DR.GURURAJ DESHPANDE MS(OBG)

ASSOCIATE PROFESSOR DEPT.OF.OBGKAMINENI INSTITUTE OF MEDICAL

SCIENCES NARKETPALLY

HYSTEROSCOPY

Contents

HISTORY INDICATIONS COUNSELLING ANAESTHESIA POSITION EQUIPMENTS DISTENDING MEDIA PROCEDURE COMPLICATIONS CONCLUSION

HISTORY:PANTALEONI 1869 T0 1970 A LONG GAP

INDICATIONS

DIAGNOSTIC• Unexplained abnormal uterine

bleeding(AUB)• Pre and post menopausal• Selected infertility cases• Abnormal HSG• Unexplained infertility• Recurrent pregnancy loss• Should be used prudently only after other

investigations

THERAPEUTIC INDICATIONS

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

PATIENT COUNSELLING

Benefits Vs Risks Other treatment options Realistic success rate Informed written consent

ANAESTHESIA

Patient anxiety Cervix status Procedure Paracervical block and IV sedation Transcervical topical anesthesia Spinal/epidural GA

POSITION

EQUIPMENTS:TELESCOPES

VIEW

DIAGNOSTIC CONTINOUS FLOW HYSTEROSCOPE

Operative sheaths and working channel for accessory instruments

OFFICE HYSTEROSCOPE (BETTOCCHI HYSTEROSCOPES)

Unipolar resectoscope consisting of working element, 8mm resectoscope sheath,4mm telescope

UNIPOLAR LOOP ELECTRODE FOR END ABLATION,MYOMA,POLYP

UNIPOLAR ELECTRODES (LOOP,NEEDLE,ROLLER,BALL)

DISTENDING MEDIA

Need to distend uterus to view as uterus is almost closed structure.

Minimum 45mm of Hg for diagnostic Upto 70mm of Hg for operative If more than MAP ,more chances of

overload Gaseous and liquid High and low viscosity medium

Carbon dioxide

Neatness Doesn't damage instruments Doesn't mess up office/OR CO2 and bleeding incompatible CO2 and blood form obscuring

bubbling foam Cannot flush debris CO2 embolism rarely

CO2

Insufflation should not exceed 100ml/min

Unlike laparoscopy which are in litres/min

Use only hysteroinsufflator Ideal for diagnostic office

hysteroscopy

HYSKON

32 percent dextran 70 in dextrose Immiscibility with blood Excellent visualization even in active

bleeding Compatible with electrosurgery and lasers Outflow less due to high viscosity Hyskon allergic reaction 0.05% treat like

anaphylaxis Pulmonary edema 0.11% due to overload

as it pulls water into intravascular space.

HYSKON

Fibrinoplastic action leading to bleeding diathesis

Clogs instruments if instruments are not washed immediately with hot water

Remains in bloodstream for 4-6 weeks

LOW VISCOCITY LIQUID MEDIAMEDIUM OSMOLALITY

mosm/kg of waterSODIUM IN mEq/L

SERUM 290 135-145

GLYCINE 1.5% 200

SORBITOL 3% 178

MANNITOL 5% 280

GLYCINE 2.2% 280

NS

308 154

RL 273 130

NORMAL SALINE

Safest Instilled with 2-3 litres bag from 6-8

feet Continuous high flow required Cannot use monopolar cautery as it

contains electrolytes, bipolar can be used.

Still overload can occur which can be treated with diuretics

Stop if deficit is 1.5 litres

1.5%GLYCINE AND 3%SORBITOL Taken from urology Hypotonic Metabolized to CO2 and free water Female brain cells cannot pump cations

due to progesterone action so more prone for cerebral edema.

Check osmolality and sodium minimum pre op intra op and 4 hr post op

Stop if >500ml deficit, Can use monopolar

5%MANNITOL AND 2.2%GLYCINE Both are safer and isoosmolar Mannitol is diuretic also Studies have shown that glycine2.2%

is very safe upto 1000ml deficit Can use monopolar Keep strict inflow and outflow Take into account the fluids infused

by anesthesiologist as RL commonly given is hypoosmolar

CONTRAINDICATIONS

Active PID Active profuse bleeding Recent perforation Pregnancy Cancer cervix Systemic disorders affecting fluid

and electrolytes

PROCEDURE

Cervical priming and dilatation if needed

Per vaginal examination to know the position of uterus

Vaginoscopic technique Systematic examination Operations with correct use of

electrosurgery and lasers

Panoramic view

Tubal ostium

Cu-T

DENSE ADHESIONS

SUBMUCOUS FIBROID

EXCISION WITH LOOP

EXCISION OF UTERINE SEPTUM

COMPLICATIONS

Due to position Anaesthetic complications Due to distending media Uterine perforation Bleeding Bowel and bladder injury Septicemia Death

Bipolar resectoscopes

Hysteromat E.A.S.I

Intrauterine BIGATTI shaver

CONCLUSION

Hysteroscopy is a part of every gynecological surgeon’s armamentarium

Generally a low risk technique using natural pathway.

Supersedes laparoscopy in philosophy of MIS

THANK YOU