SAFETY MEASURES IN

OPERATIVE HYSTEROSCOPY

Osama M Warda MDProfessor of OB/GYN

Mansoura University-EGYPT

Background

� A multicenter study of 92 centers and over 21,000

operativehysteroscopy reported a complication rate 0.22%.

The most common complication was uterine perforationThe most common complication was uterine perforation

(0.12 %), followed by fluid overload (0.06 %),

intraoperative hemorrhage (0.03%), bladder or bowel injury

(0.02 %), and endomyometritis (0.01 %).Aydeniz et al (2002)

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Safety Measures; topics

� General golden roles

� Approach to outpatient procedure

� Endometrial preparation� Endometrial preparation

� Antibiotic prophylaxis

� Safe entry and cervical negotiation

� Distending media management

� Operative challenge.Safety measures in op. Hysterosc.

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General Golden Rules

(Hamou 1993)

1. Proper patient selection.

2. Surgeon’s experience.(very important)2. Surgeon’s experience.(very important)

3. Good instrumentation (e.g.monopolar vs bipolar ).

4. Clear visualization with continuous uterine distention.

5. Concurrent laparoscopy / ultrasound.

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Approach to outpatient hysteroscopy

� The most common reasons for failure to complete an outpatient hysteroscopy are painpain, cervicalcervicalstenosisstenosis, and poorpoorvisualization.visualization.stenosisstenosis, and poorpoorvisualization.visualization.

� Advance in instrumentation, including narrowcaliberhysteroscopes, and use of local anesthetic decreased patient discomfort & facilitated an ambulatory procedure. (Readmam et al,2004)

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Endometrial preparation

� For women with regularmenses, the proliferative phase is best for visualization of the uterine cavity.

� For women with irregularmenses, thinning of the � For women with irregularmenses, thinning of the endometriumis considered before operative hysteroscopic resection of myomaor endometrial ablation for better visualization, less bleeding and less operative time (Grow DR& Iromloo K 2006 )

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Endometrial Thinning, cont.,

� Many pharmacological agents can be used

for endometrial thinningsuch as COCs, for endometrial thinningsuch as COCs,

progestins, desogestrel, raloxifene, all are

safer than GnRhagonists or danazoles .

(Cicinelli et al 2007)

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Prophylactic Antibiotics

Antibiotics are not routinely administered

during hysteroscopy for prevention of surgical during hysteroscopy for prevention of surgical

site infection or endocarditis since post-

hysteroscopy infection occurs in less than 1%

of women (ACOG Practice Bulletin No. 74, Obstet Gynecol 2006)

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Safe Entry and Cervical Negotiation

� Narrow caliber hysteroscopes (≤5mm) typically

don’t require cervical dilation, particularly in

premenopausal women. If possible, mechanical

cervical dilation should be avoidedsince it can be

painful. (Readman E, Maher PJ: 2004)

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Safe Entry and Cervical Negotiation;cont.

� For patients who require cervical dilation, cervical preparation with misoprostol(200-400mcg)may be sufficient on its own or can facilitate mechanical sufficient on its own or can facilitate mechanical dilation. ( Crane JM, Healey S: 2006).

� The vaginal route for misoprostol may be more effective than oral. (Batukan C etal:2008)

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Safe Entry and Cervical Negotiation; cont.

� In postmenopausalwomen, randomized trial data have not consistently demonstrated that preoperative misoprostoldecreases the need for preoperative misoprostoldecreases the need for mechanical cervical dilation.(da Costa AR et al:2008), (BarcaiteE et al :2005).

� Pretreatment with vaginal estrogen (25mcg E2 daily) for 2 weeks before surgery may augment the cervical dilation caused by misoprostol. (Oppegaard KS et al :2010)

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Distending media management

� AAGL Practice guidelines for the management of

hysteroscopic distending media (2013):

� 18 evidence based recommendations were � 18 evidence based recommendations were

published in the Journal of Minimally Invasive

Gynecology, Vol.20, No.2, March/April 2013.

� Some of these guidelines will be tabulated in the next 3 slides.

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AAGL Practice guidelines for the management of

hysteroscopic distending media (2013):

EVIDENCE LEVEL

RECOMMENDATION

A1-Intra-cervical injection of 8 mL of a dilute vasopressin solution (0.05 U/mL) immediately prior to the procedure reduces distending media absorption during resectoscopicsurgery.absorption during resectoscopicsurgery.

A2-The uterine cavity distention pressure should be the lowest pressure necessary to distend the uterine cavity and ideally should be maintained below the mean arterial pressure.

B3- Excessive absorption of hypotonic fluids such as glycine (1.5% or sorbitol 3%) can result in fluid overload and hypotonic hyponatremia, causing permanent neurologiccomplications or death.

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AAGL Practice guidelines for the management of

hysteroscopic distending media (2013):

B4- The risk of hypotonic encephalopathy is greater in reproductive-aged women than in postmenopausal women.

B5- When compared with electrolyte free media, saline B5- When compared with electrolyte free media, saline appears to have a safer profile

B6- Excessive absorption of isotonic fluids such as saline can cause severe complications. Continuous and accurate fluid monitoring is mandatory.

B7- The risk of systemic absorption varies with the procedure and increases when myometrial integrity is breached (e.g. with myomectomy).

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AAGL Practice guidelines for the management of

hysteroscopic distending media (2013):

B8- Due to the conflicting evidence regarding their impact on

the volume of fluid deficit during resectoscopic surgery, the

decision to use GnRH agonists should be the provider’s

decision. decision.

CRecommendations from 9 to 18 are Level C evidence and included :

-CO2 use only in diagnosticprocedures

-Air purge out the system before and during operative procedure

-Limiting preoperative oral or iv hydration

-Obtain pre-resectoscopebase-line electrolyte levels

-Use automatedfluid managemet systems

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Hysteroscopic Myomectomy

� Pre-operative evaluation with SIS, or combined office hysteroscopy and TVS to discover associated pathology (egadenomyosisor polypi) associated pathology (egadenomyosisor polypi) (Lasmar et al 2005)

� ESH types 0 , I . (Wamsteker K et al 1993), (Lasmar et al 2005).

� Diameter ≤5cm carries better prognosis.(Hart R et al 1999).

� Uterine cavity length ≤ 10cm. (Wamsteker et al 1993)

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Hysteroscopic Myomectomy cont,:

� Intra-operative sonographic guidance.(Coccia et al,2000)

� Two-step procedures if large, multiple,typeII

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� Two-step procedures if large, multiple,typeII

� Concomitant polypectomyduring hysteroscopic

myomectomy does not increase operative duration

or complication.(Linda D Bradly 2012).

Hysteroscopic Metroplasty

� Various instruments including semirigid or rigid scissors (7F) or unipolar wire loop(8mm), urologic resectoscope(21-26F), Versapoint® bipolar electrode (1.6; 5mm sheath); or lasers (KTP/532), (Nd:YAG ),( argon).sheath); or lasers (KTP/532), (Nd:YAG ),( argon).

� Use of any of them is associated with good success rates and infrequentcomplications.

� Use of micro-scissorsor bipolarelectrodes decrease operative time. (Colacurci et al 2007)

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Hysteroscopic Adhesiolysis:

� In severeadhesions :(to avoid perforation)

1. Concurrent ultrasound guide cervicaldilation

avoiding falsepassage. (Marcelle I Cedars 2012)

2. Concurrent laparoscopy (Levine & Neuwirth;1973)

3. Concurrent fluoroscopy ( Thomson et al;2007).

4. Multi-stage surgery (Zikopoulos et al 2004)

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Endometrial Ablation

� 1st generation (resectoscopic) : no significant difference in complicationsbetween ablation and resection.(Lethaby et al 2009)resection

� 2nd generation (non-resectoscopic) ; (safer)

most of these techniques don’t require hysteroscopy. Requires less experience and less operative time.

(Deb et al 2008)

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The surgeon’s skill remains the best safety measure in operative

hysteroscopy.

Safety measures in op. Hysterosc. O Warda 21

hysteroscopy.