Principles of safe and effective
hysteroscopy
© Royal College of Obstetricians and Gynaecologists
What is Hysteroscopy?
“Looking inside the uterus”
• Can be diagnostic
• Can be therapeutic
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Why Hysteroscopy?
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Abnormal bleeding
Subfertility
Recurrent miscarriage
Pre-op assessment
To remove something
(‘lost IUCD’)
• Sterilisation
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Keeping it safe
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Know your patient
• History
• Examination
• Investigations
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Valid consent
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What to expect in this lecture
1. Anaesthetic
2. Positioning the
patient/equipment
3. Cleaning/draping
4. Equipment
5. Distension medium
6. Negotiating cervix
7. Effective diagnostic
survey
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1. Anaesthetic
• None
• Local
• General
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2. Positioning the patient
• Dorsal lithotomy
– Beware back, hips,
peroneal N, other bits
• Awake patients can
position themselves!
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2. Positioning equipment
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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.
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4. Know your equipment
• General gynae
equipment
• Hysteroscopic
equipment
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5. Distension medium
Uterine cavity is virtual until distended
• Saline
• Dextran/Glycine
• CO2
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5. Distension medium
Technique for optimum cavity distension
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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
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5. Distension medium
Fluid overload and hysteroscopic surgery
Absorption of non ionic distension medium used with
monopolar resection/ablation
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Hyponatraemia
Pulmonary oedema
Cerebral oedema
Seizures
Risk increases with fibroid
resection
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5. Distension medium
Fluid absorption/TCRE
Fluid overload and hysteroscopic surgery
1500
1000
500
0
20
40
60
80
100 120 140
IUP (mmHg)
160
180
200
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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
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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)
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Contraindications
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Active uterine infection
Severe systemic illness
Pregnancy
Heavy uterine bleeding!
(Cervical Cancer)
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Complications
• Failed procedure
- <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%
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Now show video:
Basic hysteroscopy
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© Royal College of Obstetricians and Gynaecologists