EXPERIENCE WITH HYSTEROSCOPY IN A PRIVATE HOSPITAL SETTING IN NIGERIA

DR. JUDE EHIABHI OKOHUE

MBBS, FWACS, FMCOG, FICS, DMAS, CERT. (USS)

GYNESCOPE SPECIALIST HOSPITAL

WWW.GYNESCOPESH.COM

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)

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

Hysteroscopy Irrigation Sheaths 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

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

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 monitorso Pump: Manual or automated

AUTOMATED PUMP

MANUAL PUMP

TELEPAC

INDICATIONS FOR HYSTEROSCOPY1. Abnormal uterine bleeding ( In

combination with endometrial biopsy, hysteroscopy is more accurate than D&C, Loffer, 1989)

2. Amenorrhoea/Oligomenorrhoea3. Abnormal HSG report: polyp,

submucous fibroids, adhesions, septum

4. Infertility (?Pre IVF)5. Recurrent abortion6. Missing IUCD

CONTRAINDICATIONS TO HYSTEROSCOPY

1. Pregnancy2. Heavy uterine bleeding3. Pelvic inflammatory disease4. Cervical malignancy5. Recent Uterine perforation6. Cardiopulmonary disease

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), 30 - 60ml/min.

Liquids: Normal saline, Ringer’s lactate, 5% and 10% Dextrose water, 1.5% Glycine, sorbitol and dextran 70

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

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

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

OPERATIVE HYSTEROSCOPY 3 Types of Operative Hysteroscopy1. Operative sheaths with instruments

attached through channels or fixed to the sheath

2. Electrocautery – Resectoscope - Versapoint3. Hysteroscopic Morcellator – Rotating

blade that cuts lesions

RESECTOSCOPE WORKING ELEMENT WITH ELECTRODES

ERBE ELECTROSURGICAL GENERATOR (300D)

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

Maximum fluid pressure 150mmHg

Max fluid deficit for NS ?1.5litres

Max fluid deficit for Glycine 1litre

Max fluid deficit for Dextran 70 250ml

Prophylactic Antibiotics not routinely administered. Less than 1% of women develop post hysteroscopy infection (ACOG Committee on Practice Bulletins, 2006)

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

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

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

INDICATIONS FOR HYSTEROSCOPY (DEC. 2010 – NOV. 2014)

INDICATION 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)

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.

WARM WISHES FROM GYNESCOPE