2. Background
A multicenter study of 92 centers and over 21,000
operative hysteroscopy reported a complication rate 0.22%.
The most common complication was uterine perforationThe most common complication was uterine perforation
(0.12 %), followed by fluid overload (0.06 %),
intraoperative hemorrhage (0.03%), bladder or bowel injury
(0.02 %), and endomyometritis (0.01 %).Aydeniz et al (2002)
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3. Safety Measures; topics
General golden roles
Approach to outpatient procedure
Endometrial preparationEndometrial preparation
Antibiotic prophylaxis
Safe entry and cervical negotiation
Distending media management
Operative challenge.
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4. General Golden Rules
(Hamou 1993)
1. Proper patient selection.
2. Surgeon’s experience.(very important)2. Surgeon’s experience.(very important)
3. Good instrumentation (e.g. monopolar vs bipolar ).
4. Clear visualization with continuous uterine
distention.
5. Concurrent laparoscopy / ultrasound.
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5. Approach to outpatient hysteroscopy
The most common reasons for failure to complete
an outpatient hysteroscopy are painpain, cervicalcervical
stenosisstenosis, and poorpoor visualization.visualization.stenosisstenosis, and poorpoor visualization.visualization.
Advance in instrumentation, including narrow
caliber hysteroscopes, and use of local anesthetic
decreased patient discomfort & facilitated an
ambulatory procedure. (Readmam et al,2004)
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6. Endometrial preparation
For women with regular menses, the proliferative
phase is best for visualization of the uterine cavity.
For women with irregular menses, thinning of theFor women with irregular menses, thinning of the
endometrium is considered before operative
hysteroscopic resection of myoma or endometrial
ablation for better visualization, less bleeding and
less operative time (Grow DR& Iromloo K 2006 )
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7. Endometrial Thinning, cont.,
Many pharmacological agents can be used
for endometrial thinning such as COCs,for endometrial thinning such as COCs,
progestins, desogestrel, raloxifene, all are
safer than GnRh agonists or danazoles .
(Cicinelli et al 2007)
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8. Prophylactic Antibiotics
Antibiotics are not routinely administered
during hysteroscopy for prevention of surgicalduring hysteroscopy for prevention of surgical
site infection or endocarditis since post-
hysteroscopy infection occurs in less than 1%
of women (ACOG Practice Bulletin No. 74, Obstet Gynecol 2006)
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9. Safe Entry and Cervical Negotiation
Narrow caliber hysteroscopes (≤5mm) typically
don’t require cervical dilation, particularly in
premenopausal women. If possible, mechanical
cervical dilation should be avoided since it can be
painful. (Readman E, Maher PJ: 2004)
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10. Safe Entry and Cervical Negotiation;cont.
For patients who require cervical dilation, cervical
preparation with misoprostol (200-400mcg) may be
sufficient on its own or can facilitate mechanicalsufficient on its own or can facilitate mechanical
dilation. ( Crane JM, Healey S: 2006).
The vaginal route for misoprostol may be more
effective than oral. (Batukan C etal:2008)
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11. Safe Entry and Cervical Negotiation; cont.
In postmenopausal women, randomized trial data
have not consistently demonstrated that
preoperative misoprostol decreases the need forpreoperative misoprostol decreases the need for
mechanical cervical dilation.(da Costa AR et al:2008), (Barcaite
E et al :2005).
Pretreatment with vaginal estrogen (25mcg E2
daily) for 2 weeks before surgery may augment
the cervical dilation caused by misoprostol.
(Oppegaard KS et al :2010)
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12. Distending media management
AAGL Practice guidelines for the management of
hysteroscopic distending media (2013):
18 evidence based recommendations were18 evidence based recommendations were
published in the Journal of Minimally Invasive
Gynecology, Vol.20, No.2, March/April 2013.
Some of these guidelines will be tabulated in the
next 3 slides .
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13. AAGL Practice guidelines for the management of
hysteroscopic distending media (2013):
EVIDENCE
LEVEL
RECOMMENDATION
A1-Intra-cervical injection of 8 mL of a dilute vasopressin solution (0.05
U/mL) immediately prior to the procedure reduces distending media
absorption during resectoscopic surgery.absorption during resectoscopic surgery.
A2-The uterine cavity distention pressure should be the lowest pressure
necessary to distend the uterine cavity and ideally should be
maintained below the mean arterial pressure.
B3- Excessive absorption of hypotonic fluids such as glycine (1.5% or
sorbitol 3%) can result in fluid overload and hypotonic hyponatremia,
causing permanent neurologic complications or death.
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14. AAGL Practice guidelines for the management of
hysteroscopic distending media (2013):
B4- The risk of hypotonic encephalopathy is greater in
reproductive-aged women than in postmenopausal
women.
B5- When compared with electrolyte free media, saline B5- When compared with electrolyte free media, saline
appears to have a safer profile
B6- Excessive absorption of isotonic fluids such as saline
can cause severe complications. Continuous and
accurate fluid monitoring is mandatory.
B7- The risk of systemic absorption varies with the
procedure and increases when myometrial integrity is
breached (e.g. with myomectomy).
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15. AAGL Practice guidelines for the management of
hysteroscopic distending media (2013):
B8- Due to the conflicting evidence regarding their impact on
the volume of fluid deficit during resectoscopic surgery, the
decision to use GnRH agonists should be the provider’s
decision.decision.
CRecommendations from 9 to 18 are Level C evidence and included :
-CO2 use only in diagnostic procedures
-Air purge out the system before and during operative procedure
-Limiting preoperative oral or iv hydration
-Obtain pre-resectoscope base-line electrolyte levels
-Use automated fluid managemet systems
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16. Hysteroscopic Myomectomy
Pre-operative evaluation with SIS, or combined
office hysteroscopy and TVS to discover
associated pathology (eg adenomyosis or polypi)associated pathology (eg adenomyosis or polypi)
(Lasmar et al 2005)
ESH types 0 , I . (Wamsteker K et al 1993), (Lasmar et al 2005).
Diameter ≤5cm carries better prognosis.(Hart R et al 1999).
Uterine cavity length ≤ 10cm. (Wamsteker et al 1993)
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17. Hysteroscopic Myomectomy cont,:
Intra-operative sonographic guidance.(Coccia et al,2000)
Two-step procedures if large, multiple,type II
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Two-step procedures if large, multiple,type II
Concomitant polypectomy during hysteroscopic
myomectomy does not increase operative duration
or complication.(Linda D Bradly 2012).
18. Hysteroscopic Metroplasty
Various instruments including semirigid or rigid scissors
(7F) or unipolar wire loop(8mm), urologic resectoscope
(21-26F), Versapoint® bipolar electrode (1.6; 5mm
sheath); or lasers (KTP/532), (Nd:YAG),( argon).sheath); or lasers (KTP/532), (Nd:YAG),( argon).
Use of any of them is associated with good success rates
and infrequent complications.
Use of micro-scissors or bipolar electrodes decrease
operative time. (Colacurci et al 2007)
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19. Hysteroscopic Adhesiolysis:
In severe adhesions :(to avoid perforation)
1. Concurrent ultrasound guide cervical dilation
avoiding false passage. (Marcelle I Cedars 2012)
2. Concurrent laparoscopy (Levine & Neuwirth;1973)
3. Concurrent fluoroscopy ( Thomson et al;2007).
4. Multi-stage surgery (Zikopoulos et al 2004)
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20. Endometrial Ablation
1st generation (resectoscopic) : no significant
difference in complications between ablation and
resection.(Lethaby et al 2009)resection
2nd generation (non-resectoscopic) ; (safer)
most of these techniques don’t require hysteroscopy.
Requires less experience and less operative time.
(Deb et al 2008)
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21. The surgeon’s skill remains the best
safety measure in operative
hysteroscopy.
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hysteroscopy.
