Sunday-November 19, 2017 
    
      Home | Procedures | Pre-Surgery Form | Registration | Search | About Us  
 
FORBES magazine names YourSurgery.Com as one of it's "Best of the Web"
 
Hysteroscopy
and Resectoscopy

The hysteroscope is a lighted fiberoptic instrument used to diagnose abnormal pathology of the female uterus while a resectoscope is an electrical instrument that is passed through the hysteroscope to remove abnormal uterine tissue. With increasing technology many surgical procedures can be performed with the hysteroscope and resectoscope. Using the cervical canal as the opening passage to the uterus, many less invasive procedures can be performed in a safe and efficient manor.

Anatomy and Physiology

  • The uterus or womb is a pear shaped organ that is found in the female pelvis at the top of the vagina. It varies in size and shape depending on the hormonal and childbearing status of the woman. The uterus has a cavity, which is closed when the woman is not pregnant (Figure 1 and 2)
Figure 1 - Anatomy of the uterus and surrounding organs as seen in a section through the middle of the body. © C. ScaliciFigure 2 - Uterus as seen from in front. © C. Scalici
  • The inside lining of the uterus, called the endometrium, separates from the uterine wall each month. The vaginal bleeding that occurs is called the menses or period. The menses do not occur during pregnancy and normally continues until the menopause
  • The lowest portion of the uterus at the point that it connects to the vagina contains the neck of the uterus or cervix. The opening in the center of the cervix is the entrance to the uterine cavity
  • The Fallopian tubes are found at the upper end of the uterus. There is one Fallopian tube on each side of the uterus. These hollow tubes allow for the fertilized egg to travel to the uterus
    1. The ovaries lie just beneath the other end of the Fallopian tubes and contain the female's eggs. Each Fallopian tube hangs over the ovary like a hood
    2. When an egg leaves the ovaries, it is directed by the hood into the Fallopian tubes and then through the tubes into the uterus where the egg may implant into the uterine wall. The openings of the tubes into the uterus are called the ostia (Figure 3)
  • There are a series of ligaments that attach the uterus and Fallopian tubes to the pelvic wall. The blood vessels to the uterus and ovaries are contained within these ligaments
  • Lymph nodes are found near the uterus and along the blood vessels of the uterus. Lymph nodes are small glands about the size of a small nut that are part of the lymphatic system. The lymphatic system is found throughout the body and is composed of these nodes connected by thin channels (lymphatics) filled with a colorless fluid called lymph. This system is important since it acts as one of the first defenses against disease
  • In some patients there may occur congenital abnormalities of the uterus including a complete double uterus or a doubling of only parts of the uterus. Sometimes there is only one Fallopian tube
Figure 3 - Fibroid tumors in the submucosa (left) and muscle (right) of the uterus. © C. ScaliciFigure 4 - Ostium of a Fallopian tune as seen through the hysteroscope. Courtesy P. Corsi, MD

Pathology

  • Endometrial polyps are growths that develop from the lining of the uterus or cervix. Theses polyps generally are not cancerous. They commonly produce bleeding between menses
  • Submucous leiomyomas (fibroids) occur from the overgrowth of cells from the muscular portion of the uterus. Fibroids can grow next to the lining of the uterus. These are frequently called submucous fibroids (Figure 4-above). Abnormal bleeding, cramping and early pregnancy loss can occur
  • Uterine septum is a structure without blood vessels, which divides the uterus into two separate sides. Some women have reproductive problems with spontaneous abortions during the late first and early second trimesters of pregnancy
  • Removal of a lost intrauterine devise (IUD), which is a form of birth control that lies within the uterus to prevent pregnancy. A small string is found within the cervical canal for removal of the IUD. Rarely the string will be displaced and the IUD will become lost within the uterus
  • Intrauterine adhesions are scar tissue, which forms within the uterus. They most commonly occur from previous surgical procedures. Depending on the extent of the adhesions the patient may present with menstrual abnormalities such as no menstrual bleeding or very light menstrual cycles. Such adhesions may cause infertility
  • Plugs of debris or protein material may plug the Fallopian tubes and cause infertility
  • Heavy menses may occur that last greater that 7 days

History

  • The most common reason for hysteroscopy is to evaluate and sometimes treat abnormal uterine bleeding
  • Abnormal uterine bleeding can occur as women begin to age
  • Menses may become very heavy lasting for over 7 days in duration
  • Bleeding may become irregular with bleeding in between the menstrual cycle
  • Postmenopausal bleeding is abnormal. This may be a sign of uterine cancer
  • Medical or anatomical problems may be the cause of heavy or irregular bleeding
  • Medical conditions such as thyroid disease or bleeding disorders can cause irregularities in the cycle
  • Some women will change their cycle because of the hormonal level change that occurs in at the time of menopause
  • Other causes of abnormal uterine bleeding include cervical cancer, uterine cancer, uterine fibroids, endometrial polyps, endometrial hyperplasia, abnormal pregnancy or ectopic pregnancy (pregnancy within the Fallopian tube)

Diagnostic Tests

  • Blood tests such as a pregnancy test, tests of thyroid function, tests of blood coagulation and levels of female hormones are useful
  • Ultrasound of the abdomen is performed by placing a transducer probe on the abdomen. The transducer sends out a signal which is reflected off the organs and returned to the transducer. The contour of the uterus can be determined to find irregularities such as fibroids. The thickness of the endometrium can also be evaluated
  • Transvaginal ultrasound is performed by placing a transducer probe inside the vagina. The sound waves are able to detect the contour of the cervix, uterus and ovaries with great detail. With transvaginal ultrasound, the endometrial lining may be examined in detail looking for signs of submucosal (below the endometrium) fibroids, endometrial polyps, endometrial hyperplasia (thickening), uterine cancer or abnormal pregnancy. Cervical problems can also be identified such as endocervical (within the cervix) polyps
  • Pap smear may be used to determine any sign of precancerous or cancerous cells
  • Sonohysterography is performed by filling the cervix and uterus with fluid at the same time a ultrasound is used to evaluate the lining inside the uterus. The test is helpful in identifying the endometrium for polyps and submucosal fibroids
  • Hysterosalpingography is a special x-ray procedure in which a small amount of liquid that shows on X-ray is inserted inside the cervical cavity. This allows the radiologist to evaluate the contour of the uterus and whether the Fallopian tubes are open. This procedure is helpful to evaluate tubal blockage and intrauterine pathology such as adhesions, polyps and submucosal fibroids
    Indications/Contraindications
  • Diagnostic hysteroscopy is used to evaluate causes of abnormal uterine bleeding and to confirm other tests such as transvaginal ultrasound, sonohysterography or hysterosalpingography.
  • Operative hysteroscopy is indicated to treat the following
    1. Endometrial polyps
    2. Submucous Leiomyomas (fibroids)
    3. Uterine septum
    4. Removal of a lost IUD
    5. Intrauterine adhesions
    6. Cannulation of the Fallopian tube
    7. Resection or ablation of endometrium for heavy menses
    8. Selective endometrial biopsies
  • Hysteroscopy is contraindicated in infection of the uterus or Fallopian tubes

Surgical Procedure

  • The patient is placed on the operating table in stirrups
  • A gentle pelvic examination is performed to determine the size and location of the uterus
  • The vagina and cervix is cleaned with an antiseptic solution
  • A speculum is placed in the vagina and the top portion of the cervix is gently grasped with a straight instrument (Figure 5)
  • Local anesthesia (most commonly lidocaine - see Anesthesia) is used to numb the cervix
  • An instrument called a cervical dilator is placed into the cervical canal. After the smallest dilator is used, successively larger ones are used to dilate the cervix. Care is taken to determine the direction of the cervical canal to prevent perforation of the cervix or uterus (Figure 6)
Figure 5 - Speculum placed in the vagina. The cervix is grasped with a clamp. Note the submucosal fibroid tumor. © C. ScaliciFigure 6 - Dilator is used to dilate the opening in the cervix. © C. Scalici
  • An instrument then determines the uterine cavity size
  • Under direct visualization the hysteroscope is inserted though the cervical canal to evaluate the cervical canal, uterine cavity and the opening of the Fallopian tubes. Saline solution is continuously irrigated through the hysteroscope to wash out any blood or debris
  • Operative procedures may then be performed:
    1. Targeted hysteroscopic biopsy. After evaluating the entire cervical and uterine canal selective hysteroscopic biopsy may be performed to evaluate focal areas of endometrium, which may be suspicious of cancer. A small biopsy instrument is placed though the hysteroscopic canal to remove a biopsy sample
    2. Removal of endometrial polyps
      • Under direct visualization the base of the polyp is identified with the hysteroscope (Figure 7, left)
      • Using a resectoscope or semirigid scissors the base of the polyp is cut flush to the contour of the endometrial cavity
      • Once transected the polyp is removed thought the cervical canal and sent to the pathologist for evaluation
      • The hysteroscope is placed back into the cavity to make sure the entire polyp is removed (Figure 7, right)

       

    Figure 7 - (Left) Large endometrial polyp as seen through the hysteroscopeFigure 7 - (Right) Endometrial wall after removal of the polyp. Courtesy P. Corsi, MD
    1. Removal of submucous fibroids
      • Under direct visualization the base of the fibroid is identified with the hysteroscope (Figure 8, top)
      • Using a resectoscope, laser or semirigid scissors pieces of the fibroid are removed to the contour of the endometrial cavity (Figure 8, center and bottom)
      • Pieces of the fibroid are removed though the cervical canal
      • During this time the hysteroscopic fluid is monitored to prevent too much fluid being absorbed into the patient circulation
      • Sometimes the surgeon will use a laparoscope through the abdominal wall to safely remove the fibroid

       

      Figure 8 - (Top) Hysteroscopic view of a fibroid tumor.
      Figure 8 - (Center) Fibroid being removed piecemeal (chips of tissue) using a resectoscope.
      Figure 8 - (Bottom) Uterus wall after fibroid removal. Courtesy P. Corsi, MD
    1. Treatment of uterine septum
      • The hysteroscope is placed through the cervical canal
      • Under direct visualization with the hysteroscope the uterine septum is divided with the use of either semirigid scissors, resectoscope or fiber optic laser (Figure 9, left and right)
      • The division is performed in the middle of the septum going from side to side until the openings of both Fallopian tubes are seen
      • A laparoscope is also used during the procedure to monitor the operation and prevent perforation of the uterus
      • After the procedure a devise may be placed in the uterus to allow healing and prevent adhesions

       

      Figure 9 - (Left) Uterine septum. Arrowheads outline the edge of the septum. The left ostium is seen; the right ostium is behind the septum. Figure 9 - (Right) Scissors used for removal of the septum. Courtesy P. Corsi, MD
    1. Hyteroscopic treatment of intrauterine adhesions
      • Intrauterine adhesions occur following trauma to the endometrial cavity
      • The hysteroscope is inserted though the cervical canal.
      • Using semiriged scissors, laser or a thin wire resectoscope the adhesions are identified and cut
      • After all the adhesions are removed a catheter is placed within the uterine cavity to prevent formation of further adhesions.
      • Antibiotics and estrogen are given in the postoperative days
    1. Endometrial ablation (removal of the endometrium)
      • The hysteroscope is placed thought the cervical canal (Figure 10, left)
        1. Gas or liquid is placed within the uterus to expand the cavity
        2. Using an electrical loop or rollerball tool the lining of the uterus can be destroyed. As the loop or ball is pulled across the endometrial surface, an electrical current is applied to the surface to destroy the lining down to the muscular portion of the uterus (Figure 10, right)
        3. Alternatively a laser may be used remove the endometrium
      • For more complicated cases a laparoscope may be used to view the outside of the uterus to prevent perforation of the uterus
      • Another method involves inserting a soft flexible, silicone rubber balloon attached to a thin catheter
        1. The balloon is inflated with sterile fluid to expand the balloon to fit the inside of the uterus
        2. The fluid is heated to 87ºC (188ºF) and the temperature maintained for eight minutes and then the fluid and catheter are removed
        3. The lining of the uterus sloughs off over the next 7 to 10 days. (Figure 10, right)
    2. Removal of IUD
      • The hysteroscope is placed thought the cervical canal
      • A gas or liquid fluid is placed within the uterus to expand the cavity
      • The IUD which may be imbedded in the cavity wall is grasped with a tool though the hysteroscope
      • The IUD is then removed though the cervical canal
Figure 10 - (Left) Endometrium as seen through the hysteroscope. Figure 10 - (Right) Endometrial wall after thermalablation using the balloon technique. Courtesy P. Corsi, MD

Complications

  • There is no surgical procedure that is free of the possibility of complications
  • As with any surgical procedure there may be a complication of the anesthetic
  • Injury to the cervix with cervical laceration
  • Scarring of the endometrial lining
  • Infection of the uterus or Fallopian tubes
  • Uterine perforation (hole in the uterus) leading to possible bowel perforation or significant amount of bleeding into the uterus
  • Hemorrhage that may require a blood transfusion
  • Damage to bowel, ureter, bladder and Fallopian tube
  • In case of significant injury or bleeding, possible need to open the abdomen and suture the uterine wound
  • Possible need to remove the uterus (see Hysterectomy)

Care after the procedure

  • After the procedure the patient is taken to the recovery area for a short period of time before leaving for home
  • A patient should plan on having an escort for transport
  • The patient may experience some nausea from the anesthesia
  • Mild uterine cramping may be experienced. The surgeon may prescribe pain medication for the discomfort
  • It is not uncommon to experience vaginal bleeding and discharge for some time
  • Most commonly the patient may resume normal activity after a few days
  • The patient should refrain from placing anything inside the vagina until instructed by the doctor because the cervix has been opened and this may allow bacteria to pass up into the uterus
  • The endometrium will build up within the next month. The next menstrual cycle may not be regular. It may be late or early
  • The patient should inform the doctor if experiencing any of the following:
    1. Fever
    2. Increasing abdominal pain
    3. Heavy vaginal bleeding (greater than a pad per hour)
    4. Foul smelling vaginal discharge