Techniques and instruments for performing hysteroscopy

By Cristiano Antonino On Dec 28, 2022

Hysteroscopy is an endoscopic technique that allows direct visualisation of the cervical canal and uterine cavity

Through a series of technological advances, we have now obtained an instrument capable of applying the technique to all patients in all conditions and in the most varied situations.

All this with less and less invasiveness and discomfort.

In fact, today hysteroscopy is an outpatient technique that, in good hands, always allows access to the uterine cavity and therefore diagnosis and treatment at the same time endoscopically.

Numerous and increasingly diverse are the applications of this technique, which is increasingly finding its way into gynaecological practice.

As the technique has progressed, in parallel with the spread of a correct mentality, the indications have increased: a whole series of diagnostic and operative possibilities have gradually been added, deriving above all from the great versatility of the instrument.

Advantages of office hysteroscopy

It is applicable to all patients, even those who are very young or very old, regardless of the integrity of the hymen or of previous operations (such as conization or neck amputation), in the very obese and in various limiting conditions (asthma, hypertension, coagulopathies, diabetes).
It does not require any type of anaesthesia.
It allows direct vision and therefore immediate diagnosis.
It allows the execution of a targeted biopsy and the removal of small pathologies (polyps-fibroids).
It is easily repeatable.
It is burdened by few and modest complications.
It has very few contraindications: pregnancy, menstruation in progress (can be performed during other bleedings), acute pelvic inflammatory disease, carcinoma of the cervix.

Main indications for hysteroscopy

AUB or abnormal uterine bleeding;
Infertility;
The need to check the uterine cavity (on indication of other techniques: ultrasound, hysterosalpingography cytology);
Pathological situations already highlighted: polyps, myomas, synechiae, dislocated or lost IUDs;
Patients taking Tamoxifen and needing control of the uterine cavity;
Secondary amenorrhoea (post abortum or from synechiae).

Hysteroscopy: techniques and instruments

The two fundamental elements are: good dexterity and appropriate instruments.

We speak of good dexterity because the execution requires the simultaneous use of both hands with different gestures and movements.

Imagine a violinist who, while plucking the strings with his fingers and holding his arm in place, with the other hand pushes the bow and makes it dance, all of which requires lengthy training.

Add to this the fact that the image is mediated by the monitor and this involves an adaptation effort that has been calculated to be about four times as much as a direct vision.

To these elements must necessarily be added the general and specific training of the doctor performing the examination and not least his humanity (i.e. the ability to interact with the woman who is to undergo the examination).

It is certainly not superfluous to dwell on the fact that before an endoscopic examination one must carefully gather the anamnesis, clarify any doubts and obtain consent (after all, it is not essential that it be written consent).

What matters and becomes decisive on the smooth running of the examination is that the woman not only gives consent but actually ‘accepts’ the event

But let’s go back to the instrumentation and accessories: the most modern endoscope (the one that is used without the vaginal speculum) has a maximum diameter of 4 mm, i.e. about half a child’s little finger, and like it, its cross-section is not circular but oval, making it suitable for passing through the cervical canal, which is the segment that connects the bottom of the vagina with the uterine cavity.

In reality, the cervical canal is more oval than round and therefore the profile of the instrument must be adapted to the section of the canal: this discovery has finally made it possible to overcome the difficulties encountered in reaching the inside of the uterus, and above all has made the examination painless and easy to perform, of course provided that the equipment meets the requirements described, in fact it is enough for the hysteroscope to be 1 millimetre longer or for it not to be oval-shaped but round-shaped for everything to become difficult and painful if not impossible (all of which are still part of the present because many doctors have not yet adapted).

It must also be said that it is precisely for these reasons that many consider hysteroscopy to be a painful and invasive examination and still recommend general anaesthesia: today the examination should be conducted without any anaesthesia whatsoever and this is simply because it is not necessary.

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