the vaginal vault. The internal os is an important anatomic landmark during hysteroscopy because it marks the boundary between the uterine cavity and the endocervical canal, the location at which the main blood supply, the uterine arteries and veins, enters the uterus. Manipulation of the scope during hysteroscopy should cease when this landmark is reached. Vigorous operative procedures, including an unsuspected perforation during cervical dilation, in this area may result in excessive bleeding.

The wall of the body of the uterus is composed of three layers: (1) the outermost layer, the serosa, (2) the middle and thickest layer, the myometrium, and (3) the innermost portion, which lines the entire uterine cavity, the endometrium. The endometrium is a thin, pale pink, velvet-like membrane normally measuring in thickness from 0.5 mm to 5 mm, depending on cyclic changes that occur throughout the reproductive life of a woman. The endometrium is perforated by a large number of tiny openings, referred to as uterine gland ostia, which are easily visualized during a hysteroscopy.

Hysteroscopic findings should be described schematically, mentioning both negative and positive findings at the different levels of anatomy of the uterine cavity: cornua and tubal ostia, fundus, isthmus, internal cervical os, and the endocervical canal. A description of the appearance of the endometrium and endocervical mucosa should also be included.

Indications

Contraindications

Equipment

In order to perform hysteroscopy safely the mind set of the physician should be the same, whether the procedure is performed in the office or in an operating room. The choice of equipment is important, especially if the physician plans to perform “operative procedures” after gaining proficiency with simple diagnostic hysteroscopies.

The basic hysteroscope is a simple rigid (solid rod lens) device (Fig. 140-1). The diameter of the scope preferably is no greater than 5 to 5.5 mm when the introducing sheath is over the scope (used to protect the scope from breaking and provides a channel for continuous flow for fluid distention or an instrument). Size is important because the smaller the diameter of the scope, the less cervical dilation is required, and the more comfortable the procedure is for the patient. The angle of view for the scope is commonly 0 degrees, which provides a panoramic view once inside the uterine cavity and is an ideal all-around hysteroscope. Some surgeons prefer a 30-degree view with a more limiting, downward-looking vista.

Figure 140-1 A, Diagnostic hysteroscopes with continuous-flow outer sheaths. The fenestrations on the distal tip of the sheath improve circulation of the liquid distention media. When using CO₂ distention, a single-flow sheath may be preferable. B, Example of a diagnostic rigid hysteroscope and continuous-flow operating sheath with an operating channel used to pass a biopsy forceps or other instrumentation.

Currently the most common device used is the flexible hysteroscope (Fig. 140-2). The flexible distal tip can improve maneuverability once inside the uterine cavity because of the ability to deflect the distal tip from 90 degrees to over 120 degrees. These flexible scopes are small in diameter (3.5 to 5 mm), do not require an outer sheath, and possess an operating channel, and the latest generations have moved from fiberoptic bundle technology to digital chip-on-the-tip camera sensors (Fig. 140-3).

Figure 140-2 Flexible small-diameter hysteroscopes are easy to manipulate and are comfortable for patients but may lack a large-diameter operating channel for the passage of biopsy instruments, tubal sterilization inserts, or other procedure instrumentation.

(Courtesy of Olympus Surgical America.)

Figure 140-3 Technologic advances in electronics and hysteroscope designs have produced “all-in-one” systems that contain a camera controller, light source, documentation digital photo/video recorder, and, in this example, a flexible hysteroscope. These systems are portable and have a small “footprint,” allowing them to fit easily on a countertop.

(Courtesy of VisionSciences, Inc.)

All newer flexible hysteroscopes are designed to accommodate instrumentation for office procedures such as the Essure sterilization. These flexible scopes are more costly than a rigid system. The high initial cost may be offset by the increased reimbursement achieved with the variety of procedures that can be performed with the flexible scope.

A light source ranging from 100 to 300 watts is needed. A halogen light is acceptable, but a xenon light source is preferred because it emulates natural daylight and provides superior illumination of the uterine cavity.

In addition, a simple grasping forceps, biopsy forceps, and scissors will round out the special instrumentation necessary to perform simple operative procedures such as endometrial biopsy, polyp removal, and removal of retained IUDs.

An optional piece of equipment is a video endoscope (Fig. 140-4). A camera eliminates the need to look through the eyepiece of the hysteroscope and improves the working position, comfort, and visualization. It also allows the patient to partake in the procedure by watching simultaneously as the hysteroscopic evaluation is performed. Some vendors now produce systems with all these components in one stand-alone unit (Fig. 140-5).

Figure 140-4 Video cameras can directly attach to the eyepiece of the hysteroscope, dramatically improving visualization of the uterine cavity.

Figure 140-5 New electronic equipment designs for office hysteroscopy have resulted in systems that allow the hysteroscope (in this case a flexible design) to connect directly to one unit, which contains the camera controller, light source, documentation recorder, and LCD monitor.

Additional video equipment provides the ability to record and document the procedure so that photographic documentation of findings can be included in the patient’s operative report. It also allows a physician to send detailed information back to a referring colleague. These pictures should be maintained as an integral part of the patient’s chart.

Choose a distention medium. Uterine distention is crucial to the success of any hysteroscopic procedure. Most office hysteroscopic procedures are performed with saline. CO₂ distention is mainly used for diagnostic hysteroscopy. Hyskon is difficult and “messy.” CO₂ is more difficult for the novice because of the tendency for troublesome gas bubbles to form, and it cannot be used if any bleeding occurs. Sorbitol and glycerine are for electrical (bipolar) operative procedures. Saline, then, is the “consensus gold standard” for office hysteroscopy. It is safe, physiologic, and inexpensive. A gravity flow system can be used for the majority of diagnostic procedures, providing more than adequate uterine distention (Fig. 140-6). A method for monitoring the amount of fluid used to distend the uterus is needed. It is uncommon to have fluid and electrolyte complications if less than 1 L of fluid is used during the procedure. Commercial systems are available to control the flow and accurately record the fluid deficit during hysteroscopy. For short diagnostic procedures, the amount of fluid used to distend the uterus to 500 mL or less is sufficient. For slightly larger volumes, monitoring the amount of fluid used to distend the uterus and collecting the residual fluid in a pouched drape for subsequent measurement is an option. Carbon dioxide is also commonly used with few complications and low risks of complications (Fig. 140-7). Instructions on the use of both normal saline and carbon dioxide are noted later.

Figure 140-6 Systems used to achieve distention of the uterine cavity during diagnostic hysteroscopy. A, A 1000-mL bag of saline with large-bore tubing used for gravity flow distention. B, A closed system designed to capture the outflow distention fluid. C, A simple pressure cuff used to increase flow of distention medium; it offers no control of intrauterine pressure.

(B, Courtesy of Gynex.)

Figure 140-7 Use of CO₂ as a distention medium for diagnostic hysteroscopy mandates an appropriate device for instillation of the CO₂ gas. Intrauterine pressure must be precisely maintained to avoid passage of distention media into the fallopian tubes and subsequently into the abdominal cavity.

(Courtesy of Karl Storz.)

A standard tray for hysteroscopy includes instruments for anesthesia and cervical dilation (Fig. 140-8A and B):

Figure 140-8 A, Typical instrument setup for office diagnostic hysteroscopy. B, Disposable office packs make procedure setup and clean-up simple. These packs contain all the necessary items required to perform an office hysteroscopy. C, Example of a disposable, self-illuminating LED, open-sided speculum.

(B and C, Courtesy of OBP Medical, Inc.)

Precautions

Poor visualization increases the risk of complications. Larger uteri may take a bit longer to achieve adequate distention. Plan on spending the amount of time needed with each patient to ensure adequate distention and visualization.

Preprocedure Preparation

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