Principles of hysteroscopic surgery

Abstract

As there is increasing evidence that congenital and/or acquired uterine pathologies interfere with implantation and reproductive outcome, hysteroscopic surgery gained interest during the last decades in patients with fertility problems and repeated abortions. In the mean time, the introduction of smaller endoscopes and bipolar instruments added to the safety of the hysteroscopic operative procedures. With less discomfort for the patients, shorter operating times and better visualization, the use of watery distension medium is reported to be superior to the use of CO2. Concurrent use of ultrasound during operative hysteroscopic procedures is highly recommended in most of the operative procedures in the prevention of uterine perforations and in the identification of the different planes of cleavage and presence of normal endometrial tissue. Uterine cavity pressure should be the lowest pressure necessary to distend the uterine cavity and ideally should be maintained below the mean arterial pressure. The use of normal saline combined with bipolar energy reduces the risk of hyponatremia, but an excessive intravasation (>1,500 ml) still remains a risk and might cause cardiac overload. The most frequent surgical complications are uterine perforations. As most of the complications are entry related, introduction of the hysteroscope under direct visualization is mandatory. Necessary precautions should be taken pre- and intra-operatively to avoid complications: pre-operative thinning of the endometrium, continuous control of fluid balance, minimal intrauterine pressure, reduction of operating times, and concurrent use of ultrasound when cutting into the myometrium. It is without saying that the experience of the endoscopist is of utmost important.