View the surgical video: Hysteroscopic Polypectomy
by Keith Isaacson, MD with Aarathi Cholkeri, MD
For the past three decades, gynecologists have been utilizing the hysteroscope in the office to diagnose a variety of conditions that can be responsible for symptoms such as abnormal uterine bleeding, recurrent miscarriage, infertility, and post menopausal bleeding. The most common lesions found during diagnostic office hysteroscopy include cervical and uterine polyps, submucous myomata, uterine septae, intrauterine adhesions, endometrial hyperplasia and endometrial cancer.
Most often, when benign intrauterine and intracervical lesions are diagnosed by office hysteroscopy or even sonohysterography, patients are scheduled to have the lesions removed or treated within the operating room theatre. There are many reasons for this including a greater availability of anesthesia, operating room personnel and operative equipment and the perceived risks and discomfort for patients within the office setting. In addition, physicians are concerned about the cost of purchasing capital equipment necessary for performing office hysteroscopic procedures and the limited reimbursements available to them.
While all of the above concerns are understandable, there are equally compelling reasons why it is advantageous to perform procedures within the office. It can be argued that patients are more comfortable in an office setting. For the physician, there are advantages not having to fill out history and physical paperwork, not having to arrange his or her schedule around the operating room schedule, not having to deal with turnover times and delays. There is a great deal of personal satisfaction when a procedure is performed in the office and the patient is able to get off the table and immediately return to her normal activities.
Of course, no physician is going to perform office based surgery if there is not appropriate reimbursement. Providers in the United States are beginning to understand the cost savings of performing procedures in the office setting as opposed to the ambulatory or general surgical suite. For a limited number of procedures (i.e. diagnostic hysteroscopy, hysteroscopic tubal occlusion, endometrial ablation), there are new CPT codes that will now pay a professional and facility fees for the services provided. Clearly, the number of office based procedures with appropriate RVU assignment will increase as the patient and physician demands continues to rise.
There have been several case and series reports on performing operative hysteroscopy and endometrial ablation in the office using a combination of IV or oral narcotics as well as a paracervical block for anesthesia. For the purposes of this discussion, I will only address office hysterosocpic procedures that can be performed with a “mini” continuous flow hysteroscope (< 5.5 mm O.D.). As a result, the majority of these procedures can be performed with either no anesthesia, oral NSAIDs and or at most, a paracervical block.
Office Operative Hysteroscopic Procedures (Table 1)
Biopsy under direct visualization
Equipment Needed for Operative Office Hysteroscopy (Table 2)
Video set up (camera, monitor, light source, printer, cart)
Mini-hystersocope system (4 mm – 5.5 mm outer diameter (O.D,)
Continuous inflow and outflow
Rod lens or fiber optic lens Zero to 30 degree angle
Mechanical instruments (1-2 mm O.D.)
Scissors – blunt tip and sharp
Cup biopsy forceps
Twizzle bipolar electrode (Gynecare Inc) - Optional
When performing operative hysteroscopic procedures, it is best if a non-viscous, physiologic solution is used i.e. Saline or Lactated Ringers as opposed to CO2 gas. CO2 is commonly used for diagnostic hysteroscopy but is difficult to use in the presence of blood or mucous.
Adequate distention pressures (50-70 mmHG) can be achieved in the office by the use of gravity or a pressure bags. Most office based procedures are of short duration and no more than 2 liters of solution should be utilized. In this situation, it is not necessary to monitor fluid inflow, outflow and deficits in the office setting.
Standard approach -
The standard access approach to the cervix involves placing a speculum within the vagina (preferably side opening), placing single tenaculum on the anterior lip of the cervix, injecting the cervix with local anesthesia (if necessary), and placing the rigid continuous flow hysteroscope within the cervical canal. In most patients, including nulliparous and post menopausal patients, it is not necessary to dilate the cervix prior to insertion. Once the hysteroscope is within the cervical canal, the speculum should be removed, the fluid flow is begun and the hysteroscope is advanced through the cervical canal and into the uterine cavity under direct visualization.
Vaginoscopic approach – (See video)
Drs. Bettocchi and Selvaggi first described the vaginoscopic approach in 1997 (Bettocchi S, Selvaggi L. A vaginoscopic approach to reduce the pain of office hysteroscopy. J Am Assoc Gynecol Laparosc 1997;4:255-8.) The vaginoscopic approach involves placement of the hysteroscope into the vagina without using a speculum. The scope is guided into the posterior fornix of the vagina while the fluid is on in order to create vaginal distension. The hysteroscope is slowly withdrawn until the cervix is identified. The hysteroscope is visually guided into the cervical canal without the use of a tenaculum. When using an oval shaped hysteroscope system such as the Karl Storz Betocchi system, it is often advantageous to rotate the scope 90 degrees to assist with insertion into the uterine cavity. Utilizing the vaginoscopic approach, it is typically not necessary to place a paracervical anesthetic block. This approach has been successfully utilized in over 3000 procedure reported by Cicinelli et al (Cicinelli E, Parisi C, Galantino P, Pinto V, Barba B, Schonauer S. Reliability, feasibility, and safety of minihysteroscopy with a vaginoscopic approach: experience with 6,000 cases. Fertil Steril 2003;80:199-202.)
Hysteroscopic Polypectomy – (Video One)
Either using the standard approach or the vaginoscopic approach, the rigid hysteroscope is inserted into the cervical canal and the fluid distention flow is begun. Under direct visualization, the hysteroscope is advanced into the uterine cavity using an atraumatic approach; the outer sheath should not create a crater in the cervical or endometrial surface. This requires different techniques depending on the angle of the lens being utilized.
Once the hysteroscope is within the uterine cavity, the outflow channel should be adjusted so that there is adequate flow of fluid and distention of the cavity. A complete survey of the cavity should include visualization of both tubal ostium and a panoramic view from the cervix in order to locate all pathology.
Polyps with a narrow base are the most ideal to remove with the mini-hysteroscopes. While it is tempting to grasp the base of the poly with the grasping forceps, it is often more difficult to twist off at the base than anticipated. It is easier to cut the base of the polyp with scissors and grasp the polyps with the grasping forceps. The polyp can not be removed through the narrow 5-7 Fr working channel so the entire hysteroscope system should be removed while pulling the polyp through the cervical canal.
Because of the consistency of most fibroids, they are not easy to remove through an undilated cervix even if they are detached from the endometrium or myometrium. Gallinat has demonstrated a technique of dissecting type I and II myomata from the myometrium using traction and scissors. This is a skilled maneuver that should only be entertained by an experienced hysteroscopist.
An alternative approach is to vaporize small myomata with a bipolar electrode (Versapoint – Gynecare Inc). This technique does not require fibroid chip removal. This is a 5 Fr instrument that can be placed through a mini-hysteroscope. As well, physiologic distention media is utilized because of the bipolar RF energy used to vaporize the myoma.
Because intrauterine adhesions are not innervated, it is painless to the patient when lysing intrauterine adhesions. The patient does complain of discomfort when the normal endometrium or myometrium are injured. Many surgeons prefer to use a monopolar or bipolar needle to cut intrauterine scar tissue. Because Asherman’s syndrome patients are at high risk for uterine perforation and the fact that laparoscopy is not utilized in the office setting, only blunt tip or sharp tip scissors should be used to cut intrauterine scar tissue.
The goal of the adhesiolysis procedure is to identify both tubal ostium and restore the uterine cavity to a normal shape and volume. Should a small perforation occur, loss of uterine distention will occur and the procedure should be discontinued.
Reformation of intrauterine scar tissue after adhesiolysis continues to be a problem. In effort to reduce reformation, surgeons have postoperatively placed patients on high dose estrogen therapy and placed various foreign bodies i.e. IUDs, balloon catheters, within the uterine cavity. The goal of these devices is to keep the uterine walls apart while healing takes place.
Instead of placing a foreign body into the uterus, we have elected to perform follow up or second look office hysteroscopy with a flexible hysteroscope within 7-14 days after the initial adhesiolysis. The flexible scope can break up any filmy adhesion reformation and we have shown that the adhesion reformation rate is comparable to the use of a balloon catheter (data in press). In addition, we place the patients on 2.5 mg of conjugated estrogens(Drug information on estrogens) for 25 days and add 5 mg of medroxyprogesterone(Drug information on medroxyprogesterone) acetate on days 20-25.
Cutting a uterine septum with blunt or sharp tipped scissors is very similar to lysing intrauterine adhesions. Prior to cutting the septum, both uterine horns should be explored and the tubal ostia identified. The scissors are used to cut the septum midway between the anterior and posterior uterine walls. The septum is cut until the fundus is reached or there appears to be normal vasculature within the septal tissue. No follow up hysteroscopy is needed in these patients as it is rare to have scar tissue development in these patients.
This topic was recently thoroughly reviewed by Dr. Radha Syed for OBGYN.net. For the purposes of this discussion, it should be noted that the Essure device can be placed into both fallopian tubes utilizing the vaginoscopic technique. When using this technique, the entire procedure can be performed in less than five minutes and the patients can return to normal activity within 15 minutes.
There is little doubt that we have seen the “tip of the iceberg” when it comes to office based procedures. The majority of the equipment that we are using was designed for utilization within the operating room and we have adapted this technology for office use just by making the equipment smaller. For 20 years we saw very little development in operative laparoscopic instrumentation. When the general surgeons expanded the market, the technology proliferated and we all benefited from the technological advances.
Office based reimbursement and patient demand will stimulate the advancement of office based technology just as we saw in laparoscopy over 15 years ago. Soon, we will be performing myolysis procedures with ultrasound guidance. We will have hysteroscopes designed to reduce three handed procedures to a single handed procedures. The possibilities are limited only by our imagination.