evidence based practical tips for office hysteroscopy by dr shashwat jani

Evidence Based Practical Tips For

Office Hysteroscopy

Dr. Shashwat Jani.M.S. ( Gynec ).

Diploma in Advance Endoscopy ( France ) .

Assistant Prof., Smt. N.H.L. Mun. Medical College,

Ahmedabad, Gujarat.

Mobile : +91 99099 44160.

E- mail : drshashwatjani@gmail.com

27-Nov-14 Dr Shashwat Jani. 9909944160 2

Greetings From Ahmedabad . . .

What is E.B.M. ...???

Evidence Based Medicine…?

Experience Based Medicine…?

Eminence Based Medicine....?

SourcesCochrane library .

Royal College of Obstetricians &Gynecologists (RCOG) Guidelines.

Journal of Evidence Based Obstetrics & Gynecology.

National Guideline Clearinghouse . ( U.S. Govt. ).

New Zealand Guidelines Group

PubMed.

Italian Society of Gynecological Endoscopy.

International Society Of Gynecology Endoscopy.

American Association Of Gynecology Laparoscopist.

27-Nov-14 5Dr Shashwat Jani. 9909944160

What is Office Hysteroscopy .???

“ Diagnostic hysteroscopy and some operative hysteroscopic procedures should be conducted outside of the formal operating theatre setting in an appropriately equipped and staffed ambulatory situations & yet guarantying patient’s safety & privacy. “

No Anesthesia nor Analgesia.

No drugs ( Atropine only ).

No speculum nor Tenaculum.

Operative procedures.27-Nov-14 Dr Shashwat Jani. 9909944160 7

Prof Bettocchi A pioneer in the field of office hysteroscopy,

Prof Bettocchi, in 2004 reported on 4863

operative hysteroscopic procedures where a vaginoscopic technique was used without analgesia or anesthesia.

As technology has further advanced and hysteroscopes have reduced in size, office procedures have become even more feasible.

There have also been improvements in energy sources such as bipolar (as opposed to monopolar) that have decreased complications related to the operative distension media, this has made operative hysteroscopy more acceptable.

Set Up

SET UP

Hysteroscopy Instrumentation

Lockable cabinet Telescope Sheath system Hysteroscope

- Diagnostic- Operative

Resectoscope Distention systems

Fluid delivery system Light source and cable Video cameras and monitors

Indications…DIAGNOSTIC : Unexplained abnormal Uterine bleeding (AUB) .

Peri and post menopausal bleeding.

Selected infertility cases.

Abnormal HSG.

Unexplained Infertility.

Recurrent pregnancy loss.

Should be used prudently

only after other investigations.

INDICATIONS…

Therapeutic: IUD removal Biopsy of intrauterine lesions Hemangioma and A-V malformations Resection of uterine septum Uterine synechiae Cannulation of fallopian tubes Sterilization . Uterine polyps. Submucous myomas. Endometrial ablation.

Timing…

Ideally Post menstrual Period

Anesthesia…

3 mm Flexible/Rigid• Usually not needed

5.5 mm Rigid w/o Dilatation• Parous usually not needed

• Tenaculum site local

• 1% Lidocaine

5.5 mm Rigid with Dilatation• Tenaculum site local

• Paracervical block

Analgesia…

Routine use of Opiates NOT recommended.

Women without contraindications should

be advised to consider taking standard doses

of NSAIDs around 1 hour before their

scheduled outpatient hysteroscopy

appointment with the aim of reducing pain in the immediate postoperative period.

Cervical Preparation…

Routinely NOT recommended…

See and Treat

• Cervical dilation usually not needed

• 3 mm flexible hysteroscope with sheath.

Misoprostol

• Cramping and bleeding

• Give narcotic pain medication

Misoprostol

Misoprostol is not required in every patient, but should be considered in selective patients :

- Post menopausal patients, - Nulliparous patients, - Patients who have had previous cervical surgery

or where the procedure is assessed to be difficult in dilating cervix.

Oral / Vaginal 400 μgm 6-8 hr prior.

Sublingual 400 μgm 2-4 hr prior.

Types of Hysteroscope

Miniature hysteroscopes (2.7mm with a 3 –3.5mm sheath) should be used for diagnostic outpatient hysteroscopy as they significantly reduce the discomfort experience by the woman.

1.9 mm Microhysteroscope should be reserved for special cases like severe cervical stenosis.

There is insufficient evidence to recommend 0° or fore-oblique optical lenses (i.e. 12°, 25° or 30°off-set lenses) for routine outpatient hysteroscopy.

Now ,,,

Types Of Hysteroscopes?

Flexible hysteroscopes are associated with less pain during outpatient hysteroscopy compared with rigid hysteroscopes.

However, Rigid hysteroscopes may provide better images, fewer failed procedures, quicker examination time and reduced cost.

Thus, there is insufficient evidence to recommend preferential use of rigid or flexible hysteroscopes for diagnostic outpatient procedures.

Choice of hysteroscope should be left to the

discretion of the Operator…!!!27-Nov-14 20Dr Shashwat Jani. 9909944160

Distension Media

For routine outpatient hysteroscopy, the choice of distension medium between Carbon dioxide and Normal Saline should be left to the discretion of the operator as neither is superior in reducing pain, although uterine distension with normal saline appears to reduce the incidence of vasovagal episodes.

Uterine distension with Normal saline allows improved image quality and allows outpatient diagnostic hysteroscopy to be completed more quickly compared with carbon dioxide.

Operative outpatient hysteroscopy, using bipolar electrosurgery, requires the use of normal saline to act as both the distension and conducting medium.

Local Anesthesia & Cervical Dilatation

Miniaturization of hysteroscopes and increasing use of the vaginoscopic technique may diminish any advantage of Intracervical or paracervical anesthesia.

Routine administration of intracervical or paracervical local anaesthetic should be used where :

larger diameter hysteroscopes are being employed (outer diameter greater than 5mm) &

where the need for cervical dilatation is anticipated (e.g. cervical stenosis).

Routine administration of intracervical or paracervical local anesthetic is Not indicated to reduce the incidence of vasovagal reactions.

Conscious Sedation

Conscious sedation should not be routinely used in outpatient hysteroscopic procedures as it confers No advantage in terms of pain control and the woman’s satisfaction over local anaesthesia.

Life-threatening complications can result from the use of conscious sedation.

Appropriate monitoring and staff skills are mandatory if procedures are to be undertaken using conscious sedation.

Antibiotics

Routine use of Antibiotic is

NOT recommended after Diagnostic Office Hysteroscopy.

But should be given in Operative Hysteroscopy.

Vaginoscopy

Vaginoscopy should be

the standard technique for outpatient hysteroscopy, especially where successful insertion of a vaginal speculum is anticipated to be difficult and where blind endometrial biopsy is not required.

Tips for the Bettochi vaginoscopic technique :

Enter into the vagina, aiming for deep in the posterior fornix.

Initially place the hysteroscope light lead at 6 o’clock and try to localize the cervix.

Once through the external os, follow the endocervical canal (seen as a ‘Black Hole’).

At the internal os turn scope on its side by turning the light lead 90 degrees as this facilitates entry of scope into the uterine cavity.

Role In Infertility

As a Screening test…

Given the low invasiveness and the safety of office hysteroscopy and the desire for the infertile couple to shorten as much as possible the diagnostic period which is often a source of anxiety and uncertainty, it is reasonable to recommend the evaluation of uterine cavity by office hysteroscopy in the diagnostic work up of infertile couples.

(LEVEL OF EVIDENCE VI,

STRENGH OF THE RECOMMENDATION B).

Prior to IVF….

Hysteroscopy should be recommended for women with repeated implantation failure.

(LEVEL OF EVIDENCE I ,

STRENGH OF THE RECOMMENDATION A).

However, a “screening” office hysteroscopy should be performed before including patients in an IVF program in order to minimize any negative intrauterine influence on IVF outcome.

H/o of Recurrent Miscarriage…

Diagnosis and treatment by hysteroscopy of uterine malformations and intrauterine adhesions in such patients may improve live birth rate and therefore, their treatment could be recommended.

(LEVEL OF EVIDENCE V,

Role In AUB…

Hysteroscopy should be always performed in women presenting with AUB, in whom other tests (Sonohysterography and/or Transvaginalultrasound) have already reported OR have been unable to rule out endouterine pathologies.

( LEVEL OF EVIDENCE III ,

STRENGHT OF THE RECOMMENDATION B ).

Post menopausal Bleeding…

It is reasonable to recommend evaluation of endometrial cavity by hysteroscopy in cases of repeated AUB in such women.

Role in Biopsy…

Target-eye biopsy is more accurate than blind biopsy, and therefore hysteroscopy with multiple target biopsies should be used in place of blind techniques in the diagnostic work-up for atypical lesions.

( LEVEL OF EVIDENCE II,

The possible risk of the spreading of neoplastic cells to the abdominal cavity should not limit the use of hysteroscopy in favour of blind techniques.

(LEVEL OF EVIDENCE II,

STRENGH OF THE RECOMMENDATION A ) .

TIPSFor

Managing & Minimizing

Operative Complications27-Nov-14 36Dr Shashwat Jani. 9909944160

“ Ignoring contraindications to hysteroscopic surgery increases the risk of complications and is the single greatest factor leading to patient injury and physician liability. “

Contraindications

Acute pelvic inflammatory disease

Pregnancy

Genital tract malignancies

Lack of informed consent

Inability to dilate the cervix

Inability to distend the uterus to obtain visualization

Poor surgical candidates who may not tolerate fluid overload because of renal disease, or radiofrequency current when a cardiac pacemaker is present.

Unfamiliarity with equipment, instruments or technique

Lack of appropriate equipment or staff familiar with the equipment.

A False Passage…

If muscle fibers are visible and the tubal ostea are not, assume the passage is false.

Slowly remove the hysteroscope and identify the true cavity for confirmation.

Discontinue the procedure—even if no perforation is detected—to prevent distention fluid from being absorbed into the circulation through the injury. Adequate distention is not possible at this time.

Delay repeat hysteroscopy for 2 to 3 months.

A False Passage…

Myometrial fibers signal that a false passage has been created.

To Avoid Creating A False Passage…

Dilate the cervix with slow, steady pressure and stop as soon as the internal os opens; do not attempt to push the dilator to the uterine fundus.

Often the external os opens, but the internal os cannot be dilated the extra 1 to 2 mm necessary to accommodate the 27- French resectoscope. Rather than exert more force and risk perforation or laceration, simply turn on the resectoscope’s inflow with the outflow shut off, and let the fluid pressure dilate the cervix.

Always insert the hysteroscope or resectoscope under direct vision rather than use an obturator.

Keep the “dark circle” in the center of the field and slowly advance the hysteroscope toward it until the cavity is reached.

Avulsion of the Myometrium

Small bowel visible within the uterine cavity after avulsion of uterine wall at the time of myomectomy.

To Prevent Myometrial Avulsion…

Keep the myoma grasper away from the fundus when removing myoma segments, and avoid excessive traction on what may be a thin segment of myometrium.

Injuries can occur when the grasper perforates the uterus and bowel is inadvertently grasped.

Large injuries require laparoscopic repair.

Perforation is more likely in repeat procedures.

Perforation…

In the AAGL survey, the incidence of perforation was 14 per 1,000.

It was even higher during transection of lateral and fundal adhesions: 2 to 3 per 100.

Although perforation is more common with thermal energy sources, it may occur mechanically when scissors are used to transect a uterine septum, synechiae, or polyps.

Perforation…

Hysteroscopic view of perforation at the fundus. The small bowel is visible beyond the perforation at left.

When perforation occurs…

During the use of thermal energy, laparoscopy is necessary to assess the organs overlying the site.

During setup for laparoscopy, bring the hysteroscope near the area of perforation to inspect the bowel beyond the uterus.

Since the pelvis fills quickly with distention fluid, the hysteroscope can even be placed through the perforation to yield an excellent view of the undersurfaces of the bowel immediately adjacent to the injured area.

Disconnect the electrosurgical cord before doing this..!!!

Intra operative bleeding…

Bleeding is unlikely unless vessels are lacerated or injured in the cervical canal or lower uterine segment during dilation or deep ablation or vaporization.

Bleeding is more common when endomyometrial resection is performed with the wire loop electrode or during ablation or vaporization of fibroids.

To achieve hemostasis

1 ) Insert a Foley catheter with a 30-cc balloon into the uterine cavity, inject 15 to 20 mL (or more for a larger cavity) of fluid into the balloon, and observe the patient.

2 ) Pack the uterus.

1/2-inch–gauge packing that has been soaked in a dilute vasopressin solution.

(20 U [1 mL] in 60 mL Normal Saline).

Benefits of Vasopressin :

Before balloon tamponade or Packing the uterus,Inject very dilute vasopressin :(4 U [0.2 mL] in 60 mL normal saline)

directly into the cervix 2 cm deep, at the 4 and 8 o’clock positions.

Electrosurgical & Gaseous Complications

Most electrosurgical complications involve activation of an electrode at the time of perforation, or current diversion to the outer sheath.

To Avoid…

Avoid perforating the uterus by applying current only when the electrode is moving toward the operator, not the fundus.

To avoid return-pad injuries :

Keep the patient’s thigh completely dry; ensure that the pad is flat against the skin at application, with no bubbles or creases; and use only return electrode monitor (REM) dispersive pads.

Gas Embolism :

Carbon dioxide is a soluble gas, so these emboli generally resolve rapidly.

In contrast, room air emboli are more likely to be fatal.

To reduce risk of gas embolism :

Avoid Trendelenburg positioning

Remove last dilator just before inserting the resectoscope

Limit repeated removal - reinsertion of the resectoscope

Vaporizing myomas eliminates the need to remove fibroid chips

Intracervical injection of vasopressin may block gas from entering circulation.

Distension Media :

Continuously record inflow and outflow using the electronic monitor with the deficit alarm set to 500 mL.

Keep distention fluid at room temperature and monitor the patient’s core temperature continuously.

Significant fluid intravasation will lower the patient’s temperature, and this may be the first sign of fluid overload.

Perform operative hysteroscopy under spinal or epidural anesthesia so the anesthesiologist can continually assess the patient’s sensorium.

Confusion and irritability are early signs of dilutional hyponatremia.

Hysteroscopy is a technologically dependent surgery and before starting surgery every surgeon should have reasonably good knowledge of Hysteroscopic procedures.

Please put a board in your Hospital :

“ Your Safety Is Our First Priority. “

Safety First…

55drshashwatjani@gmail.com

Thank you

evidence based practical tips for office hysteroscopy by dr shashwat jani

dr shashwat jani

operative hysteroscopy

hysteroscopy evidence

operative procedures

office procedures

diagnostic hysteroscopy

field of office hysteroscopy

journal of evidence

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