Minimally Invasive Surgery : Hysteroscopy

27 December 2012

Introduction
Hysteroscopy = endoscopy of the cavity of the uterus It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy). Hysteroscopy can be performed in the outpatient setting or as an inpatient under general anaesthetic

Development
In 1869, Pantaleoni first performed hysteroscopy in a living patient when he used his endoscope for visualization of the uterine cavity, and chemically cauterized a polypoid growth in a 60-year-old woman with postmenopausal bleeding. Rubin, who in a 1925 study used carbon dioxide (CO2) for distention of the uterine cavity.

In 1927, Von Mikulicz-Radecki and Freund introduced electrocoagulation of the intramural portion of the tubes.

 In 1962, Silander introduced a latex rubber balloon attached to the distal portion for distention of the uterine cavity with normal saline instead of air. In 1970, Edstrom and Fernstrom published their results with 32% dextran for distention of the uterine cavity. allowed both excellent visualization and biopsy of lesions and surgical manipulation within the uterine cavity.

Since then, several media have been used successfully for distention of the uterine cavity, such as 32% dextran, 5% dextrose (D5W), CO2, Ringer's lactate, and normal saline.

Hysteroscopic Instrumentation
The hysteroscope is a telescope consisting of light bundles and a sheath through which the telescope is inserted. For pure diagnostic use, the telescope is inserted alone,whereas for operative capabilities, it is inserted in conjunction with other instruments. 2 types of telescope rigid and flexible fibreoptic.

Rigid telescopes are most commonly 1-5mm in diameter for diagnostic procedures, and operatively hysteroscopes typically range from 8-10mm in diameter.

Indications
Evaluation and treatment of abnormal uterine bleeding Premenopausal/postmenopausal bleeding Uterine polyp or submucous fibroids Directed biopsy in atypical adenomatous hyperplasia patient Evaluation and treatment of infertility Habitual abortion Known uterine septum Foreign body (eg broken or imbedded IUD) Submucous fibroids Cornual occlusion Intracervical, intrauterine or intracornual adhesions Congenital anomaly Possible intrauterine infection Endometrial polyp

Contraindications
Absolute Pelvic Inflammatory disease Uterine perforation Pregnancy Sensitivity to anaesthetic or distension medium Lack of proper equipment Operator inexperience Relative Heavy bleeding limiting visual field Known gynecologic cancer especially endometrial, cervical, tubal and ovarian
risk of flushing cancer cells into the peritoneal cavity.

Advantages
Direct visualization of the endometrial cavity avoids diagnostic errors associated with dilatation and curettage (D&C) or blind endometrial biopsy procedures. As an outpatient procedure, it requires only local anesthesia.

It is acceptable to patients because discomfort is minimal.

Its risks are minor. The average duration of the procedure is 5 minutes. Compared to surgery as a means of sterilization, hysteroscopy promises reduced hospitalization, pain, and discomfort, and rapid return to normal activities.