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

9. AUTOMATED PUMP

10. MANUAL PUMP

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