Diagnostic Hysteroscopy

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Diagnostic Hysteroscopy Presented by Dr.Narayan
M.Patel M.D.,D.G.O. FICS Emeritus Professor
Muni. Medical college Postal address-- Mahalaxmi
Institute of medical teaching, 3, Shantiniketan
park, Naranpura, Nr.Sardar Patel Colony,
AHMEDABAD- 380 014 (Gujarat) INDIA T.N.(079)
27682572, Mobile- 98252 95530 E mail-
nmpatel1932_at_wilnetonline.net

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• Historical aspect of Hysteroscopy
• 1869--Pantaleon visualize
• polypoidal tumor in uterus
• 1925---Rubin used cysto urethroscope to look
  into uterus. Used water to distend Uterus
  and to wash
• lense. He also used carbon dioxide

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Historical aspect of Hysteroscopy
1971- Lindeman used Carbon Dioxide.50 to 100 cc/
minute. Pressure should be 100 mm of Hg. Co2 is
easy to get, does not wet surgeons cloths as
fluid does, or mix with blood and has good
visibility. Co2 is popular for office diagnostic
hysteroscopy. Hysteroflator is a special
instrument for using Co2 as distending media as
shown below..
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Historical aspect of Hysteroscopy
1960-70 low viscosity fluids like saline or
ringer lactate, with pressure of 50 to 100 mm of
Hg, is popularly used in diagnostic hysteroscopy.
It is cheap and easily available. Fluid bottle is
suspended high over a stand, as shown. Some
people used blood pressure cuff wrapped in
collapsible bottle,to raise pressure in bottle.
Disadvantage is poor visibility if bleeding
occurs. It may wet surgeons cloths.
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Historical aspect of Hysteroscopy
HYSCON 1971--Menken used high viscosity
fluid HYSCON It is 30 Dextran in 10
glucose Molecular Wt. 7000 Fern storm Viscosity-
220 centipoises Retractile index 1.39 Costly
and not available in India, Caramelizing effect
on Instruments if not washed immediately after
use.
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K-Y Jelly is also used by some doctors in India
as a distending media. It is cheap, easily
available and does not mix with blood Late
Dr.Khandwala in India used 50 glucose as
a distending media for dignostic hysteroscopy.
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5 mm telescope
Obturator
6 mm Sheath for Diagnostic hysteroscopy
Sheath for Operating Hysteroscopy
Instruments required for Diagnostic Hysteroscopy
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Diagnostic Hysteroscopy

• Hysteroscopy is technically quite different from
  Laparoscopy and expertise with the laparoscopy is
  no guarantee of success with hysteroscopy.
• Co2 insufflators used for laparoscopy, should
  never be used for Hysteroscopy.
• In laparoscopy the flow of Co2 is in litters,
  while in hysteroscopy it is in ccs, with 100mm
  pressure to distend, uterine cavity. Patients
  have died in past due to wrong use of
  instruments.

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For hysteroscopy one is sitting on a low level
stool while operation table Is to be raised, for
the surgeon to be comfortable, as shown in
picture. For introduction of Hysteroscope with
sheath, one may need occasionaly cervix to be
dilated up to 7 Hegar. Be very gentle in dilating
Cx. as any bleeding will interfere in your
vision. If you are using saline or ringer
lactate, let fluid run from proximal end of
scope, before you introduce it, in the
cavity. Once in uterine cavity, one should pause
momentarily until mucus bubbles have dissipated
and vision is clear.
Never advance scope blindly, as it may leads to
perforation.
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Diagnostic Hysteroscopy

• To look into endocervix
• To look Into uterine cavity
• To look at endometrium
• To look at tubal osteium

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Indications of Diagno.Hysteroscopy

• To locate submucous myoma.
• To diagnose uterine septum.
• To locate remove lost I.U.C.D.
• To locate Endometrial polyp.
• To locate uterine synechae.
• To detect endometrial cancer.

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With more and more use of carbon dioxide as a
distending media and avabilty of sophisticated
instrument like Hysterflator,Dignostic
hysteroscopy has almost become an office
procedure. which can be done without anesthesia
or some times with local anesthesia.
This slide shows Endocervix as you are advancing
scope in the uterine cavity. Unless pressure is
enough to distend cavity, you can not see
interior of cavity
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1
Picture No-1 of hysterosalpingo graphy, shows a
septate uterus. Picture No-2 shows the same
septum at Hysteroscopy. Some times diagnostic
hysteroscopy has to be converted in to operative
hysteroscopy, in the same sitting
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2
1
Picture No-1 shows tubal osteam from a distance.
Uterine cavity looks quite red and
healthy. Picture No-2 shows tubal osteam at a
closer view. It looks normal.
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Hysterosalpingography shows a filling defect
in uterine cavity. This can be due to
submucous fibroid sessile myoma. It does not look
like Synechia or an air bubble Diagnostic
hysteroscopy is the indication. During procedure,
it may have to be converted to Operative
one. Keep things ready.
Filling defect at H.S.G.
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Diagnostic Hysteroscopy

• It is most important to insure prevention of
  complications and their recognition, and their
  management, if they occur.
• Complication may occur due to
• Instrumental procedure
• Distension media.
• Inadequate visualization
• Anesthetic agent

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Diagnostic Hysteroscopy

• The Hysteroscope should never be advanced into
  the uterine cavity without adequate visibility.
• Otherwise, it can cause--
• False passage
• Perforation
• Bleeding

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Diagnostic Hysteroscopy
The out flow stopcock must never be closed
completely, as this will eliminate the liquid
flow. which is most important aspect of the C
F principle
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Contra indications of Hysteroscopy

• Acute and chronic upper genital tract
  infection.
• Recent uterine perforation.
• Pregnancy.

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Operative Hysteroscopy
Operative Hysteroscopy is not for the novice,
but should be an extension of basic skill learnt
at diagnostic hysteroscopy. It is recommended by
one author that unless you have done 500
diagnostic hysteroscopy, you should not venture
operative hysteroscopy.
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Thank you