Hysteroscopy
Encyclopedia
Hysteroscopy is 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 (operative hysteroscopy).
A contact hysteroscope is a hysteroscope that does not use distention media.
gas is introduced to expand the cavity. The choice is dependent on the procedure, the patient’s condition, and the physician's preference. Fluids can be used for both diagnostic and operative procedures. However, CO2
gas does not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. Gas embolism may also arise as a complication. Since the success of the procedure is totally depending on the quality of the high-resolution video images in front of surgeon's eyes, CO2
gas is not commonly used as the distention medium.
Electrolytic solutions include normal saline and lactated Ringer’s solution
. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Since they are conducting 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
. These solutions include glucose
, glycine
, dextran
(Hyskon), mannitol
, sorbitol
and a mannitol/sorbital mixture (Purisol). Water was once used routinely, however, problems with water intoxication and hemolysis discontinued its use by 1990. Each of these distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid.
Glucose is contraindicated in patients with glucose intolerance. Sorbitol metabolizes to fructose in the liver and is contraindicated if a patient has fructose malabsorption
.
High-viscous Dextran also has potential complications which can be physiological and mechanical. It may crystallize on instruments and obstruct the valves and channels. Coagulation abnormalities and adult respiratory distress syndrome (ARDS) have been reported.
Glycine metabolizes into ammonia and can cross the blood brain barrier, causing agitation, vomiting and coma. Mannitol
5% should be used instead of glycine or sorbitol when using monopolar electrosurgical devices.
Mannitol
5% has a diuretic effect and can also cause hypotension and circulatory collapse. The mannitol/sorbitol mixture (Purisol) should be avoided in patients with fructose malabsorption
.
or Monitored Anesthesia Care (MAC), but a short diagnostic procedure can be performed with just a paracervical block
using the Lidocaine
injection in the upper part of the cervix. The patient is in a lithotomy position
.
After cervical dilation
, the hysteroscope with its sheath is guided into the uterine cavity, the cavity insufflated, and an inspection is performed. If abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments to enter the cavity is used to perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid
resection, and endometrial polypectomy. Hysteroscopy has also been used to apply the Nd:YAG laser
treatment to the inside of the uterus.
When fluids are used to distend the cavity, care should be taken to record its use (inflow and outflow) to prevent fluid overload and intoxication of the patient.
The use of hysteroscopy in endometrial cancer
is not established as there is concern that cancer cells could be spread into the peritoneal cavity.
Hysteroscopy has the benefit of allowing 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
; this is useful for tubal occlusion procedures for sterilization and for falloposcopy.
when either the hysteroscope itself or one of its operative instruments breaches the wall of the uterus. This can lead to bleeding and damage to other organs. If other organs such as bowel are injured during a perforation, the resulting peritonitis
can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media can be encountered. The use of insufflation media can lead to serious and even fatal complications due to embolism or fluid overload with electrolyte imbalances.
The overall complication rate for diagnostic and operative hysteroscopy is 2% with serious complications occurring in less than 1% of cases.
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
by endoscopy
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy).
Method
A hysteroscope is an endoscope that carries optical and light channels or fibers. It is introduced in a sheath that provides an inflow and outflow channel for insufflation of the uterine cavity. In addition, an operative channel may be present to introduce scissors, graspers or biopsy instruments. A hysteroscopic resectoscope is similar to a transurethral resectoscope and allows entry of an electric loop to shave off tissue, for instance to eliminate a fibroid.A contact hysteroscope is a hysteroscope that does not use distention media.
Insufflation media
The uterine cavity is a potential cavity and needs to be distended to allow for inspection. Thus during hysteroscopy either fluids or CO2Carbon dioxide
Carbon dioxide is a naturally occurring chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom...
gas is introduced to expand the cavity. The choice is dependent on the procedure, the patient’s condition, and the physician's preference. Fluids can be used for both diagnostic and operative procedures. However, CO2
Carbon dioxide
Carbon dioxide is a naturally occurring chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom...
gas does not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. Gas embolism may also arise as a complication. Since the success of the procedure is totally depending on the quality of the high-resolution video images in front of surgeon's eyes, CO2
Carbon dioxide
Carbon dioxide is a naturally occurring chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom...
gas is not commonly used as the distention medium.
Electrolytic solutions include normal saline and lactated Ringer’s solution
Ringer's solution
Ringer's solution is the name given to a solution of several salts dissolved in water for the purpose of creating an isotonic solution relative to the bodily fluids of an animal. Ringer's solution typically contains sodium chloride, potassium chloride, calcium chloride and sodium bicarbonate,...
. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Since they are conducting 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
Hyponatremia
Hyponatremia is an electrolyte disturbance in which the sodium concentration in the serum is lower than normal. In the vast majority of cases, hyponatremia occurs as a result of excess body water diluting the serum sodium and is not due to sodium deficiency. Sodium is the dominant extracellular...
. These solutions include glucose
Glucose
Glucose is a simple sugar and an important carbohydrate in biology. Cells use it as the primary source of energy and a metabolic intermediate...
, glycine
Glycine
Glycine is an organic compound with the formula NH2CH2COOH. Having a hydrogen substituent as its 'side chain', glycine is the smallest of the 20 amino acids commonly found in proteins. Its codons are GGU, GGC, GGA, GGG cf. the genetic code.Glycine is a colourless, sweet-tasting crystalline solid...
, dextran
Dextran
Dextran is a complex, branched glucan composed of chains of varying lengths...
(Hyskon), mannitol
Mannitol
Mannitol is a white, crystalline organic compound with the formula . This polyol is used as an osmotic diuretic agent and a weak renal vasodilator...
, sorbitol
Sorbitol
Sorbitol, also known as glucitol, Sorbogem® and Sorbo®, is a sugar alcohol that the human body metabolizes slowly. It can be obtained by reduction of glucose, changing the aldehyde group to a hydroxyl group. Sorbitol is found in apples, pears, peaches, and prunes...
and a mannitol/sorbital mixture (Purisol). Water was once used routinely, however, problems with water intoxication and hemolysis discontinued its use by 1990. Each of these distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid.
Glucose is contraindicated in patients with glucose intolerance. Sorbitol metabolizes to fructose in the liver and is contraindicated if a patient has fructose malabsorption
Fructose malabsorption
Fructose malabsorption, formerly named "dietary fructose intolerance," is a digestive disorder in which absorption of fructose is impaired by deficient fructose carriers in the small intestine's enterocytes. This results in an increased concentration of fructose in the entire intestine.Fructose...
.
High-viscous Dextran also has potential complications which can be physiological and mechanical. It may crystallize on instruments and obstruct the valves and channels. Coagulation abnormalities and adult respiratory distress syndrome (ARDS) have been reported.
Glycine metabolizes into ammonia and can cross the blood brain barrier, causing agitation, vomiting and coma. Mannitol
Mannitol
Mannitol is a white, crystalline organic compound with the formula . This polyol is used as an osmotic diuretic agent and a weak renal vasodilator...
5% should be used instead of glycine or sorbitol when using monopolar electrosurgical devices.
Mannitol
Mannitol
Mannitol is a white, crystalline organic compound with the formula . This polyol is used as an osmotic diuretic agent and a weak renal vasodilator...
5% has a diuretic effect and can also cause hypotension and circulatory collapse. The mannitol/sorbitol mixture (Purisol) should be avoided in patients with fructose malabsorption
Fructose malabsorption
Fructose malabsorption, formerly named "dietary fructose intolerance," is a digestive disorder in which absorption of fructose is impaired by deficient fructose carriers in the small intestine's enterocytes. This results in an increased concentration of fructose in the entire intestine.Fructose...
.
Procedure
Hysteroscopy has been done in the hospital, surgical centers and the office. It is best done when the endometrium is relatively thin, that is after a menstruation. Diagnostic can easily be done in an office or clinic setting. Local anesthesia can be used. Simple operative hysteroscopy can also be done in an office or clinic setting. Hysteroscopic intervention can also be done under general endotracheal anesthesiaAnesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
or Monitored Anesthesia Care (MAC), but a short diagnostic procedure can be performed with just a paracervical block
Paracervical block
A paracervical block is an anesthetic procedure used in obstetrics and gynecology, in which a local anesthetic is injected into between two to six sites at a depth of 3-7 mm alongside the vaginal portion of the cervix in the vaginal fornices....
using the Lidocaine
Lidocaine
Lidocaine , Xylocaine, or lignocaine is a common local anesthetic and antiarrhythmic drug. Lidocaine is used topically to relieve itching, burning and pain from skin inflammations, injected as a dental anesthetic or as a local anesthetic for minor surgery.- History :Lidocaine, the first amino...
injection in the upper part of the cervix. The patient is in a lithotomy position
Lithotomy position
The lithotomy position is a medical term referring to a common position for surgical procedures and medical examinations involving the pelvis and lower abdomen, as well as a common position for childbirth in Western nations...
.
After cervical dilation
Cervical dilation
Cervical dilation is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery...
, the hysteroscope with its sheath is guided into the uterine cavity, the cavity insufflated, and an inspection is performed. If abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments to enter the cavity is used to perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid
Fibroid
Fibroid is a term used for two different types of tumors:* Fibroids is the common term for uterine fibroids; leiomyoma originating in the uterus. It is a benign neoplasm composed of smooth muscle cells....
resection, and endometrial polypectomy. Hysteroscopy has also been used to apply the Nd:YAG laser
Nd:YAG laser
Nd:YAG is a crystal that is used as a lasing medium for solid-state lasers. The dopant, triply ionized neodymium, typically replaces yttrium in the crystal structure of the yttrium aluminium garnet , since they are of similar size...
treatment to the inside of the uterus.
When fluids are used to distend the cavity, care should be taken to record its use (inflow and outflow) to prevent fluid overload and intoxication of the patient.
Indications
Hysteroscopy is useful in a number of uterine conditions:- Asherman's syndromeAsherman's syndromeAsherman's syndrome , also called "uterine synechiae" or intrauterine adhesions , presents a condition characterized by the presence of adhesions and/or fibrosis within the uterine cavity due to scars...
(i.e. intrauterine adhesions). Hysteroscopic adhesiolysis is the technique of lysing adhesions in the uterus using either microscissors (recommended) or thermal energy modalities. Hysteroscopy can be used in conjunction with laparascopy or other methods to reduce the risk of perforation during the procedure. - Endometrial polypEndometrial polypAn endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base or be attached to the uterus by an elongated pedicle . Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If...
. Polypectomy. - Gynecologic bleeding
- Endometrial ablationEndometrial ablationEndometrial ablation is a medical procedure that is used to remove or destroy the endometrial lining of a uterus. This technique is most often employed for people who suffer from excessive or prolonged bleeding during their menstrual cycle but cannot or do not wish to undergo a hysterectomy. ...
(Some newer systems specifically developed for endometrial ablation such as the Novasure do not require hysteroscopy) - MyomectomyMyomectomyMyomectomy, sometimes also fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy the uterus remains preserved and the woman retains her reproductive potential.-Indications:...
for uterine fibroids. - Congenital Uterine malformationUterine malformationA uterine malformation is a type of female genital malformation resulting from an abnormal development of the Müllerian duct during embryogenesis...
s (also known as Mullerian malformations). Eg.septumSeptumIn anatomy, a septum is a wall, dividing a cavity or structure into smaller ones.-In human anatomy:...
, - Evacuation of retained products of conception in selected cases.
- Removal of embedded IUDs.
The use of hysteroscopy in endometrial cancer
Endometrial cancer
Endometrial cancer refers to several types of malignancies that arise from the endometrium, or lining, of the uterus. Endometrial cancers are the most common gynecologic cancers in the United States, with over 35,000 women diagnosed each year. The incidence is on a slow rise secondary to the...
is not established as there is concern that cancer cells could be spread into the peritoneal cavity.
Hysteroscopy has the benefit of allowing direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result in Asherman's syndrome
Asherman's syndrome
Asherman's syndrome , also called "uterine synechiae" or intrauterine adhesions , presents a condition characterized by the presence of adhesions and/or fibrosis within the uterine cavity due to scars...
.
Hysteroscopy allows access to the utero-tubal junction for entry into the fallopian tube
Fallopian tube
The Fallopian tubes, also known as oviducts, uterine tubes, and salpinges are two very fine tubes lined with ciliated epithelia, leading from the ovaries of female mammals into the uterus, via the utero-tubal junction...
; this is useful for tubal occlusion procedures for sterilization and for falloposcopy.
Complications
A possible problem is uterine perforationUterine perforation
Uterine perforation is a potential complication of any intrauterine procedure. It may be associated with injury to surrounding blood vessels or viscera such as the bladder or intestine. If not diagnosed at the time of the procedure it can result in massive hemorrhage or sepsis...
when either the hysteroscope itself or one of its operative instruments breaches the wall of the uterus. This can lead to bleeding and damage to other organs. If other organs such as bowel are injured during a perforation, the resulting peritonitis
Peritonitis
Peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...
can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media can be encountered. The use of insufflation media can lead to serious and even fatal complications due to embolism or fluid overload with electrolyte imbalances.
The overall complication rate for diagnostic and operative hysteroscopy is 2% with serious complications occurring in less than 1% of cases.
External links
- http://www.acog.org/publications/patient_education/bp084.cfm ACOGACOGACOG may refer to:*Advanced Combat Optical Gunsight*Atlanta Committee for the Olympic Games*American Congress of Obstetricians and Gynecologists...
education pamphlet