Download - Hysteroscopy
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Hysteroscopy
Moderator : Dr. Diana
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Hysteroscope is an
endoluminal endoscope
that can be used as an
aid to visualize uterine
cavity or to direct the
performance of variety
of intrauterine procedures.
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Historical aspect• 1869: Pantaleon visualize polypoidal tumour in uterus.• 1925: Rubin used cystourethroscope to visualize
uterus; he used water to distend uterus and to wash lens. Later he used C02
• 1960-70 – low viscosity fluids like saline or ringer lactate with pressure 50-100mmhg; popularly used in diagnostic hysteroscopy. Cheap and easily available.
• 1971 – Hyson- used by Menken- 30% dextran in 10% glucose
( K Y jelly is been used in India as distending media for diagnostic hysteroscope)
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Instruments
• Hysterocsope:
-Telescope : eyepiece, barrel & objective lens.
- Angle options : 0,12 ,15, 25, 30 & 70 degree.
- 0 degree provides a panoramic view.
- angled one improve the view of ostia in an abnormally shaped uterine cavity.
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• Rigid hysteroscope
- in-patient and complex operating room procedures.
- 3-5mm in diameter
- more durable and provide superior image.
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• Flexible hysteroscope
- most commonly used for office hysteroscopy
- flexibility; tip deflection of 120-160 degree.
- irregularly shaped uterus & navigation around intrauterine lesions.
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Light source.
-halogen and xenon; xenon generator provides white light, which gives a superior color and intensity.
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Camera Equipment
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Diagnostic sheaths
-to deliver the distention media
-fit by means of a watertight seal lock
- 4 to 5 mm in diameter, with a 1 mm clearance between the inner wall and the telescope, through which the distention media is transmitted.
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• Operative sheaths
- larger diameter - 7 to 10
- allows space for instillation of medium, for the telescope, and for the insertion of operating devices.
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• Resectoscope
-three basic electrodes: a ball, barrel, and a cutting loop.
• Accessory instruments
- alligator grasping forceps, biopsy forceps, and scissors, morcellator
-monopolar and bipolar electrodes
-A new bipolar system named VersaPoint™
(saline may be used as distention media)
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• DISTENTION MEDIA
-muscle of uterine walls requires a minimum
pressure of 40 mm Hg to distend the cavity.
-types of distention media
- gaseous
-liquid - high-viscosity and low-viscosity fluids
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• Carbon dioxide
- colorless gas
-ideal for office hysteroscopy.
- given through insufflator
- it allows entry evaluation of the endocervical canal.
- disadvantages – gas embolism, no effective way to remove blood and debris.
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• High viscosity fluids
- Dextran 70 (Hyscon )
• Low viscosity fluids with electrolytes
-normal saline and lactated ringer’s solution
-easy availability and low cost
- miscibility with blood hence obscuring the vision
- pulmonary and cerebral edema
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• Low viscosity fluids without electrolytes
-1.5 % glycine is the most commonly used medium.
-Other non-electrolyte media - 5% glucose and sorbitol/mannitol.
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Procedure
Preparation of the patient:
– Detailed history and complete physical
examination
– In proliferative phase of menstrual cycle
– Informed consent
– bimanual examination
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Therapeutic Hysteroscopy Anesthesia
• Local - Paracervical block plus fentanyl 100 mcg IV or ibuprofen 600 mg with diazepam 5mg po 1hr before
• Spinal – allows monitoring of sensorium with respect to hyponatremia
• General anesthesia with paracervical block
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Vasopressin in Paracervical Block
• Less force (about ½) needed for dilation
• Less fluid absorbed (about 1/3)
• Ed’s solution= 5U (1/4 ml) vasopressin in 30ml 1% chloroprocaine or lidocaine (+3ml NaCO3). Inject 6-
10ml each side.
• Alternatively misoprostol (200-400 microgram) can
be use 12-24 hrs prior.
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IndicationsDiagnostic tool:
- Abnormal uterine bleeding : - Premenopausal- Postmenopausal
- Infertility :- Intrauterine adhesions (Asherman’s
syndrome)- Submucous fibroids. - Endometrial polyps.
- Uterine malformations( abnormal hsg or tvs)
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• Recurrent spontaneous abortion
• Unexplained infertility
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Therapeutic tool
First generation
Neodymium YAG laser
Endometrial resection
Roller ball endometrial
ablation
Versapoint
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Second generation
Uterine thermal balloon
Hydrothermal ablator
Microwave endometrial
ablation
Nova sure
Her option(cryosurgery)
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– Correct uterine malformation like septate uterus by resection of the septum. (bicorneate uterus is corrected by laparotomy using metroplasty)
– Polypectomy.
– Intrauterine adhesions
– Myomectomy
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Used as a therapeutic tool- Removal of foreign bodies and IUCD.
- CANNULATION OF FALLOPIAN TUBE
- to canalize the tube:interstitialobstruction secondary to cellular debris and tubal spasm.
- to place intra tubal device for sterilization.
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• treatment of hemangiomas and arteriovenousmalformations
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Management of Intramural fibroids
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Wamsteker’s classification
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Indication
Mennorhagia
Infertility?
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• Myomas treated hysteroscopically
- All submucosal myomas:
( two step procedure are considered)
- Single Intramural fibroid <5 cm that lie close to endometrium
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Contraindications
• Pregnancy.
• Current or recent pelvic infection.
• Current vaginitis, cervicitis and
endometritis.
• Recent uterine perforation.
• Active Bleeding.
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Complications
• Intra-operative bleeding
- increase the pressure of distention media above the mean arterial pressure, this compresses the wall of the uterus sufficiently to stop bleeding.
-bleeding vessel can be coagulated with a 3 mm
ball electrode.
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• Bleeding can be controlled by inserting a Foleys balloon and inflating it to 3 to 5 ml. The balloon can be kept in situ for 6 to 12 hours
• rare cases when the bleeding is arterial- uterine artery embolization or even hysterectomy may be needed.
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• Delayed postoperative bleeding - associated with endometrial slough, chronic endometritis or spontaneous expulsion of intramural portion of previously resected submucous myoma
• Uterine perforation
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- Complications related to distention media:
due to CO2 insufflation:
-Cardiac arrhythmia due to excessive absorption.
-Gas embolism.
due to fluid:
- Anaphylactic reaction
- Pulmonary edema
- Adult RDS
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• Acute hyponatremic state- fluid deficit equal or greater than 500 ml should alert a surgeon to a likelihood of hyponatremia and hypoosmolality, which can furthur lead to cerebral edema an CNS abnormality. Close monitoring of inflow and outflow and thereby the deficit can avoid these
complications.
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Complications- Late onset:
- Infections, PID
- Vaginal discharge: common after ablative procedures and it is self limiting.
- Adhesion formation
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• Prevention of adhesion formation:
- Second or third look hysetroscopic adhesiolysis.
- Barrier methods (seprafilm,amnion graft)
-Mechanical methods ( IUD, lippes loop, foley’sballoon)
- Hormone treatment ( estrogen, progesterone, GnRH analouges)
- Pharmological agents( antibiotics, antihistaminics, NSAIDS)
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Robotic Surgery
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ACOG Committee OpinionNumber 444 – November 2009
• “Evidence demonstrates that, in general, vaginal
hysterectomy is associated with better outcomes and fewer complications than laparoscopic and abdominal hysterectomy. When it is not feasible to perform a vaginal hysterectomy, the surgeon must choose between laparoscopic hysterectomy, robot-assisted hysterectomy or abdominal hysterectomy.”
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da Vinci® Gynecology
Improving the Quality of Life for Women
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• Gynecologic Conditions
• da Vinci® Surgical System
• da Vinci Gynecologic Surgery da VinciHysterectomy for Early Stage Gynecologic Cancer
da Vinci Hysterectomy for Benign Conditions
da Vinci Myomectomy
da Vinci Sacrocolpopexy
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Drawbacks with Conventional Laparoscopic Surgery
• Surgeon operates from a 2D image
• Straight, rigid instruments (limited range of motion)
• Instrument tips controlled at a distance
• Reduced dexterity, precision and control
• Unsteady camera controlled by assistant
• Dependent on assistant for surgical support through an accessory port
• Greater surgeon fatigue
• Makes complex operations more difficult
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How to overcome these drawbacks?
Improve visualization
Improve instrument control
Enhance dexterity for technically challenging aspects of the procedure
Use superior ergonomics
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da Vinci Hysterectomy
Dexterity for complex
dissections (e.g
endometriosis)
Vaginal cuff suture
closure with ease
Improved visualization
and access around the
cervix for a colpotomy
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da Vinci Sacrocolpopexy
Easier, quicker and more
precise suturing
Complete control of the
camera and all three
operative arms
A reproducible approach
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