Hysteroscopy: The Basics, feat. Andrey Dolinko, MD

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Today we’re joined for a first part of a two-part talk on hysteroscopy with special guest, Dr. Andrey Dolinko! Andrey was our co-resident at Brown and is currently a second-year fellow in reproductive endocrinology and infertility at the University of Pennsylvania.

What is hysteroscopy?

  • Ancient Greek hustérā, “the womb” & Skopéō - to see 

  • History (Rudic-Biljic-Erski et al 2019)

    • First developed in mid-19th century

      • Pantaleoni performed hysteroscopy on a 60yo woman to diagnose an endometrial polyp and treated it with silver nitrate. Used cystoscope developed by Desormeaux that used series of concave mirrors and light source

    • Early 20th century

      • Carbon dioxide used as first distention medium in 1925

      • 1926 - two-channel hysteroscopy (introduction and suction of distention media)

      • 1927 - operative channel introduced

      • 1928 - irrigation system

      • 1930s - fixed optic systems and fluid delivery systems

    • Second half of 20th century

      • Fiberoptic cable added to hysteroscope in 1965 (cold xenon light)

      • Operative hysteroscopy and use of different distention media takes off in 1970s

      • Videoendoscopy started in 1982

      • 1996 - Bettocchi office hysteroscope

      • 1990s - resectoscopes, first monopolar and then bipolar

    • 21st century

      • Morcellators - i.e., MyoSure

How does hysteroscopy work?

  • Contraindications

    • Pregnancy

    • Cervicitis

    • Active PID

    • Comorbidities that may be exacerbated by intravascular volume expansion

  • Timing

    • Reproductive-aged women: proliferative phase CD5-12, ideally not during active bleeding

    • Exclude pregnancy!

    • Post-menopausal-aged women: any time

  • Positioning

    • Dorsal lithotomy position

    • Avoid steep trendelenburg because risk of air embolism

      • Causes negative pressure in pelvic veins

  • Patient prep

    • Vaginal prep w/4% chlorhexidine gluconate soap or providone-iodine

  • Antibiotics

    • not indicated

  • Anesthesia (ranges)

    • None

    • Can do PO/IM/IV NSAIDs, benzos

    • Paracervical blocks

    • Regional anesthesia

    • IV sedation

    • General LMA

    • GETA

  • Vaginal instruments

    • Speculums and retractors

    • Tenaculum

    • Dilators

    • Curettes

  • Hysteroscope

    • Hysteroscope components

      • Scope

        • Eyepiece

        • Barrell

        • Objective lens

          • 0 to 70 degrees (typically 0 or 30)

      • Inner sheath w/inflow

      • Outer sheath w/outflow for operative scopes

      • Light source

        • Most-commonly Xenon or LED these days

      • Camera-head and video monitor

    • Diagnostic

      • Flexible

      • Rigid

    • Operative

      • Rigid operative scope

      • Scopes to be used with hysteroscopic tissue removal systems

      • Resectoscopes

    • Distention media

      • Fluid choice

        • Historical

          • Gas - CO2

          • High-viscosity 32% Dextra (Hyscon)

        • Current

          • Low viscosity

            • Electrolyte-rich

              • Saline

              • LR (rarely)

            • Electrolyte-poor

              • 5% Mannitol

              • 3% Sorbitol

              • 1.5% Glycine

      • Fluid deficit

        • A reflection of potnetial systemic fluid absorption

          • Surgical disruption of endometrium and myometrium provides direct access to sinus/vessels

            • If intrauterine pressure greater than vascular pressure → intravasation -> a fluid bolus!

        • Where else may the fluid be going?

          • Out the tubes

          • Out the vagina

          • Onto the floor

    • Fluid management systems help to determine deficit

      • Simple

        • Gravity

        • Pressure bag

      • Automated systems

        • Can set fluid deficits for automatic calculation

        • Uterine pressure setting