More than 100 years ago, Pantaleoni performed the first hysteroscopy using a tube and a candle as a light source to remove a nasal polyp and an endometrial polyp in the same woman. Hysteroscopy has come a long way since then. With increasing sophistication of instrumentation and enhanced operator expertise, the indications for diagnostic and operative hysteroscopic surgery cover a wide variety of conditions. Currently, hysteroscopy is the gold standard for the diagnosis and surgery of several intracavitary lesions. Additionally, hysteroscopy gives an extremely good clue to endometrial pathology and is diagnostic of atrophic endometritis even when ‘no tissue obtained’ on curettage, strongly indicative of tuberculosis (Nettle’s syndrome) and adenomyosis depending on specific findings on directly looking inside the uterus.
The advantage over other diagnostic procedures like transvaginal routine (TVS) and saline-infusion sonography (SIS) and hysterosalpingography (HSG) is the ability of the hysteroscopist to see-and-treat at the same time.
The indications for hysteroscopy are all causes of Abnormal Uterine Bleeding: post-pregnancy complications like polyps, retained products and follow up of molar pregnancy; post-menopausal bleeding when endometrial thickness is ≥ 4 mm; severe anaemia with menorrhagia even with normal sonography; abnormal ultrasound findings; in cases of endometrial cancer for endocervical evaluation; in DUB when medical treatment over 3 months fails, with several previous D&Cs and especially when endometrium is secretory.
Infertile patients require hysteroscopy in all situations where there are abnormal findings on sonography and HSG and it is mandatory before IVF because removal of even very small submucous fibroids before IVF doubles the pregnancy rate as compared to controls. Hysteroscopy is excellent for surgical treatment of intracavitary lesions like polyps, submucous myomas, septum, intrauterine adhesions, foreign bodies like IUDs, heterotopic bone, broken cannula and for cannulation of tubes. The results of Operative Hysteroscopy are far better than open procedures in terms of cure rates, recurrence of problem, fertility, complications, hospitalization, requirement of anaesthesia, return to normal activity, vaginal delivery over caesarean delivery rates and overall satisfaction.
Diagnostic Hysteroscopy requires a telescope fitted with a sheath to allow distension of the uterine cavity. Small diameter telescopes allow Office Hysteroscopy without requirement of cervical dilatation and anaesthesia. A fibreoptic cable attached to the light port on the sheath filters out the infra-red component of light from the light source to allow ‘cold light’ for viewing without ‘cooking’ the tissues. Through a side port on the sheath operative instruments of 5 Fr: scissors, grasper, needle, screw and electrodes, can be passed for operative work at the same sitting. For large pathology, the continuous flow resectoscope must be used which allows larger electrodes to be attached for faster surgery.
Most of the hysteroscopic work at this centre is done as Day-Care procedures under local anaesthesia with i/v sedation using normal saline and pressure bags for distension of uterus. All hysteroscopies are planned during the post-menstrual phase unless it is a diagnostic hysteroscopy which I wish to combine with endometrial biopsy so that two procedures on the same patient are avoided. I always cover the patient with antibiotics – simple 1st generation cephalosporins for diagnostic work, co-amoxyclav + metrogyl for operative hysteroscopy and good, appropriate antibiotics for high risk situations like valvular disease (SABE prophylaxis), Diabetes Mellitus, previous PID, patient on corticosteroids.
This presentation demonstrates, by video clips, different types of hysteroscopic surgeries as well as different hysteroscopic procedures for the same pathology using blunt dissection, scissors, forceps and electrocautery – both as day care procedures and resectoscopic surgery, in admitted patients, using monopolar current as well as bipolar intrauterine electrosurgery in resection and vaporization techniques.