Endoscopy in minimally invasive gynecologic surgery

Preoperative imaging: Ultrasound

Surgical readiness is facilitated by preoperative imaging, which almost universally involves a sonographic study . Gynecologic ultrasound is a cost-effective, noninvasive, and accessible imaging technique that can help elucidate the nature and extent of pelvic disease ( ). Ultrasound is easily integrated into the process of gynecologic investigation and preoperative planning; for example, a transabdominal “visceral slide-test” can yield information about the likelihood of adhesive disease at the site of planned trocar placement, decreasing procedure-related complications and increasing patient safety ( ). The observer-dependent nuances of an ultrasound examination in real time can be informative for the gynecologic surgeon, assessing the presence and nature of uterine or adnexal pathologic changes, elucidating the likelihood of infiltrative endometriosis or pelvic adhesions, and helping to clarify what surgical options are reasonable or contraindicated. When ultrasound is performed as a point-of-care study, the patient becomes an integral part of the ongoing discussion of findings, and this enhances the process of shared decision making.

Minimally invasive surgical options for definitive diagnosis with the twin goal of symptom relief can be offered to the patient, guided by ultrasound findings and concomitant physical examination. Uterine fibroids might be visualized within the myometrium by ultrasound in a perimenopausal woman with heavy and painful menses, or the clinician might surmise that adenomyosis has infiltrated throughout the myometrium by the diffuse inhomogenous echotexture and thickened uterine wall apparent on transvaginal ultrasound. A classic ovarian endometrioma or an ovarian dermoid cyst might be visualized sonographically in the setting of a palpable pelvic mass. Should the ultrasound appearance of the adnexa be suspicious for an ovarian malignancy, prompt referral to a gynecologic oncologist can be arranged.

In the setting of abnormal bleeding, a thin endometrial lining of normal contour in a postmenopausal patient or in the early follicular phase of a premenopausal patient by ultrasound essentially rules out intracavitary pathologic conditions ( ). It is acceptable then to forego a potentially painful endometrial biopsy in such a patient and concentrate on causative factors for the abnormal bleeding other than endometrial pathologic conditions in the initial workup. An endometrial polyp or submucosal fibroid can be identified by a properly timed ultrasound as a mass within the uterine cavity and is often missed by an endometrial biopsy ( ). With ultrasound as first-line triage in the setting of abnormal uterine bleeding or infertility, when an endometrial mass is visualized, it is not unreasonable for hysteroscopy to be the next step, as the only invasive intervention for diagnosis and treatment of what is likely an endometrial polyp or myoma.

Additional imaging options

Adjuncts to the standard gray-scale ultrasound evaluation include Doppler flow to evaluate lesion vascularity in the uterus or adnexa, informing the gynecologist about the likelihood of an endometrial polyp versus intracavitary fibroid versus a mere blood clot and providing information indicating the likelihood of a benign versus malignant process in the adnexa. Sonohysterography involves placing a small catheter to instill either saline or gel into the uterine cavity under ultrasound guidance and can help rule out the presence of an endometrial mass in the setting of a relatively thickened endometrial appearance when no discrete mass is seen by standard ultrasound . If no mass is apparent, an endometrial biopsy could suffice for endometrial diagnosis and hysteroscopy deferred. Sonohysterography has been shown to be comparable to hysteroscopy in delineating the presence of intrauterine pathologic conditions such as polyp or submucosal fibroid formation ( Fig. 10.1 ), retained products of conception, a cesarean section scar defect, or uterine septum ( ). Three-dimensional (3-D) ultrasound is an excellent tool to ascertain the presence of uterine anomalies or an intrauterine device (IUD) location and can be used in lieu of magnetic resonance imaging (MRI) to delineate fibroids before a complex laparoscopic myomectomy; 3-D ultrasound with gel instillation has been referred to as “virtual hysteroscopy” and can be helpful as an adjunct to ultrasound for preoperative planning before a more complicated hysteroscopic myomectomy.

Preoperative MRI imaging is helpful in selective patients to assess a fibroid uterus for signs of adenomyosis or sarcoma or map fibroids before a laparoscopic or hysteroscopic myomectomy procedure . Computed tomography (CT) is less helpful in the pelvis for elucidating gynecologic pathologic conditions but can be informative with delineation of the urinary tract and gastrointestinal systems and in investigating pelvic abscess formation. Fluorescence studies are increasingly helpful intraoperatively in delineation of disease. In addition, intraoperative transabdominal or laparoscopic ultrasound can provide crucial information to guide surgical interventions.

Indications for hysteroscopy

Endometrial polyps are a common cause of abnormal uterine bleeding, found in up to 35% of patients with postmenopausal bleeding ( ) and not infrequently in women on tamoxifen. These usually benign endometrial growths can cause abnormal bleeding and subfertility in premenopausal woman. Submucosal fibroids within the endometrial cavity can cause profoundly heavy uterine bleeding and anemia in premenopausal women and can contribute to infertility and pregnancy loss, as well as IUD expulsion. Because both endometrial polyps ( Fig. 10.2 ) and submucosal fibroids are often missed by a blind endometrial biopsy, ultrasound is an evidence-based initial step in the investigation of abnormal uterine bleeding in both reproductive-age and postmenopausal patients, with hysteroscopic evaluation the gold standard for diagnosis and treatment of these intracavitary lesions. Indications for hysteroscopy include diagnosis and treatment in patients with abnormal bleeding and the finding of an endometrial mass on ultrasound or sonohysterography. In patients with nondiagnostic imaging, endometrial biopsy can be performed in lieu of or at the time of hysteroscopy to rule out endometrial carcinoma or precancerous endometrial pathologic conditions.

Intrauterine adhesions are usually caused by prior uterine instrumentation and can present with amenorrhea and infertility as a condition called Asherman syndrome ( ). This agglutination is best diagnosed by hysteroscopy and can be treated with scissors or instrumental dissection under hysteroscopic visualization. Another indication for hysteroscopy is the management of a retained or impacted intrauterine device, which can be removed under direct visualization with a hysteroscopic 5-French grasper. Uterine anomalies such as septal defects ( Fig. 10.3 ) can be confirmed hysteroscopically and resected with a small 5-French bipolar tip or hysteroscopic scissors; other energy sources can also be used, with care taken not to damage the endometrium. Retained products of conception remote from delivery or after a pregnancy loss might be amenable to cold-loop resection or mechanical morcellation under hysteroscopic guidance ( Fig. 10.4 ). A cesarean scar defect can be evaluated hysteroscopically concomitant with laparoscopic surgical correction or, if the patient is not interested in a future pregnancy and abnormal bleeding is a problem, treated with hysteroscopic resection under ultrasound guidance ( Fig. 10.5 ).

Hysteroscopic sterilization is anticipated to again be an option in the future; its global use from 2002 to 2018 is now historical because there is no longer a device on the market for blockage of the proximal aspect of the fallopian tubes by hysteroscopic means. Hysteroscopy can be used to remove Essure implants when a significant component of a retained sterilization device is present in the uterine cavity; familiarity with the implant is necessary to ensure the entire coil set is extracted.

Indications for hysteroscopy are listed in Box 10.1 . Relative contraindications for hysteroscopy include pregnancy and genital tract infections, including active herpes.

Hysteroscopic equipment

A hysteroscope can be rigid ( Fig. 10.6 ) or flexible, and the tip diameter can range in size from approximately 3 to 9 mm. The wider the tip of the hysteroscope, the greater the potential for patient discomfort and cervical trauma because progressive cervical dilation will likely be required for the larger hysteroscope to be advanced through the endocervical canal and into the endometrial cavity. The tip of a rigid hysteroscope can be 0 degrees or angled, depending on the operator’s preference; l2- to 30-degree lenses are most often used. A light source is required, and a camera with attached video monitor is usually included. The reimbursement profile for hysteroscopy has shifted to significantly favor office-based procedures, supporting the capital investment in equipment. One obstacle to office-based hysteroscopy can be the reprocessing of instruments, but this challenge is not insurmountable. A case-by-case expenditure is an alternative with disposable setups and hysteroscopes, although these are not as versatile as most reusable systems. Future trends in instrumentation will likely include reposable, hybrid systems with LED and Bluetooth mechanisms.

Hysteroscopic instruments

Hysteroscopes have an operative port through which graspers, scissors, tenacula, or bipolar tips can be placed ( Fig. 10.7 ). These working instruments are usually 5 French in diameter, fit easily into a standard 5-mm hysteroscope, and can release, incise, grasp, or biopsy endometrial pathologic tissue under direct visualization. The polyp, small leiomyoma, or biopsy specimen can often then be extracted along with the hysteroscope. Endometrial polyp forceps and specialized myoma forceps can be used to gently grasp and remove any endometrial pathologic tissue inadvertently released within the uterine cavity, and ultrasound guidance can be used to assist with this process if desired. This simple technique works well with endometrial polyps and can also be used with fragments of myomas from resectoscopic surgery. These small 5-French instruments can also be used through an operative port to remove a retained IUD or Essure coil and to treat intrauterine adhesions or an intrauterine septum.

Specialized hysteroscopes are available that can incorporate an energy-based modality for operative intervention under direct visualization. These options for intracavitary treatment include the electrosurgical resectoscope ( Fig. 10.8 ) and the mechanical morcellator ( Fig. 10.9 ), and they are especially helpful with fibroid removal and also with larger polyps. Advanced technology has resulted in ever smaller prototypes of these hysteroscopes, essentially the equivalent of a 5-mm office hysteroscope, and so these procedures as well are being moved into the office setting. For challenging cases, however, such as those requiring significant dilation of a stenotic cervix or for which a large-bore hysteroscope is needed, IV sedation in the operating room setting might be imperative.

Office-based hysteroscopy and minimal impact technique

The office or clinic is a cost-effective venue for many hysteroscopic procedures, efficient for the gynecologist, and convenient for the patient ( Box 10.2 ). A meta-analysis comparing office hysteroscopy with operating room hysteroscopy showed no significant difference in adverse events or treatment success ( ). Office hysteroscopy was substantially less expensive in all randomized trials compared with the operating room counterpart. There was greater reported postoperative pain associated with the office venue, however, and the authors’ conclusion was that a shift to an office venue should be “thoughtfully considered.” Effective strategies can be employed to enhance patient comfort ( Box 10.3 ).

Preoperative nonsteroidal medication has been shown to decrease postoperative discomfort after office hysteroscopy, and can be taken by the patient in advance of the appointment. Ingestion of a light meal is encouraged because it might also ward off any tendency to a vasovagal reaction and can help decrease any NSAID-associated gastrointestinal upset. Engagement with the patient is helpful, and this can include live observation of the procedure on the video monitor, as well as conversation, humor, and music.

Hysteroscopic procedures