This chapter should be cited as follows:
Liew NC, Plans C, et al, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.418503

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 4

Benign gynecology

Volume Editor: Professor Shilpa Nambiar, Prince Court Medical Centre, Kuala Lumpur, Malaysia

Chapter

Office Endoscopic Techniques for the Gynecology Patient

First published: December 2023

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ABSTRACT

Endoscopic procedures that were traditionally theater based in hospital, are now being performed in the office setting as the first line treatment in many units. This has certainly been shown to be both cost effective and acceptable to patients. This document will provide an overview of the indications, current up-to-date guidelines, and best safe practice techniques for clinicians performing both diagnostic and therapeutic office endoscopies.

INTRODUCTION

This document outlines the office endoscopic techniques for the gynecology patient. This is an opportunity for quality improvement to support and future-proof gynecological services. It will optimize patient flow, improve efficiency and service capacity and provide an enhanced user experience. Benign gynecological services are currently challenged by difficulties in delivering care to urgent cases as well as prolonged waiting times for outpatient, ultrasound, and planned inpatient assessment. The establishment of an office endoscopic techniques for the gynecology patient will improve the efficiency and effectiveness of benign gynecological care, while making best use of available resources. Women will benefit from assessment in a designated environment, potentially without need for hospital admission, general anesthesia, and significant absence from work. It will also provide educational and research opportunities within the hospital environment. This development of a good office endoscopic techniques will allow the delivery of “the best possible patient experience in a safe and clean environment and in the most effective and efficient way possible.” Most of the time outpatient operative hysteroscopy offers the “see and treat hysteroscopy” in which the operative part is completely integrated in the diagnostic hysteroscopy. Currently, hysteroscopy is considered the gold standard for examination of the uterine cavity.¹ It is usually performed for investigation of abnormal uterine bleeding (AUB), where endometrial pathology cannot be excluded or is suspected via transvaginal ultrasound scan, speculum, smear, swabs and pipelle (Table 1). AUB includes intermenstrual bleeding (IMB), postcoital bleeding (PCB), menorrhagia, irregular bleeding, or postmenopausal bleeding (PMB). Evolution in the procedure has made it easy to perform and reduced discomfort for the patient, this has become ideal in office regimens.^2,3 Local anesthesia is no longer required. Endometrial polyps, submucous fibroids, and selected cases if uterine septum and cavitary adhesions can be safe and successfully managed as in-office procedures.⁴ Second-generation ablation techniques are feasible as office endoscopy procedures. The future is leaving the operating theater environment and moving towards ambulatory and office endoscopy procedures.⁵ Selection of patients and skilled endoscopists are necessary so as to keep the best clinical results, the lowest complication rate and in times of high cost of national health services, an optimal cost-effectiveness.

SERVICE PROVISION

The National Clinical Guidelines in Obstetrics and Gynecology (Institute of Obstetrics & Gynecology, Royal College of Physicians in Ireland (IOG, RCPI)), the Royal College of Obstetricians and Gynaecologists (RCOG), and the British Society of Gynecological Endoscopists (BSGE) endorse office endoscopy technique for benign gynecology and suggests that newer methods of investigations, such as outpatient endometrial biopsy, transvaginal ultrasonography, and hysteroscopy have superseded (inpatient) D&C.

All services should have a dedicated outpatient hysteroscopy service away from the operating theater with an appropriately sized and staffed treatment room with adjoining private changing facilities and toilet. Written patient information should be provided before the appointment and consent for the procedure should be taken. A chaperone should be present regardless of the sex of the clinician, they should act as an advocate for the woman undergoing the procedure with so called “verbal anesthesia” reassuring and relaying any anxieties the patient may have.

The service of a dedicated outpatient office endoscopy

Prerequisites for office endoscopy service include trained and engaging staff, well-equipped endoscopy room (i.e., appropriately sized and staffed treatment room with adjoining private changing facilities and toilet), up-to-date, regularly serviced equipment, patient selection, chaperone, patient information leaflets, updated guidelines and pathways and recourse to resuscitation facilities. The patient must be well informed about the investigation to be undergone, and welcomed in a familiar and calm environment for a comfortable gynecological session.

“OFFICE” PROCEDURES

The first hysteroscopes had a diameter of about 5.5–6 mm and offered low-quality vision. Miniature hysteroscope (2.7 mm with a 3–3.5 mm sheath) should be used for diagnostic outpatient hysteroscopy as they improved patient’s compliance during diagnostic and office procedures, reducing pain sensation and allowing to overcome several anatomic impediments of the cervix (5,6,7). 1–2 mm of reduction reflects a parallel reduction of about 50–75% of the sheath. RCOG recommend using the smallest available for diagnostic endoscopy; diameter of 2.7 mm with a 3–3.5 mm sheath. This reduces the need for cervical dilatation resulting in less discomfort for the woman. The endoscopes come with various angle options; ranging from 0 to 70 degrees. 0 degree scope provides a panoramic view of the uterus whereas the angle scope provided allow for improved views of the ostia or abnormal shaped uterine cavity. Scopes come as flexible or rigid. Flexible scopes means less discomfort but an increased in-procedure time and higher failure rate. The type and angle of the scope should be left at the discretion of the operator. The equipment should remain sterile and be assembled by the nurse assisting at the procedure.

Distension medium

Carbon dioxide (CO₂) and normal saline are the most used media for intracavitary distention in outpatient hysteroscopy. Although CO₂ is generally well tolerated, uterine distention with normal saline is preferable as it is associated with less vasovagal reactions, faster procedure times, better image quality, and can be used for operative procedures. Normal saline is more cost-effective than carbon dioxide. However, the choice of distension medium should be left to the discretion of the operator as neither is superior in reducing pain. Operative outpatient hysteroscopy, using bipolar electrosurgery, requires the use of normal saline to act as both the distension and conducting medium.¹

Vaginoscopy

Vaginoscopy is the standard technique for outpatient hysteroscopy, is a “no touch” technique, atraumatic approach that significantly reduces the pain caused by the use of the tenaculum and speculum, as well as manipulation of the hysteroscope within the cervical canal. Therefore, no analgesia or local anesthesia is necessary. Vaginoscopy has its role in the setting of a stenotic cervix, because it involves hydro-dilatation of the cervical canal for entry with a lower caliber scope. Its method entails inserting a hysteroscope into the vaginal canal and using normal saline to dilate the vaginal vault. The scope will descend into the posterior fornix, and by pulling back to examine the upper third of the vagina, the external cervical ostium can be seen. Then the scope can be guided into the cervical canal.¹

ANESTHESIA AND ANALGESIA FOR OFFICE-BASED UTERINE ENDOSCOPY

There is no conclusive evidence for the routine use of analgesics prior to performing outpatient hysteroscopy. Most units recommend the use of non-steroidal anti-inflammatory tablets a few hours before the procedure.

A recent Cochrane Review showed the benefit for local anesthetic during the procedure and for a period of time after but the difference was not felt to be clinically significant. The evidence for the 48-hour duration is basically anecdotal, as we have not had an opportunity to compare this regimen with the published approach describing administration of mefenamic acid about an hour prior to the procedure.⁶

Most literature suggests that it is a well-tolerated procedure and recommends the use of local anesthesia only in selected patients. Different routes have been described:

• Paracervical local anesthesia is injected into the uterosacral and/or broad ligaments, thereby resulting in cervical anesthesia, at 2, 4, 8 and 10 o’clock of 2% lignocaine in 1 : 80 000 (12.5 micrograms/ml) (Figure 6).
• Intracervical local anesthesia is injected into the cervical stroma. Hysteroscopy should be performed after 2–3 minutes after anesthesia is given (Figure 7).
• Topical local anesthesia spray, cream, or gel is applied either to the endocervix or in the cervical canal.

When difficulty with cervical dilatation is anticipated, dose of vaginally/orally administered misoprostol (200–400 mcg) can be considered but be aware of the side effects that can be troublesome. The major reason for “cervical stenosis” is a cervical canal that is anatomically tortuous and one that is effectively navigated under direct hysteroscopic vision.

Quality working practice standards for office endoscopy

• Women should be offered verbal information and be sent written information on the procedure prior to their appointment.
• Women must be sent an appropriately worded invitation with a contact name, telephone number, and clinic times.
• Women must be positively motivated to undertake it.
• Locally produced information leaflets tailored to the needs of the local population and reflecting the local office endoscopy service should be sent with the office endoscopy invitation.
• Take consent for the procedure if this has not already been done.
• Pregnancy to be excluded.
• Explain procedure and reassure patient.
• Place patient in dorsal lithotomy position.
• Wash with warm disinfectant and drape.
•  Perform bimanual examination.
•  At this stage you can choose either conventional hysteroscopy or vaginoscopy.
•  Systematically inspect uterine cavity.
•  Inspect endocervix on withdrawing hysteroscope.
•  Take biopsy of endometrium or focal lesion.
•  Clinics operating a “see and treat” policy must ensure that women who are offered treatment at their first visit have been sent adequate and appropriate information in advance of their appointment.
•  Good practice dictates that patients should have their history taken and be counseled with an independent interpreter if required.

Patient selection

Patient selection is the key to successful outpatient hysteroscopy (and all ambulatory procedures) – a patient who fully understands the procedure and is positively motivated to undertake it. If the patient has found a speculum or pipelle biopsy in clinic too uncomfortable, it may not be appropriate to manage them in the outpatient setting. Other exclusions are patients who have not been able to tolerate a procedure previously or when pregnancy cannot be excluded. Previous treatment on the cervix such as large loop excision of transformation (LLETZ), being nulliparous, or previous myomectomies are not contraindications for outpatient hysteroscopy. The procedure room is one with a very relaxed atmosphere, and anything that can be done to enhance this (music, paintings, and color selection) is probably worthwhile. It is important that the room is both warm and perceived to be clean and tidy. It is important that the staff project the aura of competence and compassion that facilitates a sense of confidence on the part of the patient. Two care pathways are shown below.

Technique for conventional hysteroscopy

• Clean and drape the patient – to maintain a sterile field, reducing the risk of infection.
• Perform bimanual examination.
• Insert speculum – vaginoscopy has been shown to cause the least discomfort and lack of speculum allow greater maneuverability. However, it may be useful to inspect the vagina and cervix in most cases.
• Administer local anesthetic if required.
• Grasp anterior lip of cervix with tenaculum.
• Dilate cervix if required (better avoided).
• Place tip of hysteroscope against external cervical os and it should be slowly entered when the cervix is dilated by fluid. Hysteroscope should be placed into the vagina, guided along the operator's finger and the fluid turned on to distend the vagina and identify the cervix.
• Start uterine distension.
• Gradually guide hysteroscope into uterine cavity under vision.
•  The images will appear on the screen and the black area should be followed to find the internal os and uterus.
•  Once inside the uterus the ostia should be identified for confirmation of correct positioning within the uterus and images taken digitally and stored.
•  Anterior and posterior walls of the uterus should be examined and biopsies taken under direct vision from any abnormal looking area.
•  Hysteroscope should be slowly removed.
•  Following the procedure, the patient should be given a few minutes to recover, helped to sit up and there should be a waiting area for the patient to recover in, if necessary.
•  Discussion on the procedure and its findings.
•  Patient should be given written information about what to expect postprocedure and contact details in case of late occurring complications.

“No touch” technique/vaginoscopy as a “standalone” procedure

• Drape the patient.
• Assemble hysteroscopy and connect irrigation tubing.
• Attach video camera to eyepiece.
• Connect light lead.
• White balance and start irrigation.
• Insert hysteroscopy into the lower vagina and find the cervix.

According to RCOG/BSGE, vaginoscopy reduces pain during diagnostic rigid outpatient hysteroscopy. Vaginoscopy should be the standard technique for outpatient hysteroscopy, especially where successful insertion of a vaginal speculum is anticipated to be difficult and where blind endometrial biopsy is not required.

Operative hysteroscopy

Biopsy at hysteroscopy

Operative channel or sheath through which forceps, scissors, or graspers can be inserted in order to take biopsies or remove polyps under direct vision (Figure 8). This has the advantage over a blind procedure, reducing the risk of injury or incomplete removal. The standard technique is a “punch biopsy” taking an endometrial sample with the jaw of the biopsy forceps' grasp. The most commonly used technique is the “grasp” biopsy technique, performed with grasping forceps. They are placed against the endometrium (0.5–1 cm), with the jaws open, then once the sample is obtained, the two jaws remain closed and the whole hysteroscope is pulled out of the uterine cavity. This technique allows the physician to perform more targeted hysteroscopic biopsies to confirm “the visual“ diagnosis. The technique would not be suitable for larger size polyps or fibroids passing through the narrow sheath.¹

Hysteroscopic resection and morcellation

The newest mechanical tissue morcellators (Truclear System, Smith & Nephew, USA (Figure of Myosure morcellator device) and Myosure, Hologic USA) allow quick operative hysteroscopy procedures without the need of a long-lasting curve, which made them ideal instruments for less experienced endoscopists, as well as the efficacy keeps steady with the lowest recurrence rate.^7,8

Monitoring fluid deficit

Mechanisms should be in place to monitor fluid deficit during operative hysteroscopic surgery. Closed systems should be used as they allow more accurate measurement of the fluid output. Drapes that contain a fluid reservoir should be used as they allow measurement of the fluid output.

Automated fluid measurement systems are more accurate than manual measurement but they can still overestimate fluid deficit. Their use cannot guarantee safety but might be useful when undertaking complex hysteroscopic procedures where fluid absorption is anticipated. Measurement of the fluid deficit should be done at a minimum of 10 min intervals during hysteroscopic surgery (Appendix 1).

Endometrial ablation

Endometrial ablation is a procedure to manage heavy menstrual bleeding that has decreased since the introduction of the levonorgestrel releasing system (MIRENA® and Jaydess®, Bayer, Germany) in the early 1990s. In patients with a normal-sized uterus, once malignancy has been ruled out and hormonal reasons, or when surgical adverse events want to be avoided, endometrial ablation is a cost-effective treatment with short recovery and scarce complication rate.

First-generation techniques were developed through the use of the resectoscope of the Nd-YAG laser, but general anesthesia was required.

Second-generation techniques with balloons, heat-free fluid, cryotherapy, radiofrequency, or photodynamic have allowed simpler and quicker procedures applied as outpatients with the help of paracervical anesthesia.

However, not all women will be suitable for endometrial ablation. The following must be met:

• Completed their families.
• Willing to continue contraception until the menopause.
• Must not have large submucosal fibroids.
• Very large cavities where endometrium may not be completely ablated or small cavities where the equipment cannot be accommodated.
• Endometrial biopsy is essential prior to ablation to exclude endometrial pathology especially among women who are >45.
• No previous uterine scar.

Complications that may arise

According to RCOG Consent Advice No. 1 (December 2008), it is recommended that clinicians make every effort to separate serious from frequently occurring risks. Women should be advised that hysteroscopy may not identify an obvious cause for presenting complaint.

Incidence of infectious complications both after diagnostic and operative office hysteroscopic procedure is very low and it cannot be modified by prophylactic antibiotic administration. Morrill et al.⁹ concluded that there is no convincing evidence that antibiotics are of value in this clinical setting.

Sterilization and maintenance of the equipment

Cleaning, sterilization, and maintenance of the instruments should be performed by only qualified nurses/midwives, considering the high cost of the equipment and how easily they can be damaged.

CONCLUSIONS

Office endoscopic techniques for gynecology will improve the efficiency and effectiveness of benign gynecological care, while making best use of available resources. It will optimize patient flow, improve efficiency and service capacity, and provide an enhanced user experience. Development of new devices and techniques has made it easier to introduce the concept of a single act “see and treat hysteroscopy” and integrate the operative hysteroscopy into the diagnostic hysteroscopy.

PRACTICE RECOMMENDATIONS

APPENDIX 1 FLUID MANAGEMENT DURING OPERATIVE HYSTEROSCOPY

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