Operative Hysteroscopy

Operative hysteroscopy is a minimally invasive gynecological procedure in which an endoscopic optical lens is inserted through the cervix into the endometrial cavity to direct treatment of various types of intrauterine pathology. Historically, urologists used the resectoscope to perform a transurethral prostatectomy. This instrument was later modified to accommodate gynecological applications. Operative hysteroscopy became popular after improvements in endoscopic technology and instruments in the 1970s and after the introduction of fluid distension media in the 1980s. ^[1] Since that time, the development of new hysteroscopic instruments, fiber optics, and digital video equipment has continued to provide more varied, efficacious, and less invasive procedures. The introduction of smaller-diameter hysteroscopes has allowed operative hysteroscopy to become a predominately office and outpatient procedure.

Abnormal uterine or heavy menstrual bleeding

Hysteroscopy is frequently used in the evaluation of abnormal uterine bleeding (AUB) or heavy menstrual bleeding (HMB), especially in cases in which prior studies (ie, endometrial biopsy and pelvic ultrasound with or without saline infusion into the endometrial cavity) are equivocal or demonstrate pathology. In cases in which anatomic abnormalities cause AUB, operative hysteroscopy allows for simultaneous diagnosis and treatment. ^[2] In women with idiopathic menorrhagia who do not desire future fertility, concomitant endometrial ablation may be performed during hysteroscopic procedures (ie, roller ball, laser, and hydrothermal ablation) or after hysteroscopic procedures (ie, NovaSure, Thermachoice, and cryoablation). ^{[3, 4]}

A discussion of the evidence behind and technique of the various methods of ablating the endometrium is beyond the scope of this article and is discussed in Hysteroscopy.

Submucosal leiomyoma

Hysteroscopic removal of submucosal fibroids is indicated if they are thought to be the etiology of AUB or infertility. ^{[5, 6, 7]} Submucosal leiomyomas are classified by the European Society for Gynaecological Endoscopy as type 0, 1, or 2. Type 0 submucosal fibroids are entirely located within the endometrial cavity, whereas type 1 fibroids have an intramural component of less than 50% of the fibroid’s diameter. Type 2 submucosal fibroids have an intramural component that comprises more than 50% of the diameter and typically require resection via laparotomy or laparoscopy.

A hysteroscopic myomectomy is most successful for type 0 and 1 submucosal fibroids. ^{[8, 9, 10]} However, following what may appear to be a complete resection, the residual intramural component of a fibroid may deliver into the endometrial cavity. Large submucosal leiomyomas with a generous intramural component may require multiple separate operations to remove the entire fibroid. ^[11] In fact, it has been noted that 15-20% of hysteroscopic myomectomies require a subsequent surgery to treat persistent symptoms or residual tumor. ^{[12, 13]} Prior to proceeding with the operation, a complete characterization of the patient’s anatomy with a diagnostic hysteroscopy, saline infusion sonohysterogram (SIS), or pelvic MRI is recommended. Concurrent endometrial ablation has been described and may be considered for women who do not desire future fertility. ^[14]

Uterine polyps

Endometrial polyps can cause AUB and may also be implicated in cases of infertility. Studies indicate that hysteroscopic polypectomy improves fertility outcomes. ^{[15, 16, 17, 18]} In addition, endometrial polyps in patients with risk factors for endometrial carcinoma have shown a propensity for malignant transformation. ^{[19, 20]} Thus, the removal of polyps noted by diagnostic hysteroscopy or sonography is indicated.

Uterine septum

A uterine septum is the embryologic result of incomplete medial regression of the Müllerian ducts following fusion in the midline and may be incidentally noted by hysterosalpingogram (HSG), SIS, or pelvic MRI, or during the work-up of infertility or recurrent pregnancy loss (RPL). ^[21] Uterine septa are noted to be a major etiology of RPL and resection significantly improves live birth rates. ^[22] Historically, uterine septum resection was performed via a laparotomy and hysterotomy incision with significant morbidity. Laparotomy has largely been replaced by hysteroscopy as a less morbid intervention for uterine septa. ^{[23, 24, 25]}

Lysis of adhesions

Intrauterine adhesions (IUA), synechia, or Asherman syndrome is a result of obstetrical or nonobstetrical instrumentation of the uterus or infection of the urogenital tract. Uterine adhesions can lead to AUB, infertility, or RPL, and are diagnosed by HSG or SIS. ^[26] Hysteroscopic resection is the standard treatment of symptomatic intrauterine adhesions. In cases of infertility or RPL caused by uterine synechia, the density of the lesions and amount of endometrial obliteration directly affect subsequent pregnancy and live birth rates following adhesiolysis. ^{[26, 27, 28]}

Cannulation of fallopian tube ostia

Proximal fallopian tube occlusion is usually noted on HSG during the work-up of infertility and has various etiologies, including pelvic inflammatory disease (PID), tubal spasm, endometriosis, salpingitis isthmica nodosa, polyps, and mucus-plugging, or tubal debris. ^[29] Hysteroscopic proximal tube cannulation can be performed to open blocked tubes and is typically done concurrently with laparoscopy so that the possibility of distal tubal disease can be evaluated and tubal patency can be confirmed with chromopertubation. ^{[29, 30]}

Removal of a foreign body

A retained intrauterine contraceptive device (IUD) is the most common uterine cavity foreign body encountered; however, another rare etiology is a residual fetal bone following pregnancy termination. ^[31] Inability to locate IUD strings is occasionally encountered and is commonly a result of the strings being cut too short following placement. In addition, an IUD may migrate after placement or become embedded in the myometrial wall during insertion or after prolonged use. ^[32]

Obtain ultrasonographic images, and if needed, other radiologic studies, to locate the IUD before any attempts at retrieving the device. ^[33] Various procedures and tools can help the clinician to remove IUDs with missing strings, including hook devices and suction curettes, grasping tools, and thread retrieval devices. Once the IUD has been retrieved, inspect the device to ensure it's been removed in its entirety. ^[33]

Hysteroscopy can also be used to locate, grasp, and remove the foreign body from the uterine cavity. ^{[31, 32, 34]} Because an IUD may have also perforated the uterine wall, abdominal imaging should be performed prior to hysteroscopy to aid in device localization. The use of concurrent laparoscopy may facilitate removal for migrated, perforated, or deeply embedded devices. ^[32]

Sterilization

Hysteroscopic alternatives to laparoscopic or mini-laparotomy sterilization techniques that can be performed in the outpatient setting with minimal or no anesthesia are now available. ^{[35, 36, 37]}

Essure (Conceptus) is a procedure whereby microinsert coils comprised of nickel-titanium (nitinol) surrounding polyethylene terephthalate (PET) fibers are hysteroscopically placed into the proximal fallopian tubes. The coils hold the device in place while the PET fibers incite a fibrotic in-growth of tissue resulting in permanent occlusion of the tubal lumen. ^[38]

The Essure device is successfully placed in 88-95% of cases and has a failure rate comparable to laparoscopic sterilization techniques. ^{[39, 40, 41]} In a retrospective study of over 4,300 ambulatory cases performed at one center, the most commonly reported complication was vasovagal syncope (1.9%); other rare complications included device expulsion (0.4%), myometrial placement (0.06%), migration into the peritoneal cavity (0.04%), and PID (0.04%). ^[42] If microinsert expulsion is suspected, the coil should be localized by fluoroscopy, hysteroscopy, or laparoscopy and removed; a new device should be reinserted if desired. In postmarketing evaluations, 64 (approximately 0.1%) unintended pregnancies have occurred out of approximately 50,000 Essure procedures performed. ^[43]

There are also reports of Essure being used off-label to occlude hydrosalpinges prior to in vitro fertilization when laparoscopy or salpingectomy is contraindicated or impossible. ^{[44, 45]}

In April 2018, the US Food and Drug Administration ordered restrictions to the sale and distribution of the Essure permanent contraceptive device in order to ensure that all women are provided with adequate risk information so that they can make informed decisions whether to use the permanent contraceptive. On December 31, 2018, Bayer stopped selling and distributing the Essure device in the United States. As of December 31, 2019, all unused Essure units should have been returned to Bayer so that they are no longer available for implantation. ^[46]

Another hysteroscopic sterilization technique termed Adiana (Hologic) involves the application of thermal energy to the proximal fallopian tube followed by placement of a biocompatible silicone elastomer matrix via disposable catheters. Over the following few months, a wound healing mechanism of tissue in-growth into the matrix results in permanent tubal occlusion. ^[38] Success rates of bilateral placement and occlusion on subsequent HSG for Adiana are comparable to that of Essure. ^[38] Adiana was noted to have a 2-year cumulative failure rate of 1.82% in the phase III clinical trial. ^{[47, 48]} As part of the settlement of the patent infringement lawsuit between Conceptus and Hologic, Adiana was removed from the market in 2012. Although the Adiana devices are no longer for sale, stockpiles continue to be used by some providers.

Following either procedure, an HSG is performed after 3 months to confirm tubal occlusion.

The patient should be instructed to use an alternate form of contraception during this period. ^[43] If complete tubal occlusion is not documented by HSG, repeat HSG should be performed in an additional 3 months. Continued tubal patency at 6 months denotes a failure, and alternative contraception is required.

Few contraindications to operative hysteroscopy are noted. These include pregnancy, cervicitis, or active pelvic infection, known cervical or endometrial cancer, and surgeon inexperience. Comorbidities that may be exacerbated by intravascular volume expansion are a relative contraindication. ^[31] Additionally, patients known to have a nickel allergy should not have Essure sterilization, and patients with an allergy to radiographic contrast media are not candidates for hysteroscopic sterilization procedures. ^[38]

The vast majority of operative hysteroscopic procedures may be performed in an ambulatory setting under monitored anesthesia care (MAC). On occasion, general endotracheal anesthesia is required for more complex or lengthy procedures or when concurrent laparoscopy is expected. For a more detailed discussion of anesthesia for hysteroscopic procedures, see Diagnostic Hysteroscopy.

For a more detailed discussion of the equipment used in hysteroscopy (ie, hysteroscope, light source, distension media, camera, and gynecologic instruments), please refer to Diagnostic Hysteroscopy. Equipment unique to operative hysteroscopy is described in greater detail below.

Rigid operative hysteroscope

A rigid operative hysteroscope typically consists of a 0º, 12º, or 30° optical lens; an operative bridge that contains ports for hysteroscopic instruments (ie, shears, graspers, and biopsy forceps); and an outer sheath with a 5.5- to 9-mm outer diameter. The outer sheath contains distension media input and output channels that allow for continuous laminar flow and irrigation. ^[49] The input and output channels also permit the calculation of distension medium fluid deficit either manually (every 15 min) or with commercially available systems such as the Dolphin II (Gyrus ACMI), Hysteroscopic Fluid Management System (Smith & Nephew), or Aquilex (Hologic).

See the image below.

The use of automated systems is preferred because they provide real-time fluid deficit calculations and can control the pressure at which distension medium is instilled. The output channel may also be used to evacuate (by vacuum or gravity) intrauterine blood or particulate matter.

Resectoscope

Unlike rigid operative hysteroscopes, resectoscopes have both inner and outer sheaths.

See the image below.

The inner sheath houses the optical lens and acts as the input for distension medium. The outer sheath is 7 to 10 mm and houses the monopolar loop, which may be extended and retracted back into the outer sheath with a spring mechanism. ^[50] In addition, numerous small holes in the distal end of the outer sheath allows for fluid outflow. Because the resectoscope loop relies on a monopolar electrical current, an electrolyte free distension medium (ie, mannitol, glycine, or sorbitol) is required to prevent current dissipation. In all hysteroscopy, the surgeon should be mindful of the ongoing fluid deficit; this is especially true when using hypotonic fluids that may dramatically alter volume status and serum chemistries.

Bipolar hysteroscope

The Gynecare Versapoint (Ethicon) operative hysteroscope is similar in design to the monopolar resectoscope. The Versapoint has multiple operative tip attachments including 0º and 90° loops for resection and cutting in addition to various tips for vaporization. The most dramatic difference is the use of bipolar electrocautery. ^[50] This allows for the use of isotonic distension media (ie, normal saline or lactated Ringer's solution), which lessens the risk of hyponatremia in cases of fluid overload.

Karl Storz Endoskope and Richard Wolf Medical Instruments have also developed bipolar resectoscopes. The Princess (Richard Wolf Medical Instruments) has a 7-mm outer diameter and is the smallest currently available bipolar resectoscope. The Chip E-Vac System (Richard Wolf Medical Instruments) may be used in conjunction with a monopolar or bipolar resectoscope to remove chips of tissue created during resection; this is thought to improve visualization and decrease operative time.

Morcellator

Although there is a paucity of long term data, hysteroscopic morcellators appear to be safe and effective and reduce operative time. ^{[51, 52, 53]} The hysteroscopic morcellators consist of a multiport operative hysteroscope with an angled eyepiece and a morcellating hand piece insert. The morcellating attachments are composed of 2 hollow tubes positioned one within the other; the inner tube rotates or oscillates within the outer tube and can be seen through the outer tube’s operative window located at the distal tip. The pathology is drawn into the cutting window via suction, removed by the cutting action, and collected into a net bag for histopathologic examination.

Smith & Nephew offers 2 Truclear operative hysteroscopes. The Truclear 8.0 has an outer diameter of 9 mm and may be used with a reciprocating or rotary handpiece. The Reciprocating Morcellator 4.0 is recommended for myomectomy, while the Rotary Morcellator 4.0 is recommended for polypectomy. The newer Truclear 5.0 has a 5.6-mm outer diameter, accommodates the Truclear Incisor Plus Blade 2.9, and is recommended for polyp removal. ^[54]

Hologic also offers 2 MyoSure Hysteroscopic Tissue Removal Systems with simultaneous rotating and oscillating cutting blades. The MyoSure Rod Lens Hysteroscope has an outer diameter of 6.25 mm and may be used with the MyoSure Classic or MyoSure Lite handpieces. The MyoSure Classic is designed for all polyps and fibroids 3 cm or less in diameter. The MyoSure Lite has a lower price point, smaller cutting window, and is best for polyps 3 cm or less in diameter. The MyoSure XL hysteroscope with 7.25-mm outer diameter and larger cutting blade may be used to remove any intrauterine pathology, including larger fibroids. ^[55]

Karl Storz has also developed a hysteroscopic morcellator.

Operative hysteroscopy is best performed with the patient in the dorsal lithotomy position using candy cane, Yellowfin Elite or Ultrafin (Allen Medical Systems) stirrups. Allen stirrups are adjustable, reduce incidence of nerve injury, and give the surgeon positioning flexibility during the procedure. ^[56] A 10% povidone-iodine vaginal and perineum preparation is preferred for hysteroscopic procedures.

General operative hysteroscopy

A thorough history and physical examination to evaluate for comorbidities, pregnancy, or active gynecological infection should be performed prior to any hysteroscopic procedure. ^[57] Operative hysteroscopy is best performed in the proliferative phase of the menstrual cycle after menstrual flow has stopped when the endometrium is thin. Use of various agents (ie, progestins, combined oral contraceptive pills, gonadotropin-releasing hormone [GnRH] agonist, GnRH antagonist, or danazol) may be used to induce endometrial atrophy. ^{[31, 58]}

The American College of Obstetricians and Gynecologists does not support the routine use of prophylactic antibiotics for most hysteroscopic procedures because postoperative infection rates are low. ^{[59, 60, 57]} Considering that postoperative endometritis may have devastating fertility outcomes, many support the use of antibiotics when significant resections (ie, myomectomy, septum resection, or lysis of adhesions) or more involved procedures are performed. Appropriate antibiotics include a cephalosporin or doxycycline. A quinolone or clindamycin plus gentamicin may be used in cases of penicillin anaphylaxis. ^[59]

After informed consent is obtained, the patient is transferred to the operating room. A “time out” procedure confirming patient identity and drug allergies, procedure to be performed, and a valid consent is executed with the operating room staff. Once adequate anesthesia is obtained, the patient is positioned, examined under anesthesia, and sterilely prepared and draped. After a Foley catheter is placed into the bladder, the surgeon may proceed. Visualization of the cervix must first be obtained. This can be done with a side-arm bivalve speculum or a weighted-speculum and concurrent use of a right angle or Dever retractor, depending on preference.

The cervix has numerous pressure-sensitive receptors and is therefore grasped with the smallest purchase necessary using a single-tooth tenaculum. Some surgeons prefer to infuse a small amount of local anesthetic into the cervix prior to grasping with a tenaculum; this is particularly beneficial when using monitored anesthesia care (MAC).

A paracervical or intracervical block may then be used for additional anesthesia. ^{[61, 62, 63]} A paracervical block significantly decreases the pain associated with tenaculum placement, cervical dilation, and hysteroscope insertion, but has little effect on the pain experienced with uterine distension. ^[61] During a paracervical block, approximately 10 mL (5 mL on each side) of local anesthetic (ie, lidocaine, mepivacaine, prilocaine, ropivacaine, bupivacaine, or etidocaine) is directed at the cervical branches of the sensory and sympathetic uterine, pelvic, and hypogastric plexuses.

In order to achieve an adequate block and decrease the possibility of intravenous injection of anesthetic, injections can be made with a small-gauge needle 10 mm deep at the 4- and 8-o’clock positions in the lateral fornices. ^[62] Prior to injection, one should draw back on the plunger of the syringe to insure that the injection is not made into a vessel. An intracervical block is achieved by injecting dilute local anesthetic without epinephrine into the cervical stroma. In order to avoid the cervical vasculature, a total of 10 mL of anesthetic may be injected at the 2-, 4-, 8-, and 10-o’clock positions.

The typical diameter of an operative hysteroscope ranges from 7-10 mm, and dilation of the cervix is usually required. Preparing the cervix for dilation may be achieved with laminaria tents, misoprostol (Cytotec, Pfizer), or injection of a dilute vasopressin solution. Laminaria may be placed the evening prior to or morning of the procedure and removed just prior to sterile preparation of the vagina. ^[31] Following cleansing of the cervix, the laminaria are grasped on the tethered end using ring forceps. While counter-traction is applied with a tenaculum placed on the anterior lip of the cervix, the laminaria is inserted to a level just through the internal cervical os.

One hundred micrograms of misoprostol, a synthetic prostaglandin E₁ analogue, orally or vaginally the evening prior to the procedure has also been shown to be effective at decreasing the difficulty of and pain associated with cervical dilation. ^{[64, 65, 66, 67]} No significant differences in efficacy between oral and vaginal misoprostol were reported by a double-blind randomized study by Nada et al. ^[68]  Misoprostol is potentially less effective in postmenopausal women, however. ^{[65, 66]} A meta-analysis evaluating misoprostol in operative hysteroscopy did not rule out a potential beneficial effect on cervical dilation and reduction of surgical complications; however, it did show an increase in adverse effects (ie, cramps, nausea, and diarrhea). ^[69]

Alternatively, a 0.05 U/mL solution of vasopressin (Pitressin, Goldshield Pharmaceuticals) in injectable-grade normal saline or local anesthetic has been shown to reduce the force required for dilation, fluid intravasation, operative time, and procedural blood loss. ^{[70, 71]}

The cervix is then progressively dilated to the required diameter (depending on the operative hysteroscope being used) with the surgeon’s preference of cervical dilators (ie, Hegar, Hank, or Pratt).

After all hysteroscopic equipment is set up and functional, the flow of distension medium is started and flushed through the hysteroscope. The scope is then introduced to the external cervical os and advanced into the dilated cervical canal. At this time, attention is directed to the viewing monitor, and care should be taken to maintain the endocervical canal central in the viewing field if using a 0° hysteroscope. Visualization of the endocervical canal is important when applying forward pressure to prevent cervical injury.

As the hysteroscope is slowly advanced into the uterine cavity, continuous gentle counter-traction is applied with the tenaculum. Once the distal tip of the hysteroscope breaches the internal os and is within the uterine cavity, the distension medium is allowed to expand the intrauterine space. In addition to pathology, cervical and intrauterine landmarks should be noted at this time. Pathology may be treated as described below. Following conclusion of the procedure, the distension medium is evacuated and all instruments are removed from the uterus and vagina.

Myomectomy

A resectoscope or bipolar resecting hysteroscope may be used to remove a submucosal fibroid. Both operative hysteroscopes allow for electrocautery resection of a myoma. As stated before, the resectoscope uses monopolar cautery and nonelectrolyte distension media, whereas bipolar resectoscopes use electrolyte media. With either hysteroscope, a 90° loop electrode is placed through the operative port.

The loop is then advanced past the fibroid; continuous-wave (cutting) electrocautery at 80 to 100 watts is applied, and the loop is retracted back into the operative sheath.

To minimize thermal injury and risk of uterine perforation, electrical energy should only be applied while the loop is being retracted. As the electrode retracts back, a strip of leiomyoma is excised and floats in the endometrial cavity. This technique is repeated numerous times until the fibroid is removed entirely. The created chips of fibroid tissue may begin to obstruct visualization. If this occurs, the hysteroscope is removed from the cavity and the fibroid chips are evacuated from the uterine cavity blindly with polyp grasping forceps and sent for histopathologic examination. Alternatively, a chip evacuating system may be used. Repeated removal and insertion of the hysteroscope increases the risk of uterine perforation, air embolus, and fluid deficit miscalculation, or intravasation, and should be avoided.

The resection is complete when the fibroid base is even with the adjacent myometrium because resection beyond this point increases the chance of uterine perforation. Alternatively, the surgeon may halt the resection and allow the surrounding myometrium to contract and deliver the remaining fibroid tissue into the cavity. Administration of the prostaglandin F_2α carboprost (Hemabate, Pfizer) has been shown to aid in delivery of residual tumor into the uterine cavity. ^[72] Resection can then be resumed.

A submucosal fibroid with a significant intramural component is an obstacle to complete resection in a single procedure. A “cold loop” technique has been suggested as a beneficial method during these circumstances. In this technique, the fibroid capsule is separated from the surrounding myometrium by pushing and pulling with the resectoscopic loop without applied electrical current. ^[73] Another author describes enucleation en toto of the myoma. This procedure involves creation of an elliptical incision in the endometrium overlying the fibroid followed by a combination of blunt and electrocautery dissection. ^[74]

A hysteroscopic morcellator may also be used to perform a myomectomy. Once the hysteroscope is inserted into the uterine cavity, the handpiece is placed through the operative channel of the uniquely designed operative hysteroscope and is used to morcellate the noted fibroid. The window at the distal tip of the handpiece should be placed adjacent to a rough or irregular edge of the fibroid. See the image below.

The cutting action is activated with a foot pedal, and the fibroid is drawn into the window by suction. See the image below.

The handpiece remains stationary with the action engaged, and the myoma is morcellated as it delivers into the endometrial cavity. The morcellation is complete once the fibroid bed is flush with the adjacent myometrium. When myomectomy via a hysteroscopic morcellator was compared to resectoscopy, morcellation appeared to be faster and easier, with a shorter learning curve and decreased risk of fluid-related complications. ^{[51, 52]} See the images below.

Polypectomy

Hysteroscopic polypectomy can be accomplished using several different techniques. The first option is to place a standard rigid operative hysteroscope into the uterine cavity and remove the noted polyp using grasping forceps inserted through the operative port. The grasping forceps should be directed at the base of the polyp, and grasping pressure is maintained while the forceps are removed through the hysteroscope. Several attempts may be required to remove the polyp in its entirety. This approach is typically well tolerated with minimal or only local anesthetic and may be conducted in the office setting. Similar to the technique of myomectomy as described above, a monopolar or bipolar resectoscope with a 90º loop may be used to remove larger or more numerous endometrial polyps.

Another technique involves the use of a hysteroscopic morcellating device; this option is particularly useful when multiple polyps are visualized within the cavity. The authors prefer to use the MyoSure (Hologic) or Truclear (Smith & Nephew) rotary hand piece for most hysteroscopic polypectomies because morcellation is fast and effective and allows collection of a specimen that may be sent for pathologic examination. Once the handpiece is inserted into the operative channel, the window of the instrument is placed adjacent to the most distal aspect of the polyp, and the cutting action is engaged via a foot pedal. The hand piece is held stationary while suction draws the polyp through the window into the morcellating blade.

See the image below.

A sweeping motion across the endometrial surface may aid in the removal of multiple polyps and fluffy endometrium.

Metroplasty

Resection of a uterine septum (also referred to as metroplasty or septoplasty) may be performed with endoscopic shears, electrocautery, neodymium:yttrium-aluminum-garnet (YAG) laser, or a hysteroscopic morcellator, but is best performed with a standard rigid operative hysteroscope and endoscopic shears. After insertion of the scope and identification of the septum, hysteroscopic shears are placed through the operative channel.

See the image below.

Bilateral visualization of the fallopian tube ostia is crucial because the ostia serve as landmarks throughout the resection.

Resection of the septum should commence at the most caudal portion of the septum and in the vertical midline. The surgeon may then work cephalad and laterally towards each ostium as needed. Of note, a tendency to carry the resection posterior in an anteverted uterus and anterior in a retroverted uterus is recognized. Prior to each incision with the shears, the ostia should be visualized, and the surgeon should confirm positioning in the correct plane. The uterine septum is avascular, so the operative bed remains hemostatic. Myometrium, in contrast, is extremely vascular and bleeds if incised. Bleeding indicates that the resection line is either too anterior or posterior or that the uterine fundal myometrium has been reached.

Alternatives to resection with hysteroscopic shears include the use of monopolar or bipolar cautery on a blended (coagulating) setting of 70 to 100 watts. A 0° loop electrode may be inserted through the operative channel of a resectoscope or bipolar operative hysteroscope and may be used to divide the septum in a similar manner as to what is described above.

The patient should be aware of and consented for the possibility of simultaneous diagnostic laparoscopy. An endoscopic lens inserted into the peritoneal cavity may be used to visualize transillumination from the hysteroscope indicating thinning myometrium. Laparoscopy is recommended when the surgeon is using electrocautery or laser to divide the septum, but this step may be omitted if shears or a morcellator is used. Transabdominal ultrasonography may also be useful for guiding resection of a uterine septum.

In order to improve visualization of the uterine cavity, the bladder is filled with 300-500 mL of sterile normal saline though a Foley catheter, and the catheter is clamped. A transabdominal ultrasound probe is then place on the lower abdomen, and the surgeon uses a combination of direct visualization via the hysteroscope and sonographic imaging to guide the resection. The bladder is drained prior to reversal of anesthesia.

Although data supporting or refuting that placement of an intrauterine balloon or pediatric Foley catheter to decrease intrauterine adhesion formation after a septoplasty is sparse, this is suggested by some authors. ^{[23, 24, 25]} The triangular shaped Balloon Uterine Stent (Cook Medical) is placed using uterine dressing forceps after removal of the hysteroscope and is inflated with 1-5 mL of normal saline or water. Alternatively, a pediatric Foley catheter may be inserted into the endometrial cavity and instilled with up to 10-15 mL of normal saline or sterile water. If the surgeon elects to use a balloon or Foley catheter, the patient should receive estrogen therapy and antibiotic prophylaxis (doxycycline 100 mg twice daily). ^[31] Estradiol patches (0.1 mg/day) or oral tablets are used until the balloon is discontinued. The balloon should be deflated and removed in the outpatient setting 10-14 days following placement.

Lysis of adhesions

Uterine synechia are incised using a standard rigid operative hysteroscope. Following placement of the scope into the endometrial cavity, hysteroscopic shears are advanced through the operative channel and used to divide any noted adhesions. See the image below.

Adhesiolysis should begin with the most centrally located adhesions and proceed to those located at the periphery of the cavity. Uterine synechia may also be transected using a YAG laser or 0° monopolar or bipolar electrocautery loop inserted through a resectoscope or bipolar operative hysteroscope.

Dense adhesions may require use of a resectoscopic or bipolar electrocautery loop. In cases involving lysis of extensive or dense adhesions with significant obliteration of the endometrial cavity, it may be beneficial to perform the resection with concurrent laparoscopy to decrease the risk of perforation. Like hysteroscopic septoplasty, patients with disrupted or denuded endometrium after an extensive resection may benefit from postoperative placement of an intrauterine balloon or Foley catheter and estradiol treatment as described above. ^[75]

Fallopian tube cannulation

For ease of ostia visualization, a 12º or 30° optical lens is typically used for proximal fallopian tube cannulation. The Novy Cornual Cannulation Set (Cook Medical) is the most frequently used instrument in the cannulation of fallopian tube ostia. The catheter consists of a guide wire surrounded by inner and outer cannulas. Following placement of a rigid operative hysteroscope, the cannulation catheter is placed through the operative channel of the scope into the uterine cavity.

The outer cannula, which is slightly bent to facilitate ease of placement, is situated adjacent to one of the ostium. The inner cannula is then inserted approximately 2 cm into the proximal tube bypassing or treating the etiology of the occlusion, and the guide wire is removed. A dilute indigo carmine or methylene blue solution is then injected through the catheter, and spill of dye from the distal tube can be visualized via simultaneous laparoscopy. Both cannulas are then removed from the ostium, and the procedure is repeated on the contralateral side. The Novy catheter is flexible, but perforation of the fallopian tube may occur. ^[30] Because the catheter is of such small diameter, perforations are generally hemostatic and do not require repair.

Removal of a foreign body

A retained intrauterine contraceptive device (IUD) is the most common uterine cavity foreign body. Although removal of an IUD is discussed below, all foreign bodies may be removed in a similar manner. Following insertion of a rigid operative hysteroscope, grasping forceps are inserted through the operative channel and used to grasp the string or stem of the IUD. The entire hysteroscope apparatus is then slowly removed from the cavity taking the foreign body with it. In some instances, the IUD may be embedded into the endometrium or myometrium and require some degree of dissection prior to removal. Concurrent laparoscopy in these cases may be useful for avoiding uterine perforation.

Sterilization

A standard rigid hysteroscope with a 5 French operative port may be used for hysteroscopic sterilization. Following insertion of the hysteroscope, the ostia should first be identified bilaterally because this is required for successful completion of the procedure.

Delivery of the Essure microinsert may be performed through the operative channel of a rigid hysteroscope. The tip of the outermost delivery catheter is first inserted into the endometrial cavity and then the tubal ostium to a pre-marked depth. As the delivery catheter is retracted into the device handle, the release or inner catheter is revealed. The microinsert uncoils and anchors to the wall of the fallopian tube as the inner release catheter is retracted back. The guide wire is then detached and removed. The same procedure is then performed on the contralateral side. Four to 8 full coils should be seen in the endometrial cavity following the procedure.

See the images below.

The Adiana system requires hysteroscopic cannulation of the tubal ostium with uniquely designed disposable catheters. Following placement of a standard operative hysteroscope into the uterine cavity, the Adiana delivery system is inserted into the operative channel, and one tubal ostium is cannulated with the delivery catheter to a pre-marked depth. The catheter is attached to a radiofrequency (RF) generator that causes 5 mm of thermal injury to the tubal endothelium by heating to 64°C for 1 minute via RF energy delivered through the distal tip of the catheter. A 3.5 X 1.6-mm wide silicone matrix with multiple small channels is then deployed via the inner catheter, and the catheter is removed. The same procedure is performed in the contralateral fallopian tube, and the hysteroscope is removed.

See the images below.

Operative hysteroscopy is a safe procedure resulting in complication in 0.95-3% of cases. ^{[76, 77, 78]} The most frequently observed complications include hemorrhage (2.4%), uterine perforation (1.5%), and cervical laceration (1-11%) ^[79] ; another rare complication is excessive fluid absorption with or without resultant hyponatremia. ^{[76, 77, 78, 80]}

Uterine perforation

Uterine perforation is one of the most frequent complications of operative hysteroscopy, with an incidence of 0.7-3%. Patients should be aware of the possible need for concurrent laparoscopy. ^{[76, 77, 78]} Uterine perforations occur most frequently during adhesiolysis, followed by myomectomy and septum resection, but can also occur during insertion of the hysteroscope. ^{[77, 78]} Perforations are generally diagnosed by direct visualization, but should also be suspected in cases of unexplained rapid increase in the fluid deficit, uncontrolled hemorrhage, and hemodynamic instability. A hemostatic perforation in the uterine fundus made by a uterine sound, cervical dilator, hysteroscope, or other blunt instrument may be managed conservatively.

Observation in the postanesthesia care unit should consist of monitoring vital signs, urine output, and, in some cases, hematocrit. Perforations through the posterior or lateral uterus or by sharp or electrocautery instruments should prompt laparoscopy because of the potential for injury to the pelvic viscera or vasculature. A cystoscopy should be performed to evaluate for bladder injury if an anterior perforation is noted. ^{[80, 81]}

Fluid overload and electrolyte imbalance

Excessive fluid absorption has an incidence of 0.2-0.76% and is a potential serious complication of operative hysteroscopy. ^{[77, 78]} Myomectomy, uterine septum resection, extensive lysis of adhesions, and prolonged operative times increase the risk of clinically significant fluid overload and hyponatremia, especially when hypotonic distension media is used. ^[77] Electrolyte free distension media can cause rapid and profound hyponatremia if absorbed in large quantities. For this reason, fluid deficits should be carefully managed, and intrauterine pressures should be kept below the mean arterial pressure. Once the fluid deficit reaches 750 mL, the surgeon should plan for completion of the procedure. The operation is terminated when deficits reach 1500 mL for nonelectrolyte fluids and 2500 mL for isotonic fluids. ^[82]

Abrupt changes in the serum sodium level (normally 135-145 mEq/L) can lead to altered mental status and progress to seizures, coma, and even death. ^[83] If intraoperative or postoperative sodium levels fall below 125 mEq/L, the patient should be transferred to an acute or critical care setting. Intravenous 3% sodium chloride may be given at a rate of 1-1.5 mEq/L/h, and furosemide should be used to achieve the appropriate amount of diuresis. ^{[81, 83]} Fluid overload resulting in pulmonary edema can occur in cases with excessive intravasation of isotonic fluids. This problem may be compounded by not decreasing the rate of intravenous fluid administration to compensate for the hysteroscopic absorption of distension media. Additionally, the uptake of relatively small volumes of Dextran 70 (Hyskon, Pharmacia Laboratories) can lead to significant intravascular volume expansion because of the fluid’s osmotic properties. ^{[84, 85]}

Hemorrhage

Hemorrhage may be encountered during or after hysteroscopy. The surgeon should first ensure that the noted bleeding is not a result of uterine perforation. Mild bleeding is typically self-limited and generally does not require intervention. If brisk bleeding occurs, electrocautery may be used to coagulate small vessels. If these conservative approaches fail to control heavy bleeding or if there is bleeding from larger vessels, a Foley catheter or intrauterine balloon can be inserted into the cavity and inflated to tamponade the hemorrhage. A Foley catheter may be connected to a collection bag to monitor blood loss. ^{[31, 80]}

Rare complications

Depending on the extent of the procedure performed, additional, rare complications may occur with operative hysteroscopic procedures. Uterine septum resection and myomectomy have been implicated in postoperative intrauterine adhesion formation and uterine rupture in subsequent pregnancies. ^{[86, 87]} A false passage within the cervix may be created by overzealous or misdirected hysteroscope insertion or inadequate cervical dilatation. Additionally, poor placement or vigorous manipulation of the tenaculum may result in a cervical laceration; bleeding lacerations of the cervix are easily repaired with a delayed-absorbable poly-filament suture. Although rare, postoperative endometritis may be treated with broad-spectrum antibiotics in the hospital setting if necessary. Gas embolism is extremely rare and is discussed in more detail in Diagnostic Hysteroscopy.

The postoperative course following operative hysteroscopy without complication is generally unremarkable. Because most operative hysteroscopies are performed in an outpatient setting, patients are able to go home the same day following a brief PACU stay. Patients are able to resume a regular diet as tolerated. For patients undergoing extensive resection, cramping or vaginal spotting for 1-2 weeks following the procedure is normal. In women desiring immediate fertility after a polypectomy, pregnancy may be attempted the following menstrual cycle. ^[88]

If a metroplasty or adhesiolysis is performed or if a myomectomy resulted in the removal of a fibroid with a sizable intramural component, pregnancy should be delayed for 3 months, and contraception should be considered. The rate of new intrauterine adhesion formation after septoplasty (88%) or adhesiolysis (76%) is higher than that of myomectomy (40%) or polypectomy (0%). ^[88] Vaginal birth is an acceptable mode of delivery following hysteroscopic myomectomy of type 0 or 1 fibroids. ^[89]

The patient is typically seen for a postoperative visit 2-4 weeks following the procedure. A repeated anatomical survey (ie, saline infusion sonohysterogram [SIS] or diagnostic hysteroscopy) may be warranted in some cases to ensure the lack of adhesion formation or complete resection of a fibroid or septum.