ISARCON 2017 Manual of Operative Hysteroscopy Narendra Malhotra, Maninder Ahuja, Poonam Loomba
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Preoperative Diagnosis and Case Selection for Operative Hysteroscopy1

Vimee Bindra,
Jatinder Chadha
Hysteroscopy is the gold standard in the diagnosis and the treatment of intrauterine lesions. Hysteroscopic surgeries have revolutionized and changed the face of endoscopic and minimally invasive surgeries in gynecological disorders.
The success of hysteroscopy depends on:
  • Choice of anesthesia
  • Type of instrumentation
  • Case selection and
  • Operator expertise.
On hysteroscopy one visualizes the following:
Cervical canal
Stenosis, polyp, false passages
Uterine cavity
Normal, small, cavity with lesions such as polyp, myoma, Müllerian abnormalities like septum, unicornuate, bicornuate or intrauterine adhesions
Atrophic, fluffy, strawberry, with increased vascularity
Ideally should be seen in one plane on panaromic view. It may be pin point ostia, blind ostia (no opening only depression is seen), or covered with adhesions
Preoperative evaluation of a case is very important before taking up the patient for operative hysteroscopy. Different investigations which help us reaching a diagnosis are:
  • Ultrasound 2D (with or without Doppler) and 3D
  • Saline infusion sonography (SIS)
  • Hysterosalpingogram
  • Magnetic resonance imaging (MRI)
The advantages and disadvantages of each imaging modality should be taken into consideration. Hysterosalpingogram (HSG) gives a better tubal patency and suboptimal uterine cavity information but MRI on 2the other hand gives accurate information about the uterine cavity but does not tell us about the patency of tubes.
Endometrial Polyps Develop as Solitary or Multile, Soft, Sessile Pedunculated Tumors Containing Hyperplastic Endometrium
  • Signs and symptoms: Infertility B/L… tubal blocks, bleeding, infections, endometritis…pain
  • Best seen in proliferative phase on ultrasonography (USG).
A diagnosis of electrophysiology (EP) is suspected when a hyper echogenic SOL with regular contours, occupies the uterine lumen either partly or full, outlining the endometrial walls on which it rested, surrounded by a small hypoechoic halo.
Electrophysiology widens the endometrial echo and gives appearance of increased endometrial thickness.
Benign endometrial polyps appear well-defined and are uniformly homogenous or hyperechoic. On color Doppler there is a feeding vessel seen.
Saline infusion sonography works better than TVUS or 3D for diagnosis of endometrial polyps and it also tells as whether it is sessile or pedunculated polyp. During fluid instillation, the polyp undulates as the anechoic fluid surrounds it. It is very easy to make exact location, size, numbers and stalk of polyp by SIS.
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Fig. 1: 2D USG picture of endometrial polyp. (1 and 2 show the size of the polyp).
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Fig. 2: Doppler with a feeding vessel to the polyp.
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Fig. 3: SIS picture of endometrial polyp (arrows–submucous polyps).
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Fig. 4: Hysteroscopic picture of endometrial polyp.
Result as a result of trauma to a recently pregnant uterus usually following:
  • Abortion/dilation and curettage (D&C)
  • Postpartum curettage
  • IUCD, CS, myomectomy, hysteroscopy
  • Vulnerable period: 1 to 4 weeks following delivery or abortion surgery
  • Infection: Genital TB, schistosomiasis
  • Pelvic irradiation.
Therefore a history of scanty menses, amenorrhea, dysmenorrhea and any of these events points to a probability of adhesion.
  • Trauma to basalis layer, causing uterine walls to coapt to each other.
USG Diagnosis of Intrauterine Adhesions
  1. In the luteal phase, if the endometrium is less than 2 mm
  2. Uterine cavity is asymmetric on a transverse scan
  3. Echogenic area is seen in cavity.
3D USG tells the extent of cavity obliterated, location of adhesions within the cavity and character of adhesions.
Saline infusion sonography is particularly helpful in case of adhesions as the acoustic window provided by the fluid helps us to distinguish scars and normal endometrium.
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Fig. 5: USG picture showing intrauterine adhesions.
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Fig. 6: Hysteroscopic picture of intrauterine adhesions.
Adhesions may appear as thin or thick bands bridging between and distorting the endometrium. There is a limitation when synechia involves the cervical canal and fluid cannot travel upwards.
Sonographic diagnosis of fibroids is quite varied and depends on their location. Fibroids may appear as iso-, hypo- or hyperechogenic. When echogenic, they may be seen distorting the contour or uterus as in subserous fibroids or distorting the endometrium in case of submucous fibroids. When they are intramural, color Doppler helps in identifying them. When hypoechogenic or hyperechogenic its easier to identify them. Now a days we can determine the exact location, number and size of fibroids and take a decision which case is suitable for hystero-scopic myomectomy. Color Doppler demonstrates vascularization on the periphery of the myoma with RI of 0.5 with better delineation of the tumor.
Using TVUS myoma is visualized as low echogenic area whereas SIS reveals the contour of the fibroid, allowing us to see the protrusion into the cavity. When planning hysteroscopic myomectomy for submucous fibroid, it is prudent to know the exact size, location, extent of protrusion in the cavity. As it is very difficult to remove fibroids hysteroscopically, if protrusion in the cavity is less than 50%.6
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Fig. 7: Hysteroscopic picture of submucous fibroid with more than 50% protrusion in the cavity.
Removal of fibroids that distort the uterine cavity may be beneficial in infertile women with unexplained infertility and in women undergoing in vitro fertilization.
(Fertil Steril. 2004 Mar;81(3):582-587) 3D Ultrasound, Hysteroscopy
Higher pregnancy rates in women with intramural fibroids who undergo myomectomy—clinical pregnancy rate—56% as compared to Women who did not undergo myomectomy—41% (Gynecol Endocrinol 2006;22:106-109).
Submucous fibroidsaccount for 5–10% of all myomas.
Type 0 = Fibroid is totally (100%) in uterine cavity
Type 1 = Fibroid is > 50% within uterine cavity
Type 2 = Fibroid is < 50% within uterine cavity
  • Fibroid ≤ 3 cm
  • Type 0 or Type 1
  • No more than 2 submucous fibroids7
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Fig. 8: Ideal patient for hysteroscopic M/muterine size = 6 weeks.
Hysteroscopic Management of Fibroids
  • Tubal patency must be checked prior to hysteroscopic myomectomy
  • Any pelvic surgery including lap myomectomy should be done after hysteroscopic procedure.
Preoperative Preparation
  1. Agents: Drugs which cause decrease in size and volume of fibroid, decrease vascularization and hence decrease intraoperative bleeding and surgical time.
    1. GnRH analogs given for 2–3 months for large myomas. Not required for solitary myoma less than 3 cm. Side effects like hypoestrogenism, cost.
      Progestogens, danazol and oral contraceptives. Used in frequently, cannot produce endometrial atrophy equivalent to facilitate hysteroscopic resection the endometrium should have limited thickness and vascularization. Several options are available.
  2. Perform a hysteroscopy in early proliferative state.
    1. Pharmacological that associated with GnRH analogs, neither do they have any effect on the volume and vascularization of the myoma. Although the side effects are more tolerable than GnRH analogs they are much less effective due to pseudodecidualization of the endometrium.
Tubal disease accounts for 25–35% of all infertility cases. Salpingitis is believed to account for more than 50% of these cases. Although it 8is occasionally in multiple sites, tubal blockage usually involves the proximal, mid or distal portion. Proximal blockage of the fallopian tube occurs in 10–20% of women with tubal disease and is mainly due to salpingitis isthmica nodosa (SIN), chronic salpingitis, intratubal endometriosis, amorphous material (e.g. mucus plugs), or spasm.
The difference between tubal obstruction and tubal occlusion: obstruction is a time limited process that may be reversible, such as tubal spasm or plugging by amorphous material as occlusion is organic pathology that is permanent, such as SIN occur primarily around the intramural and proximal isthmic endosalpinx. The first ones are amenable to cornual cannulation.
Proximal tubal obstruction can be corrected with the help of hysteroscopic tubal cannulation. HSG is still the gold standard to identify the tubal blocks but during the procedure we have to identify whether its proximal, mid tubal or distal block. Only proximal acquired blockages can be corrected by tubal cannulation while doing hysteroscopy.
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Fig. 9: HSG picture showing tubal block (arrows: cornual block).
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Fig. 10: Tubal cannulation for proximal tubal block.
Uterine Malformations
Sonography is the first line of investigation to evaluate external and internal uterine morphology. Sonographic studies of uterine malformations should always begin with transabdominal scan with partially filled bladder to assess the uterine contour, accessory horn or any other mass compressing the uterus. Also to look for lateral masses this may be a rudimentary horn or contralateral uterus. The cavity of uterus and its contour may also be visualized and there may a complete existence of another cavity as seen in case of didelphys uterus. Better assessment and delineation of uterine cavity is obtained on transvaginal sonography.
Three-dimentional ultrasonography is the most promising imaging modality for distinguishing septate from bicornuate uterus and so is the MRI. This is very important so as to avoid unnecessary laparoscopy. Conventional ultrasound, SIS, HSG cannot differentiate between septate and bicornuate uterus. Now with technical advances 3D USG is readily available and should be the choice before we go for MRI.
Magnetic resonance imaging allows accurate demonstration and morphologic classification of uterine abnormalities. The following important parameters can be noted in MRI uterine size, corneal distance, fundal contour, anatomy, presence of uterine or vaginal septum. Main advantage of MRI is that it can distinguish between septate uterus from bicornuate and septate uterus can be corrected surgically by hysteroscopy while bicornuate 10cannot be and we can avoid one unnecessary laparoscopy in such cases. Another advantage of MRI is it can identify associated renal lesions which may be associated with Müllerian abnormalities.
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Fig. 11: HSG picture of septate uterus.
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Fig. 12: 3D picture of septate uterus.
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Fig. 13: Hysteroscopic picture of septate uterus.
(It is very difficult to determine by HSG whether its septate or bicornuate so doing a 3D imaging helps identifying the type of anomaly.)
Septate uterus is the most common Müllerian duct anomaly, with an incidence of 50–80%. The differentiation between septate and bicornuate uterus is very important. Septate uterus, the anomaly carrying the worst prognosis and associated with high incidence of miscarriage and habitual abortion can easily be treated by hysteroscopy. Hysteroscopic metroplasty of the septate cavity decreases the rate of miscarriage from 85% to 15% and improves the term birth rate from less than 10% to more than 20%. On the other hand, bicornuate uterus, which has a less adverse impact on pregnancy, there is no strong evidence that surgical intervention is beneficial.
Transvaginal 3D ultrasonography is accurate for diagnosis and differentiation between septate uterus and bicornuate uterus. We recommend 3D transvaginal ultrasonography as the first and mandatory step in the assessment of the uterine cavity in patients with a suspected septate or bicornuate uterus, especially before planning surgery. MRI should be preserved for patients in whom 3D-TVS not possible like virgins.