B28. Diagnostic and operative hysteroscopy

Definition and epidemiology

Hysteroscopy is a diagnostic and/or therapeutic procedure in gynaecology. A fibreoptic endoscope is passed transcervically into the uterine cavity, which gives a view of the uterine cavity, tubal ostia, and endocervical canal.

Procedure

The hysteroscope includes a light source and equipment to infuse uterine distending media, like gas or fluid. It also contains an operating channel through which surgical instruments may be inserted and used, like scissors, biopsy forceps, electrodes, scalpel, etc. The scope may be rigid or flexible.

Most women need mechanical cervical dilation with a Hegar dilator to undergo hysteroscopy. By administering local misoprostol to the patient the day before the procedure, the cervix will ripen, making dilation easier.

During the procedure, the uterus is distended with gas (CO2) or a fluid. The fluid used is usually Isodex, a glucose solution.

It can be performed under general anaesthesia or in an outpatient setting with local anaesthetics. For diagnostic procedures and smaller therapeutic interventions, outpatient procedure with local anaesthetics is usually sufficient. Local anaesthetics are usually administered as a paracervical block (injection into upper part of cervix) and/or topically to the cervix.

Diagnostic indications

  • Evaluation of abnormal uterine bleeding
  • Evaluation of infertility, to assess the uterine and fallopian tube patency
  • Evaluation of Müllerian abnormalities

Therapeutic indications

  • Resection of submucosal or mucosal lesions, like polyps, fibroids
  • Biopsy or resection of endometrium
  • Resection of intrauterine adhesions (Asherman syndrome)
  • Sterilisation
  • Removal of foreign body or IUD

Contraindications

  • Intrauterine pregnancy
  • Active pelvic infection
  • Cervical or endometrial cancer

Complications

  • Uterine perforation
  • Fluid overload
  • Gas embolism

Complications are rare.


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B29. Laparoscopy in gynecology

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