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EXPERIENCE WITH HYSTEROSCOPY IN A PRIVATE HOSPITAL SETTING IN NIGERIA

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Presentation on theme: "EXPERIENCE WITH HYSTEROSCOPY IN A PRIVATE HOSPITAL SETTING IN NIGERIA"— Presentation transcript:

1 EXPERIENCE WITH HYSTEROSCOPY IN A PRIVATE HOSPITAL SETTING IN NIGERIA
DR. JUDE EHIABHI OKOHUE MBBS, FWACS, FMCOG, FICS, DMAS, CERT. (USS) GYNESCOPE SPECIALIST HOSPITAL

2 INTRODUCTION Hysteroscopy: Procedure for visualizing the uterine cavity with the aid of a telescope- like device called a hysteroscope. Dates back to the 19th century (Pantaleoni, 1869) One of the safest and most easily acquired skills in gynaecology (Bradley, 2004)

3 Equipments FOR Hysteroscopy
Hysteroscopy Trolley Telescopes – Flexible Telescope Diagnostic purpose Less discomfort Reduced vision Expensive - Rigid Telescope 1.5 – 4mm 0 – 30 degrees Good Resolution Better Depth Perception

4 Hysteroscopy Irrigation Sheaths Outflow sheaths Light Source
Inflow sheaths Outflow sheaths Light Source Halogen: Highly economical, yellow colour compensated for by white balancing Xenon: More natural colour, expensive LED lights: More recent

5 Total Internal reflection Bundles of optical fiber glass
Light cables - Fiberoptic cables Total Internal reflection Bundles of optical fiber glass Do not bend or twist < 15cm radius Can cause burns - Liquid crystal gel cable Transmits approximately 30% more light than fiberoptic cables. Expensive, rigid, difficult to store/maintain Used in Movies, TV, Photography

6 Camera Unit: High resolution VCU attached to the eyepiece of the telescope
CCD “sees” image taken by the telescope Camera control unit Monitor: Slightly different from TV monitor Good ergonomics RBG, Composite, S-video cables 3-D monitors HD monitors Pump: Manual or automated

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8

9 AUTOMATED PUMP

10 MANUAL PUMP

11

12 TELEPAC

13 INDICATIONS FOR HYSTEROSCOPY
Abnormal uterine bleeding ( In combination with endometrial biopsy, hysteroscopy is more accurate than D&C, Loffer, 1989) Amenorrhoea/Oligomenorrhoea Abnormal HSG report: polyp, submucous fibroids, adhesions, septum Infertility (?Pre IVF) Recurrent abortion Missing IUCD

14 CONTRAINDICATIONS TO HYSTEROSCOPY
Pregnancy Heavy uterine bleeding Pelvic inflammatory disease Cervical malignancy Recent Uterine perforation Cardiopulmonary disease

15 DISTENTION MEDIA Gas and liquids
Gas: CO2 – Medium of choice. Provides a natural view of the cavity. Used only for diagnostic hysteroscopy. Low flow from a specially designed insufflator (never use insufflator for laparoscopy), ml/min. Liquids: Normal saline, Ringer’s lactate, 5% and 10% Dextrose water, 1.5% Glycine, sorbitol and dextran 70

16 TECHNIQUE (DIAGNOSTIC HYSTEROSCOPY)
Room set up: Enough space, observe the principles of ergonomics Counsel patients properly Proliferative phase of the menstrual cycle Ask the patient to empty her bladder Dorsal lithotomy position Clean and drape the perineum Bimanual palpation Bivalve speculum Clean the cervix with antiseptic

17 Paracervical block or injection of 1% Xylocaine into the anterior lip of the cervix
Hold anterior lip with volsellum Remove the anterior blade of the speculum Articulate the hysteroscope, connect light source, camera unit and fluid channel. Hold the anterior cervical lip upwards while an assistant depresses the posterior vaginal wall Distention fluid can be introduced via gravity, an assistant or with the use of pressure cuff (< 150mmHg) Introduce the hysteroscope just within the cervical canal with the fluid running Allow pressure from the fluid to distend the canal before advancing the hysteroscope under direct vision

18 Have a panoramic view If possible, avoid prior cervical os dilatation for diagnostic hysteroscopy For surgical hysteroscopy, can dilate up to Hegar’s size 9 While observing one tubal ostium, fix the camera head and rotate the light source along its axis to view the other ostium Fluid input and output should be carefully monitored

19 OPERATIVE HYSTEROSCOPY
3 Types of Operative Hysteroscopy Operative sheaths with instruments attached through channels or fixed to the sheath Electrocautery – Resectoscope - Versapoint 3. Hysteroscopic Morcellator – Rotating blade that cuts lesions

20 Resectoscope working element with electrodes

21 Erbe electrosurgical generator (300d)

22 TECHNIQUE As in diagnostic hysteroscopy but with use of Regional or General Anaesthesia Pretreatment with 200 micrograms of misoprostol the night before surgery (vaginal insertion of misoprostol better than oral – Crane and Healy, 2006) Use electrolyte free media (e.g. Glycine) for monopolar cautery and electrolyte containing fluids (e.g. Normal saline) for bipolar

23 Maximum fluid pressure 150mmHg
Max fluid deficit for NS ?1.5litres Max fluid deficit for Glycine 1litre Max fluid deficit for Dextran ml Prophylactic Antibiotics not routinely administered. Less than 1% of women develop post hysteroscopy infection (ACOG Committee on Practice Bulletins, 2006)

24 COMPLICATIONS 0.22% (Aydeniz et al, 2002) 0.7% (Parkar et al, 2004)
1.2% (Okohue et al, 2009) Vasovagal Reactions Perforation of the uterus Cervical laceration Fluid overload Urinary tract injury Bowel injury

25 Embolism Haemorrhage Electrosurgical injury Infection/Peritonitis Anaphylactic reaction Haematometria Dissemination of tumour ?Cervical Incompetence

26 CARE OF INSTRUMENTS All instruments must be immersed in sterile water, cleaned and dried after use Commonest form of sterilization is chemical sterilization with the use of glutaraldehyde solution. Immerse in glutaraldehyde solution for 10 hours for complete sterilization. Use 15 times or within 21 days If HIV, HBV and HCV are ruled out, 20 minutes immersion will suffice Rinse well in sterile water before use Gas sterilization is very effective. Not commonly used because of cost and time needed (>72 hours) Formalin chambers – Mainly used for storage/carrying instruments from one place to another

27 INDICATIONS FOR HYSTEROSCOPY (DEC. 2010 – NOV. 2014)
FREQUENCY (%) SYNECHIAE 395 (67.75) SUBMUCOUS FIBROID 45 (7.72) POLYP 35 (6.0) > 2 FAILED IVF CYCLES 27 (4.63) AMENORRHOEA 25 (4.29) FETAL BONES 16 (2.74) POST MYOMECTOMY (OPEN) 13 (2.23) THIN ENDOMETRIUM 12 (2.06) OTHERS (REC MISC., MISSING IUCD, UTERINE SEPTUM 15 (2.58) TOTAL 583 (100)

28 CONCLUSION Hysteroscopy may be learned with relative ease
Collaboration seems to be the way to go and it is hoped that in the foreseeable future with better collaboration, MAS especially hysteroscopic skills would become part of the armamentarium of every practicing Gynaecologist.

29 Warm wishes from gynescope


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