Hysteroscopy

Interventions infobox
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Caption = Hysteroscopy 1898
ICD10 =
ICD9 = 68.12
MeshID = D015907
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Hysteroscopy is the inspection of the uterine cavity by endoscopy. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy).

Method

The hysteroscope is an optical instrument connected to a video unit with a fiber optic light source, and to the channels for delivery and removal of a distention medium. The uterine cavity is a potential cavity. It needs to be distended in order for inspection. Thus during hysteroscopy either fluids or CO₂ gas is introduced to expand the cavity. The choice is dependent on the procedure and the patient’s condition. 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. 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 patients has fructose intolerance.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 fructose intolerant patients.

A hysteroscope is in fact a modification of the traditional resectoscope, which is used for transurethral resection of the prostate. It has a double-channeled sheath allowing for continuous flow of fluid or gas media into the uterus through the larger channel, while allowing for less outflow through the smaller channel. This results in the distention of the uterine cavity. With modern optical technologies, hysteroscopes are getting smaller in diameter yet able to provide larger and brighter images for surgeons' convenience. After cervical dilation, the hysteroscope is guided into the uterine cavity 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. Typically hysteroscopic intervention is done under general endotracheal anesthesia or Monitored Anesthesia Care (MAC), but a short diagnostic procedure can be performed in a gynecologist's office with just a paracervical block using the Lidocaine injection in the upper part of the cervix.

Indications

Hysteroscopy is useful in a number of uterine conditions:
*Asherman syndrome
*Endometrial polyp
*Gynecologic bleeding
*Uterine fibroids
*Uterine malformations

Complications

A common problem is the uterine perforation when the instrument breaches the wall of the uterus. This can lead to bleeding and damage to other organs. A life-threatening condition is the bowel perforation by the instruments after the uterine perforation, resulting in acute peritonitis which can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media described above are also not uncommon. The overall complication rate for diagnostic and operative hysteroscopy is 2% with serious complications occurring in less then 1% of cases.

Variations

A "contact hysteroscope" is a hysteroscope that does not use distention media. A resectoscope is a variation of a hysteroscope that contains an electric loop to resect a submucous leiomyoma.