OUTPATIENT OPERATIVE HYSTEROSCOPY - GKSgks.fi/wp-content/uploads/2012/03/farrugia.pdf ·...
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OUTPATIENT OPERATIVE
HYSTEROSCOPY
Martin Farrugia MD MRCOG
East Kent Hospitals NHS Trust
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Concepts
• Can you do a diagnostic hysteroscopy in a clinic?
• Can you do a Pipelle biopsy without local anaesthesia?
• Do you ever see small intra-uterine pathology?
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Outpatient Surgery: Without anaesthesia????
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MONOPOLAR
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BIPOLAR
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ACTIVE
Why is Versapoint Technology innovative?
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Versapoint 5F Electrodes• Ball Electrode:
– small active electrode area– reduced lateral tissue damage: precise– very good hemostatic/desiccation effect
• Spring Electrode:
– larger active electrode– wider vapour pocket– excellent ablating instrument
• Twizzle Electrode:
– 3mm long active electrode– the cutting instrument
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Depth of Thermal Necrosis
Electrode Mean Depthof ZTN (mm)
SD
Ball 0.811 0.156
Spring 2.695 0.163
Twizzle 0.976 0.108
Loop 0.346 0.058
Zero Degree 1.337 0.133
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VERSAPOINT TECHNOLOGY
• PREDICATABLE TISSUE EFFECT
• VAPOUR POCKET– Requires tissue contact– Micro-second delay in generation
• INSULATION BETWEEN ELECTRODES– Does not cut– If electrode sticks, withdraw electrode slightly
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BASIC EQUIPMENT
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VERSASCOPE
• Continuous flow, 7F operating sheath• Outer Diameter 3.5 mm
• Allows immediate conversion from diagnostic to operative
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Mechanical 7F Instruments
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WHY SALINE AS DISTENSION MEDIUM?
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The Goals of Fluid Management are to:
- maximise visualisation
- minimise intravasation
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Normal Saline
• Metabolically inert
• Iso-osmolar
• Rapid kidney excretion
• Complications– Volume expansion
– Left ventricular failure
– Pulmonary oedema
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Normal Saline
In an Outpatient Clinic
• Allows immediate conversion from diagnostic to operative hysteroscopy
• Easy to flush blood and other debris out
• Safer profile than non-ionic media
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OUTPATIENT PROCEDURES
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7F INSTRUMENTSMechanical
Bipolar Electrosurgery(See and Treat)
HYSTEROSCOPYand
BIOPSY
Outpatient Hysteroscopy ServiceClinical history / Physical exam / TVS - SIS
GP / Consultant
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WHIPPS CROSS HOSPITALMENSTRUAL DISORDER CLINIC
Clinic Date: Hospital Number
Surname First Name
D.O.B: / / Age:
B.P._______ Weight:______(Kg) Height:_____(m) BMI______
Presenting Complaint:
Treatment so far:
Gravida: Para:
LMP / / Cycle /
Clots: Yes/No Flooding: Yes/No
I.M.B. Yes/No P.C.B. Yes/No
Premenstrual spotting Yes/No Dysmenorrhoea Yes/No
Dyspareunia Yes/No Pelvic Pain Yes/No
Smear: Contraception:
Bowel/Bladder symptoms:
Wants to keep fertility: Yes/No
MEDICAL CONDITIONS:
MEDICATIONS ALLERGIES
Bimanual Examination:
Uterine Size: Position: A/V R/V Axial
Regular/Irregular Tender/Not tender
Adnexal Mass: Yes/No
Speculum Examination:
Vulva/Vagina:
Cervix: Smear taken: Yes/No
Hysteroscopy: Satisfactory: Yes/No
Local anaesthetic: Yes/No Dilatation: Yes/No
Ostia: Left % Right % Cavity Length cm
Endometrial sample: Targeted biopsy % Pipelle %
Versapoint procedure: Yes/No
Suggested further management:
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Clinic Set-up
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A Technique modified !
• No speculum
• No tenaculum
• No local anaesthesia
• Gentle cleansing
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STEPS IN TISSUE REMOVAL
1. Assess feasibility
2. Assess size
3. Reduce fragment size
4. Vaporisation will take a long time
5. Do not disconnect completely
6. Finish off all cutting
7. Remove fragments
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COMPLICATIONS
• No intra-operative complications – Some patients experience cramps, needing
post-op NSAIDs
• No post-operative complications
• Patients allowed to go home within 30 minutes.
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Generation of Gas Products
• Bipolar – VersaPoint
– Hydrogen 51.0– Carbon monoxide 25.7
– Carbon dioxide 6.6
– Ethane 3.6
– Acetylene 2.9– Oxygen 2.9
– Methane 2.8
– Propane 1.7
– Nitrogen 1.4
• Monopolar
– Hydrogen 49.0– Carbon monoxide 26.1
– Carfbon dioxide 7.5
– Ethane 4.1
– Oxygen 3.0– Acetylene 3.0
– Methane 2.5
– Nitrogen 2.3
– Propane 1.4
Munro et al JAAGL 2000 8;4:488-494
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PATIENT QUESTIONNAIRE
• Pain score during procedure 3.2 (range 0-8)
• Satisfaction with clinic 97.2%
• Would return to same clinic if bleeding problem recurred 98.6%
• Would recommend the clinic to a friend 99.5%
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LIMITS
• Patient related
– Intrauterine pressure
– Operating time
• Technology related
• Costs
• Patients’ Choice
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When outpatient surgery is not indicated!
• Large pathology– Fibroids > 2 cm– Polyps > 3cm
• Severe adhesions
• Patients’ request
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CONCLUSIONS
• Versapoint Electrosurgery can be utilised in Outpatient
Hysteroscopy clinics to treat selected patients
• Patient satisfaction with the procedure is high
• The complication rates appear to be low
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Thank You