1. Principles of safe and effective hysteroscopy

2. What is Hysteroscopy? “Looking inside the uterus” Can be diagnostic
Can be therapeutic

3. Why Hysteroscopy? Abnormal bleeding Subfertility Recurrent miscarriage
Pre-op assessment
To remove something (‘lost IUCD’)
Sterilisation

4. Keeping it safe

5. Know your patient
History
Examination
Investigations

6. Valid consent

7. What to expect in this lecture
Anaesthetic
Positioning the patient/equipment
Cleaning/draping
Equipment
Distension medium
Negotiating cervix
Effective diagnostic survey

8. 1. Anaesthetic
None
Local
General

9. 2. Positioning the patient
Dorsal lithotomy
Beware back, hips,
peroneal N, other bits
Awake patients can position themselves!

10. 2. Positioning equipment

11. 3. Cleaning/draping Sterile or clinically clean?
Avoid all risk of patient to patient transfer of infection (viral, MRSA, CDiff, B Strep)
Minimise risk of ascending infection
It is difficult to completely cleans the vagina in an outpatient setting but the cervix should be cleaned.

12. 4. Know your equipment
General gynae equipment
Hysteroscopic equipment

13. 5. Distension medium Uterine cavity is virtual until distended Saline
Dextran/Glycine
CO2

14. 5. Distension medium Technique for optimum cavity distension
Use medium to dilate cervix for entry
Aim for continuous flow (single or two channel)
Limit amount of trauma to uterine cavity
Cavity distension pressure usually limited to 50mmHg under no/local anaesthetic because of pain

15. 5. Distension medium Fluid overload and hysteroscopic surgery
Absorption of non ionic distension medium used with monopolar resection/ablation
Hyponatraemia
Pulmonary oedema
Cerebral oedema
Seizures
Risk increases with fibroid resection

16. Fluid overload and hysteroscopic surgery
5. Distension medium
Fluid overload and hysteroscopic surgery
Fluid absorption/TCRE

17. 6. Negotiating cervix Method Dilation not usually required
Distend cervix with medium
Enter under direct vision
Understand angled tip
Double channel continuous flow for hysteroscopic surgery

18. 7. Effective diagnostic survey
Methodological approach
Understand aims of procedure
Rotation of scope to allow angled tip to visualise entire cavity
Appropriate record of findings
Written
Photography (consent especially if used for educational use at a later date)

19. Contraindications Active uterine infection Severe systemic illness
Pregnancy
Heavy uterine bleeding!
(Cervical Cancer)

20. Complications Failed procedure Problems due to distension media
- <2%
- Cervical stenosis
- Blood, gas bubbles
Problems due to distension media
- Fluid overload
Problems due to procedure itself
- Infection
- Bleeding
- Cervical/uterine damage/perforation
Anaesthetic problems
Incidence serious complications in DIAGNOSTIC hysteroscopy 0.012%

21. Now show video:
Basic hysteroscopy