endoscopy in gyanecology

1. Hysteroscopy
Moderator : Dr. Diana

2. Hysteroscope is an
endoluminal endoscope
that can be used as an
aid to visualize uterine
cavity or to direct the
performance of variety
of intrauterine
procedures.

3. Historical aspect
• 1869: Pantaleon visualize polypoidal tumour in uterus.
• 1925: Rubin used cystourethroscope to visualize
uterus; he used water to distend uterus and to wash
lens. Later he used C02
• 1960-70 – low viscosity fluids like saline or ringer
lactate with pressure 50-100mmhg; popularly used in
diagnostic hysteroscopy. Cheap and easily available.
• 1971 – Hyson
- used by Menken
- 30% dextran in 10% glucose
( K Y jelly is been used in India as distending media for
diagnostic hysteroscope)

4. Instruments
• Hysterocsope:
-Telescope : eyepiece, barrel & objective lens.
- Angle options : 0,12 ,15, 25, 30 & 70 degree.
- 0 degree provides a panoramic view.
- angled one improve the view of ostia in an
abnormally shaped uterine cavity.

5. • Rigid hysteroscope
- in-patient and complex operating room
procedures.
- 3-5mm in diameter
- more durable and provide superior image.

6. • Flexible hysteroscope
- most commonly used for office hysteroscopy
- flexibility; tip deflection of 120-160 degree.
- irregularly shaped uterus & navigation around
intrauterine lesions.

7. Light source.
-halogen and xenon; xenon
generator provides white
light, which gives a
superior color and
intensity.

8. Camera Equipment

9. Diagnostic sheaths
-to deliver the distention media
-fit by means of a watertight seal lock
- 4 to 5 mm in diameter, with a 1 mm
clearance between the inner wall and the
telescope, through which the distention
media is transmitted.

10. • Operative sheaths
- larger diameter - 7 to 10
- allows space for instillation of medium, for
the telescope, and for the insertion of
operating devices.

11. • Resectoscope
-three basic electrodes: a ball,
barrel, and a cutting loop.
• Accessory instruments
- alligator grasping forceps,
biopsy forceps, and scissors,
morcellator
-monopolar and bipolar
electrodes
-A new bipolar system named
VersaPoint™
(saline may be used as
distention media)

12. • DISTENTION MEDIA
-muscle of uterine walls requires a minimum
pressure of 40 mm Hg to distend the cavity.
-types of distention media
- gaseous
-liquid - high-viscosity and low-viscosity fluids

13. • Carbon dioxide
- colorless gas
-ideal for office hysteroscopy.
- given through insufflator
- it allows entry evaluation of the
endocervical canal.
- disadvantages – gas embolism, no
effective way to remove blood and debris.

14. • High viscosity fluids
- Dextran 70 (Hyscon )
• Low viscosity fluids with electrolytes
-normal saline and lactated ringer’s solution
-easy availability and low cost
- miscibility with blood hence obscuring the
vision
- pulmonary and cerebral edema

15. • Low viscosity fluids without electrolytes
-1.5 % glycine is the most commonly used medium.
-Other non-electrolyte media - 5% glucose and
sorbitol/mannitol.

16. Procedure
Preparation of the patient:
– Detailed history and complete physical
examination
– In proliferative phase of menstrual cycle
– Informed consent
– bimanual examination

17. Therapeutic Hysteroscopy Anesthesia
• Local - Paracervical block plus fentanyl 100 mcg IV
or ibuprofen 600 mg with diazepam 5mg po 1hr
before
• Spinal – allows monitoring of sensorium with
respect to hyponatremia
• General anesthesia with paracervical block

18. Vasopressin in Paracervical Block
• Less force (about ½) needed for dilation
• Less fluid absorbed (about 1/3)
• Ed’s solution= 5U (1/4 ml) vasopressin in 30ml 1%
chloroprocaine or lidocaine (+3ml NaCO3). Inject 6-
10ml each side.
• Alternatively misoprostol (200-400 microgram) can
be use 12-24 hrs prior.

20. Indications
Diagnostic tool:
- Abnormal uterine bleeding :
- Premenopausal
- Postmenopausal
- Infertility :
- Intrauterine adhesions (Asherman’s
syndrome)
- Submucous fibroids.
- Endometrial polyps.
- Uterine malformations( abnormal hsg or
tvs)

21. • Recurrent spontaneous abortion
• Unexplained infertility

22. Therapeutic tool
Neodymium
YAG laser
First
generation
Endometrial
resection
Roller ball
endometrial
ablation
Versapoint

23. Second
generation
Hydrothermal
Uterine thermal
balloon
ablator
Microwave
endometrial
ablation
Nova sure
Her
option(cryosurgery)

25. – Correct uterine malformation like septate uterus by
resection of the septum. (bicorneate uterus is corrected
by laparotomy using metroplasty)
– Polypectomy.
– Intrauterine adhesions
– Myomectomy

26. Used as a therapeutic tool
- Removal of foreign bodies and IUCD.
- CANNULATION OF FALLOPIAN TUBE
- to canalize the tube:interstitial
obstruction secondary to cellular debris and
tubal spasm.
- to place intra tubal device for
sterilization.

27. • treatment of hemangiomas and arteriovenous
malformations

29. Management of Intramural fibroids

30. Wamsteker’s classification

31. Indication
Mennorhagia
Infertility?

37. • Myomas treated hysteroscopically
- All submucosal myomas:
( two step procedure are considered)
- Single Intramural fibroid <5 cm that lie close
to endometrium

41. Contraindications
• Pregnancy.
• Current or recent pelvic infection.
• Current vaginitis, cervicitis and
endometritis.
• Recent uterine perforation.
• Active Bleeding.

42. Complications
• Intra-operative bleeding
- increase the pressure of distention media above
the mean arterial pressure, this compresses the wall
of the uterus sufficiently to stop bleeding.
-bleeding vessel can be coagulated with a 3 mm
ball electrode.

43. • Bleeding can be controlled by inserting a Foleys
balloon and inflating it to 3 to 5 ml. The balloon can
be kept in situ for 6 to 12 hours
• rare cases when the bleeding is arterial- uterine
artery embolization or even hysterectomy may be
needed.

44. • Delayed postoperative bleeding - associated
with endometrial slough, chronic endometritis or
spontaneous expulsion of intramural portion of
previously resected submucous myoma
• Uterine perforation

45. - Complications related to distention media:
due to CO2 insufflation:
-Cardiac arrhythmia due to excessive
absorption.
-Gas embolism.
due to fluid:
- Anaphylactic reaction
- Pulmonary edema
- Adult RDS

46. • Acute hyponatremic state- fluid deficit equal or
greater than 500 ml should alert a surgeon to a
likelihood of hyponatremia and hypoosmolality,
which can furthur lead to cerebral edema an CNS
abnormality. Close monitoring of inflow and outflow
and thereby the deficit can avoid these
complications.

47. Complications
- Late onset:
- Infections, PID
- Vaginal discharge: common after ablative
procedures and it is self limiting.
- Adhesion formation

48. • Prevention of adhesion
formation:
- Second or third look
hysetroscopic adhesiolysis.
- Barrier methods (sepra
film,amnion graft)
-Mechanical methods (
IUD, lippes loop, foley’s
balloon)
- Hormone treatment (
estrogen, progesterone,
GnRH analouges)
- Pharmological agents(
antibiotics, antihistaminics,
NSAIDS)

49. Robotic Surgery

50. ACOG Committee Opinion
Number 444 – November 2009
• “Evidence demonstrates that, in general, vaginal
hysterectomy is associated with better outcomes and
fewer complications than laparoscopic and
abdominal hysterectomy. When it is not feasible to
perform a vaginal hysterectomy, the surgeon must
choose between laparoscopic hysterectomy, robot-assisted
hysterectomy or abdominal hysterectomy.”

51. da Vinci® Gynecology
Improving the Quality of Life for Women

52. • Gynecologic Conditions
• da Vinci® Surgical System
• da Vinci Gynecologic Surgery
 da Vinci Hysterectomy for Early Stage Gynecologic Cancer
 da Vinci Hysterectomy for Benign Conditions
 da Vinci Myomectomy
 da Vinci Sacrocolpopexy

53. Drawbacks with Conventional
Laparoscopic Surgery
• Surgeon operates from a 2D image
• Straight, rigid instruments (limited
range of motion)
• Instrument tips controlled at a distance
• Reduced dexterity, precision and
control
• Unsteady camera controlled by
assistant
• Dependent on assistant for surgical
support through an accessory port
• Greater surgeon fatigue
• Makes complex operations more
difficult

54. How to overcome these drawbacks?
 Improve visualization
 Improve instrument
control
 Enhance dexterity for
technically challenging
aspects of the procedure
 Use superior ergonomics

55. da Vinci Hysterectomy
 Dexterity for complex
dissections (e.g
endometriosis)
 Vaginal cuff suture
closure with ease
 Improved visualization
and access around the
cervix for a colpotomy

56. da Vinci Sacrocolpopexy
 Easier, quicker and more
precise suturing
 Complete control of the
camera and all three
operative arms
 A reproducible approach