Hysteroscopy is the endoscopic visualization of the cervical canal and endometrial cavity that together are known as the uterine cavity. Hysteroscopic surgery comprises a spectrum of intrauterine procedures performed under endoscopic direction. Although Diomede Pantaleone first published hysteroscopic treatment of an endometrial polyp in 1869 (and in the office), hysteroscopic surgery has lagged behind laparoscopic surgery with many residents and gynecologists hampered by inadequate exposure and training. The advances in endoscopic technology that now allow “real-time” visualization of the cervical canal and endometrial cavity allow most hysteroscopic procedures to be performed in an office setting, with little or carefully applied local anesthesia, in an effective, safe, and comfortable fashion. Like any surgical approach, it is necessary to perform comprehensive investigation designed to identify appropriate patients and to understand the technical requirements, skills, and approaches that facilitate the execution of a safe and effective procedure.  
PRINCIPLES of PATIENT EVALUATION
Regardless of the clinical problem - infertility, recurrent pregnancy loss, postmenopausal bleeding or abnormal uterine bleeding (AUB) in the reproductive years - it is critically important that the patient be evaluated in a structured fashion before undertaking any procedural intervention for diagnosis and especially for therapy. There are a number of findings such as polyps and leiomyomas that may or may not be responsible for the symptom(s) presented by the patient, and other nonstructural entities such as ovulatory disorders or coagulopathies that may have a more important role. Consequently, a carefully performed menstrual history as suggested by FIGO System 1 (Munro et al 2018), and appropriately performed uterine evaluation, are mandatory components of the assessment process. We will not belabor many of them here, but will focus on uterine evaluation. This is the key to appropriate patient selection for hysteroscopic procedures, not only for efficacy, but for safety.
UTERINE EVALUATION
Evaluation of the uterus comprises assessment of the endometrial cavity and the myometrium.
Key Points
  • The structural causes of infertility, recurrent pregnancy loss (RPL), and abnormal uterine bleeding (AUB) cannot be determined by manual examination.
  • The best imaging techniques for evaluating the endometrial cavity are hysteroscopy and sonohysterography (SHG) - the latter sometimes called "saline infusion sonography", a contrast ultrasound technique that can also be performed with gel.
  • The best techniques for imaging the myometrium are ultrasonography and magnetic resonance imaging (MRI).
  • Adenocarcinoma of the endometrium can present in women with chronic AUB (AUB-M) making endometrial sampling necessary in appropriately selected women at increased risk for this diagnosis.  This risk is NOT limited to women over 45 or even over 40, it is existent in anyone with long term ovulatory disorders or in those with a related genetic history as well. 

The main structural anomalies of the uterus include the spectrum of Müllerian anomalies, while the "acquired" abnormalities include polyps, adenomyosis, leiomyomas, and malignancy, the "PALM" group of FIGO's System 2 also known as the "PALM-COEIN" system. Hysteroscopic surgery is particularly appropriate for polyps, most submucous leiomyomas (Types 0, 1 and 2), and for transection of rASRM Class 5 septums (or CONUTA U2 a & b). However, not all leiomyomas are amenable to hysteroscopic resection and transection of septums must be performed only after confirming that indeed it is an ASRM Class 5/CONUTA U2 anomaly. This process requires a diligent, conscientious, and structured approach using a spectrum of imaging techniques.

FIGO AUB System 2, the "PALM-COEIN" system for classification of causes of AUB. The leiomyoma classification system also applies to infertility

Evaluation of the Endometrial Cavity
Transvaginal Ultrasound (TVUS)
 
In the non-pregnant woman with abnormal bleeding, a normal endometrial echo complex (EEC) thickness, in combination with an absence of leiomyomas near to the EEC, is usually associated with a negative hysteroscopic examination. However, focal lesions such as polyps may be present even with an EEC thickness of less than 5 mm (Breitkoph et al 2004).

In the presence of an abnormally thick endometrium (>12 mm), when leiomyomas exist suspiciously close to the EEC, or when abnormal bleeding occurs despite a normal transvaginal scan, strong consideration should be given to additional evaluation with SHG or hysteroscopy.. 
Sonohysterography (SHG)
 
It is important to directly evaluate the endometrial cavity of at least selected women with the symptoms of intermenstrual bleeding (IMB) or heavy menstrual bleeding (HMB). Sonohysterography (SHG), sometimes referred to as saline infusion sonography (SIS) is the sonographic (usually transvaginal) evaluation of the endometrial cavity following the transcervical instillation of a gel or sonolucent liquid such as normal saline. The major deficiency, compared to hysteroscopy, is the inability to concurrently remove selected lesions at the same setting. There is good evidence that SHG has an accuracy for diagnosing structural pathology in women with AUB that is similar to that of hysteroscopy and superior to that of transvaginal ultrasound (Exacoustos et al; Leone et al) . When biopsy is needed, SHG and endometrial biopsy can be performed in the same setting with the same instruments.  
Sonohysteroscopy using 2-dimensional TVUS is accurate, quickly done, generally comfortable for the patient, and accessible to the majority of gynecologists throughout the world. All that is required is a simple catheter - an insemination catheter, an endometrial biopsy cannuula with a Luer attachment, or a specially designed single use catheter with a balloon tip all can be used - in the office setting. Even the use of sterile lidocaine gel instilled with a special applicator or a syringe and a endometrial biopsy cannula can be effective. 

Video demonstrating performance of sonohysterography (SHG) and the relationship to an endometrial polyp seen hysteroscopically

Sonohysterogram (SHG) demonstrating a deep FIGO Type 1 leiomyoma
MRI

Imaging  with MRI can be invaluable when assessing leiomyoma type, to determine feasibility and appropriateness for hysteroscopic technique. Image A.  demonstrates a relatively large but superficial FIGO Type 2 lesion (Munro et al 2018). Hysteroscopic removal can be contemplated. However the leiomyoma demonstrated in B, while of similar size, and perhaps similar appearance hysteroscopically, cannot be approached hysteroscopically because it is a FIGO Type 2-5 lesion.
Diagnostic Hysteroscopy 
The ability of diagnostic hysteroscopy to provide information not predictably obtainable by blind endometrial sampling has been adequately documented (Goldrath et al 1985, Epstein et al 2001, Guido et al 1995). While hysteroscopy can also identify suspicious areas of endometrium, which may represent focal hyperplasia or cancer, endometrial carcinoma may not be recognizable hysteroscopically, making blind catheter, or curettage-based endometrial sampling a more sensitive test for such field lesions. For women with RPL or infertility, diagnostic hysteroscopy may have value in clarifying the findings of TVUS, SHG, HSG or MRI. Of course, in such instances, it is best if the clinician performing the hysteroscopic procedure is both trained and equipped to appropriately manage findings. There is good evidence that diagnostic office hysteroscopy, using no or limited local anesthesia, is well tolerated by most women (Munro and Brooks 2010, Cooper et al 2010, de Silva et al 2020). Adequate hysteroscopic examination of the endometrial cavity requires visualization of the entire cavity, including the fundus, cornua and both tubal ostia. The findings and adequacy of examination should be documented in the patient’s medical record.
HYSTEROSCOPIC INSTRUMENTATION
The instruments used for hysteroscopic surgery can be intimidating as they appear to be vastly different from those used for vaginal, laparoscopic and laparotomic procedures. The designed reflect the need to access the endometrial cavity through the narrow confines of the cervical canal and the requirement to continuously instill and remove distention media. Nevertheless, hysteroscopic surgery, properly performed, has principles similar to surgery elsewhere with respect to the need for exposure and targeted transection and dissection of tissue. In common with laparoscopic surgery is the need for illumination of an operative field created in a potential space that is distended with selected media and visualized with an endoscope connected to a video viewing system. What is absent is the frequent need for vessel sealing/occlusion and reapproximation as is the case for other surgical techniques.  This section will provide a very simplified overview to help the novice understand the instrumentation that will be presented at the time of the course.
Hysteroscopes and Sheaths
Like other endoscopes, traditional hysteroscopes comprise an eyepiece, a distally located lens and an intervening shaft that is typically about 30 cm in length. The design includes a mechanism for transmitting the image from the distal lens to the eyepiece and fiberoptic bundles that transmit light, usually from an external source, to the distal end of the endoscope for illumination of the uterine cavity (cervical canal + endometrial cavity). The transportation of distending media to and from the endometrial cavity usually requires that the hysteroscope be inserted into one or more outer sheath, or sheathes designed for that purpose .
One way of categorizing hysteroscopes is into flexible and rigid designs. Flexible hysteroscopes are similar to those used by gastroenterologists and are self-contained, typically don't require a sheath for instillation and removal of distending media and are generally of smaller diameter than rigid systems. Both light and image are transmitted by separate bundles of optical fibers. The channel used to transmit distension media usually doubles as a portal for the insertion of operating instruments. Typical flexible hysteroscopes are “steerable” with a deflectable tip that angle the view so that lateral aspects of the endometrial cavity, including the corneal areas can be seen. The operative channel of steerable flexible hysteroscopes is generally the only port and is usually too small for most operative instruments, so they are primarily used for diagnostic imaging. 
 Whereas the viewing angle of flexible hysteroscopes can be varied or “steered”, that of rigid hysteroscopes is fixed. However, by varying the angle of the distal lens of a rigid hysteroscope, a ‘foreoblique” view can be obtained. Furthermore, the cavity can be scanned by rotation the hysteroscope on its long axis. Consequently, rigid hysteroscopes are available in a 0-degree format as well as a range of foreoblique angles in two size ranges - between 12 and 15 degrees as well as from 25 to 30-degrees (see figures A and B). The angle of the distal lens of the hysteroscope is, by convention, directed away from the location of the proximally-located light post used to attach the endoscope to the light cable.  This relationship helps orient the surgeon to the direction of view for foreoblique systems.

The choice of viewing angle is, in part, a matter of personal preference, but in part a matter of necessity. The 0-degree endoscopes provide easy orientation to the image, since it is similar to that of normal vision and they are easy to orient for insertion through the cervix into the endometrial cavity (A). However, the flat terminal end of the 0 degree hysteroscope neither lends itself to atraumatic passage through the curvilinear cervical canal nor does it allow for any angled viewing within the endometrial cavity. Visualized entry into the endometrial cavity through the cervical canal is impacted by the viewing angle. The axis of the cervix is aligned with the viewing angle for a 0º hysteroscope, but the differences posed by oblique lenses require that the surgeon adjust the insertion angle to account for this phenomenon (See A and B).
The rod lens-based construction of a rigid hysteroscope provides both a more durable instrument and a superior image. Commonly used rigid hysteroscopes vary from 2 to 4 mm in outside diameter (OD). To function most effectively channels are needed to deliver and remove media and instrumentation. Although there are some specially designed systems, most require an outer cylindrical tube or “sheath” or sheathes as they include the conduits necessary for delivery of distention media and operative instruments into the endometrial cavity. The sheath may have only a single channel for instillation of distension media but at least two media channels are preferred because continuous inflow and outflow of fluid distension media is associated with improved visualization of the operative field secondary to clearance of blood and tissue debris. Such continuous flow systems are essential for any complex operative hysteroscopic procedure.
 In addition, operative sheaths and systems include additional channels to allow for insertion of a range of integrated or accessory instrumentation These features add to the overall OD of the system placed through the cervical canal; ranging from about three to five mm for simple diagnostic systems, to between five and nine mm for electromechanical and RF resectoscopic systems. 
Systems for Distending Media Management
Hysteroscopy depends on the conversion of a potential space (the endometrial cavity) into an actual space for viewing and targeting pathology.  The media used may be gaseous CO2  or low viscosity liquids. Carbon dioxide gas requires gas tanks, a special insufflator, often referred to as a ‘Hysteroflator®’ and is unsuitable for operative hysteroscopy.. The low viscosity fluids either contain electrolytes, such as normal saline or are electrolyte free, the latter including dextrose in water and those with a sugar molecule to increase osmolality such as 3% glycine, 1.5% sorbitol and 5% mannitol. 

 There are essentially three components of fluid management. These comprise infusion of the media into the endometrial cavity, removal from the endometrial cavity and either estimation or quantification of the amount of fluid that might be absorbed into the systemic circulation, either through breaches in endomyometrial blood vessels or by extravasation through the fallopian tubes. 
The most simple system for distention is a syringe filled with fluid media attached to the hysteroscopic system directly or with tubing. Such an approach may be very useful and appropriate for simple diagnosis but is not particularly practical for operative procedures.   The most commonly used “simple” system exploits gravity by suspending a bag of distention media from the  a pole designed for intravenous solutions (“IV Pole”). The pressure generated can be changed by varying the diameter of the tubing or the height of the media above the uterus. Pressure can be augmented with an inflatable cuff placed around the bag. More sophisticated systems generate pressure using and infusion pumps that are pressure-sensitive pumps and maintain a preset intrauterine pressure. 
Simple diagnostic systems have no dedicated outflow port. Media are removed from the endometrial cavity drainage after disconnecting the infusion tubing, or by completely removing the hysteroscopic system. For systems with a dedicated outflow port, called continuous flow systems,  tubing can be connected and directed either passively into a receptacle or bucket, or, attached to low-pressure suction. 
The passage of significant volumes of distending media into the systemic circulation can pose a hazard to electrolyte balance, with electrolyte free media and to cardiac overload with any type of media (Arieff et al 1987, Ayus et al 1992, Istre et al 1994). Consequently, a number of fluid management systems are available to continuously monitor inflow and outflow of distension fluid and provide “real-time” monitoring of fluid balance. Most systems measure the discrepancy by the weight of infused versus collected fluid, or, alternatively, the volume of the infused fluid compared to the weight of the outflow fluid. This requires that the system be calibrated prior to the procedure. Most systems provide a user adjustable alarm that sounds when a preset discrepancy has occurred. Many operating rooms require the use of a fluid management system to enhance patient safety. 

Instruments for Incision, Excision, or Targeted Destruction of Intrauterine Tissue

Hysteroscopic surgery utilizes incision, excision or destruction of targeted intrauterine tissue under direct visual guidance. The instruments used for this purpose are generally either mechanical or energy-based based, the latter most commonly radiofrequency (RF) electrical energy.
Mechanical instruments
Scissors & Graspers
The most commonly used instruments include scissors as well as biopsy and grasping forceps that are narrow and flexible enough to navigate a 1- to 3-mm (3 – 7 French or Fr) diameter operating channel depending upon the design of the sheath. Although the narrow diameter permits surgery in a restricted operative field such as the endometrial cavity or cervical canal, the small size and delicate construction are factors that limit their capabilities. 
Mechanical Morcellators
Mechanical morcellators are derived from orthopedic shavers and allow intrauterine morcellation and excision of endometrial polyps and selected submucous leiomyomas. The concept is a cylindrical oscillating blade housed within a hollow tubular probe with a side fenestration. The side fenestration or "window" is placed on the target tissue and the blade oscillates, cutting the tissue as it is drawn into the probe's lumen with suction. 
The term "morcellator" is appropriate but has been fraught with controversy because of the issues surrounding laparoscopic morcellation and malignancy. 

While these systems can be very effective there are at least two issues. The single use components range from several hundred to more than $1,000 and, for deep Type 1 and Type 2 myomas everywhere, and almost any Type 1 fundal leio
myoma, they are not, used by themselves, effective. See the video.
Medtronic Hysteroscopic Morcellating Systems ("TrueClear")
Hologic Hysteroscopic Morcellating Systems ("MyoSure")
While the previous two systems are driven by an electric motor, this device, from Hologic (MyoSure) is driven by hand action, with the tissue collected in the receptacle at the proximal end of the device. Since this is designed for small to medium sized polyps, there is no need for the fluid management system and the cost, compared to electromechanical devices is much lower. 

  • A hand  operated (manual) mechanical morcellating and tissue removal device

    Button

  • Myosure manual passed through channel of Hologic hysteroscope

    Button
Electrosurgical instruments
Radiofrequency electricity is delivered either via a resectoscope or a narrow monopolar or bipolar instrument, usually 5 Fr in diameter, that is passed through the operative channel of a rigid hysteroscopic sheath. Applied properly, these instruments can be used to vaporize, incise or coagulate tissue. 
5 Fr RF Instruments
There exist a number of bipolar instruments that can be passed into the endometrial cavity through the 5Fr channel of an operating hysteroscope. These devices can be used to transect tissue, for local vaporization of very small myomas or for coagulation of bleeding vessels. An example of these in clinical use can also be seen in the below section on transection of the uterine septum. They require a proprietary RF generator and connecting cable and require saline as the distending medium. 

5 Fr "Twizzle" (a bipolar RF instrument) demonstration on a uterine septum

The Resectoscope
The gynecologic resectoscope is essentially identical to that used by urologists and is designed to apply focused RF electrical energy in the endometrial cavity via any of a number of electrode designs. An understanding of RF electrosurgical principles is mandatory for safe and effective use of these instruments. By manually sliding a component of the resectoscopic assembly called the “working element,” any the electrodes can be manipulated back and forth within the cavity. Tissue can be transected with a needle or blade electrode, excised with a cutting loop or desiccated with a rolling ball or bar. An electrode with multiple tips or edges can also be used to vaporize tissue, a process that requires an electrosurgical generator that can deliver high wattage current.
Historically, resectoscopes were monopolar in design, but increasingly, bipolar devices are dominating, largely because of safety issues. Monopolar resectoscopes require electrolyte free media to minimize dispersion of the electrical current in the distending media thereby maximizing concentration of the current on the target tissue. Bipolar resectoscopes reduce the risk associated with monopolar systems in part by functioning in electrolyte-free solutions. The difference in the design is such that both the “active” and dispersive electrode are integrated into the device, usually both at the distal tip of the instrument. Another issue with monopolar instrumentation is the potential for electrosurgical injuries to the vagina and vulva from capacitive coupling to the outer sheath of the resectoscope. Furthermore, since the monopolar resectoscope requires the use of electrolyte-free distension media, the potential for hypervolemia may be further complicated by hyponatremia.

Regardless of the design, the surgeon must be careful to avoid advancing activated electrodes through the myometrium, as surrounding viscera may be placed at risk of electrosurgical injury. Should perforation occur with an advanced and activated electrode it is mandatory to explore the peritoneal cavity to look for vascular or visceral injury. 

You can see these instruments in action below in the "Hysteroscopic Surgery"  section on myomectomy.
HYSTEROSCOPIC SURGERY
The following sections should not be seen as a replacement for a comprehensive understanding of hysteroscopic surgery, but should serve as a framework upon which to build knowledge of the various elements and techniques that comprise this endoscopic discipline. 
Patient Preparation
 
Key Points
  • Preparation for any surgical procedure, including hysteroscopic surgery, is a strategy that comprises a synthesis of education, communication and a medical process. 
  • Informed consent is more than a signed document; it is an iterative process that combines questioning, counseling and balancing the risk of an intervention with the anticipated benefit in a way that allows the patient to formulate an informed decision. 
  • The risks associated with hysteroscopy are real but are minimized if the procedures are performed by individuals with appropriate training who are practicing in an environment with adequate staff, supplies and equipment.
  • Regardless, it is important that patients are provided information regarding the risks of hysteroscopic surgery that allow them to make the informed decision.
  • There exist a number of medical interventions that may improve the outcome of a hysteroscopic surgical procedure that include suppression of endogenous estrogenic activity to thin the endometrium, ripening of the cervix to reduce the force of dilation and preemptive analgesia to reduce procedure pain if the hysteroscopic intervention is performed under local anesthesia.
Analgesia and Anesthesia
 
Key Points
  • While many women, particularly those who require diagnostic hysteroscopy only, require no analgesia, many require uterine anesthesia be it using local, regional or general anesthetic techniques.
  • Anxiety contributes to the perception of pain, so when performing hysteroscopic procedures in an office or clinic environment, efforts should be made to reduce anxiety based on the appearance of the room, its temperature and the general mood which can be affected by noise or other interruptions and the comportment of the medical and support staff.
  • Women should be reassured that if the procedure causes undue pain, it will be terminated and plans made to complete it at a later time and possibly under different conditions such as with different anesthesia and possibly in an alternate location.
  • There is evidence that music reduces both anxiety and pain.
  • There is high quality evidence that, at least for diagnostic hysteroscopy, the vaginoscopic technique is feasible and comfortable for the vast majority of women.
  • Local anesthetic techniques, appropriately applied, can allow the performance of the entire spectrum of hysteroscopic surgical procedures. There is increasing evidence that the vagina and the entire uterus should be considered and approach that recognizes the unique and variable innervation of the uterus.
  • Regardless of the analgesia or anesthetic technique used women should be encouraged to have a support individual available to accompany them home following the procedure. This is mandatory should psychoactive or systemic anesthetic agents be used for the procedure.
Uterine Local Anesthesia
There are many different perspectives on the need and techniques for performing hysteroscopic procedures without general or regional anesthesia. It is true that with narrow caliber instrumentation, and when only diagnosis is the goal that most women can undergo hysteroscopy. However, not everyone is the same - disorders such as adenomyosis and endometriosis seem to make uterine procedures more painful and there are undoubtedly other factors that impact the ability of an individual to tolearate a procedure. The technique shown in the accompanying video has been used for more than 15 years to allow performance of virtually all hysteroscopic procedures in an office setting - much as is the case for dental procedures. The results of the first 600+  were published (Keyhan and Munro 2014). All of the procedures shown in this section were performed in the office, using this regimen. All went home within 15 minutes of completing the procedure and immediately returned to their normal activities. 

Local anesthesia for intrauterine procedures including hysteroscpoic surgery.

Accessing the Endometrial Cavity
 
Key Points
  • Without successful access to the endometrial cavity, hysteroscopy is not possible, so careful attention to technique is critical to success. 
  • There exist a number of techniques whereby uterine access can be achieved and not all are applicable to all patients. Consequently, the effective hysteroscopist should be facile at more than one approach.
  • Visual entry using the hysteroscope is the preferred approach; blind entry techniques are to be discouraged
  • In some instances access is difficult, a circumstance that may necessitate the use of a number of ancillary techniques including concomitant transabdominal ultrasound. 
Vaginoscopic Technique
The vaginoscopic approach for accessing the endometrial cavity does not require the use a speculum or tenaculum and reduces discomfort at least with simple diagnostic procedures (Cooper et al 2010). The distal end of the assembled hysteroscopic system is passed into the lower vagina while the liquid distension media is infused. The pool of fluid in the upper vagina allows visualization of the exocervix and external os. The hysteroscope is gently advanced through the visualized external os into cervical canal and through to the the endometrial cavity. Vaginal distention can be facilitated by opposing the vulva with the gloved fingers of the free hand to minimize egress of fluid from the vagina. When anatomy or other clinical features makes such distention difficult, an inflatable laparoscopic vaginal pneumo-occluder, positioned and slightly inflated around the hysteroscopic sheath can facilitate this process. 
Speculum/tenaculum Technique
The traditional approach  is used when the vaginoscopic technique is neither feasible nor successful. The clinician should select the smallest speculum compatible with adequate exocervical exposure. A bivalve speculum hinged on only one side (“open-sided”) can be removed without disturbing the position of the tenaculum and hysteroscopic system. The use of weighted specula should be avoided when using local anesthesia because of patient discomfort. F

The hysteroscope should be the first instrument to enter the cervical canal and the endometrial cavity. Such a visual entry technique should reduce the risk of perforation and allows visual assessment of the cervical canal and endometrial cavity unaffected by trauma from sounds and dilators.

When cervical dilation is necessary the process should be undertaken carefully, respecting the version (orientation of the cervical access to that of the vaginal canal (version) and flexion, that of the corpus to the cervix . A tenaculum, attached to the anterior cervix, and held with subsequent gentle traction helps to reduce the degree of version  and provides a degree of counterforce to facilitate passage of the hysteroscopic assembly through the cervical canal into the endometrial cavity.  
Distending Media
 
Key Points
  • Distention media are needed for hysteroscopy for the purpose of converting the potential space of the endometrial cavity to a real space 
  • Options for uterine distention include CO2 and fluid media. CO2 is not suitable for operative procedures
  • Hypotonic, non electrolytic fluids solutions containing glycine, sorbitol and mannitol are required for the use of RF electrosurgery with monopolar instrumentation
  • Excessive absorption of hypotonic fluids can result in fluid overload and hypotonic hyponatremia, causing permanent neurological complications or death.
  • Normal saline is a safer media because, even with moderate levels of absorption, electrolyte levels are normal
  • Bipolar RF instrumentation require saline media, a circumstance that makes them safer than monopolar instrumentation when excess media is absorbed into the systemic circulation. 
  • Distention media management systems that control infusion pressure and monitor systemic absorption are recommended when it is known or suspected that the integrity of the myometrium will be breached during the procedure. 
  • The maximum allowable absorption of electrolyte free media ranges from 500 mL to a maximum of 1,000 mL
  • The maximum allowable absorption of normal saline ranges from 1,500 to 2,500 mL depending in large part on their baseline cardiopulmonary function
  • Hysteroscopic programs should have protocols that guide the termination of procedures when the preset thresholds are met
Hysteroscopy Fluid Management Guidelines (AAGL) 
AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media. Journal of Minimally Invasive Gynecology (2013) 20, 137–148 ! 2013 AAGL
Hysteroscopic Surgical Procedures

NOTE: All demonstrated procedures have been performed in an office procedure room under local anesthesia

Polypectomy
There are many ways to perform polypectomy successfully and effectively. What should NOT be attempted is "blind" polypectomy since the risk of perforation and chance of recurrence both increase (Gebauer et al 2001, Liberis et al 2003). The least expensive technique is to use reusable hysteroscopic scissors to transect the polyp and graspers to remove it. Other techniques include RF resectoscopic transection with a loop or needle electrode, and mechanical or electromechanical removal with a morcellating aspirating system. However, these systems can add substantial expense to the procedure because they include single use components that are as much as $1,000.

Hystroscopic polypectomy using 5 Fr scissors for transection and grasping forceps for extraction

 Hysteroscopic polypectomy using an electromechanical transection and aspiration system.

Adhesiolysis
Intrauterine adhesions can be extremely "mild" requiring only a few simple passes with hysteroscopic scissors, or can be quite severe, a circumstance fraught with the risk of perforation. Demonstrated are two extremes - one a simple but thick adhesion transected with scissors, and extensive adhesions including occlusion of the region of the internal os requiring simultaneous ultrasound to guide the dissection process. 

Intrauterine adhesiolysis with trans abdominal ultrasound guidance

Septum Transection
When there is failure of resorption of the septum that results from embryonic Müllerian fusion, a septum of variable length occurs - ranging from those in the upper portion of the fundus, all the way to involvement of most of the vagina. These septae may or may not  contribute to infertility, but appear to be a causative factor in recurrent pregnancy loss or malpresentation in labor (Heinonen et al 1982, Lin et al 2004, Acien et al 2014). Transection (NOT resection) of the septum can be accomplished and appears to substantially reduce the rate of pregnancy loss (Heinonen 1996, Homer et al 2000),  The technique is conceptually simple, but visualization is the key. Note that the patient here has a thin endometrium - the result of preparation with a progestin. The procedure is performed under local anesthesia with addition of anesthetic to the septum in this instance - in addition to the regimen demonstrated elsewhere in this section. No postoperative interventions are used and patients are generally advised to refrain from conception until about 12 weeks following the procedure. Such women are not contraindicated from undergoing labor and vaginal delivery.

Hysteroscopic transection (NOT resection) of a septum involving the endometrial cavity, without involvement of the cervix.

Removal of Products of Conception
It is evident that Asherman syndrome - the presence of intrauterine adhesions typically associated with reduced or absent menses - most commonly occurs following blind curettage of a recently pregnant uterus (Foix et al 1966), . The products of conception are not attached to the entire endometrial surface, but blind curettage traumatizes the entire surface, and, following pregnancy can then result in adhesions. Evolving evidence suggests that targeted removal of products of conception, using hysteroscopic guidance, can result in reduced adhesions. It is unclear where the best use of this technique lies, but delayed removal, following uterine involution, is ideally suited because the cervix is narrow enough to allow dilation of the endometrial cavity. A NON ELECTRIFIED resection loop can be used, but this is an example of an electromechanical morcellator. Note the localization of the tissue, and the ability to target the removal, minimizing trauma to the rest of the endometrium. 

Removal of products of conception hysteroscopically, rather than blind techniques that appear to increase the risk of post procedure adhesions.

Foreign Body Removal
By far the most common foreign body that exists in the uterus is an intrauterine contraceptive device or releasing system - an IUD or IUS. There are other types of foreign body however and these include suture, broken medical devices and bony fragments from a previous pregnancy. This video demonstrates the removal of a MultiLoad IUD, a common device used outside of the US. However, most, not all, are similar in that there is a crossmember, a main stem and an attached monofilament thread. It may be best to grasp the device by its base rather than the thread since the thread may break or be transected by the grasping instrument. 

Hysteroscopically directed removal of an IUD from the endometrial cavity

Myomectomy
Hysteroscopic myomectomy has truly revolutionized the treatment of AUB-Lsm and related infertility or RPL. However, the many different leiomyoma types, locations and volumes present the need for a spectrum of skills and techniques. Demonstrated here are three different techniques - one is pure RF electrosurgical, one pure electromechanical, and one a combination of RF, scissors dissection and electromechanical morcellation and removal. Both loop electrodes and electromechanical devices are morcellating systems that DO NOT lend themselves to removal of leiomyomas that substantially involve the myometrium. The FIGO Type 2 technique has been published (link) and another example is demonstrated here. 

Radiofrequency (RF) loop electrosurgical resection/morcellation of a FIGO Type 1 leiomyoma. Removal of the morcellated fragments, not seen, is performed manually with forceps/curette

Electromechanical removal of a FIGO Type 0 leiomyoma.

The 37year old patient in the accompanying video had AUB-L as well as secondary infertility.  Her superficial FIGO Type 2 leiomyoma was removed in the office setting under local anesthesia. Demonstrated will be preprocedure imaging, the formation of a circumferential incision into the pseudo capsule using a bipolar RF needle, dissection in the pseudo capsule with scissors and then further dissection, morcellation and removal of the leiomyoma with an electromechanical device. The measured systemic absorption was approximately 770 mL and the patient drove herself home 15 minutes after the procedure was completed. This technique has also been published in the peer review literature (Munro 2016).

SUMMARY and CONCLUSIONS

Hysteroscopic surgery is an essential part of minimally invasive gynecologic surgery (MIGS), being the least invasive of the surgical techniques. There are no visible incisions and the approach allows direct access to pathology that causes symptoms such as AUB, infertility and recurrent pregnancy loss, without the need for transecting the abdomen or the myometrium. Because the access is through  pre-existing channels (vagina, cervical canal) hysteroscopic surgery can also be considered a type of "natural orifice" surgery. However, there are perils to hysteroscopic surgery, especially if the surgeon is not careful - both with preoperative evaluation and with surgical techniques. Consequently, it is imperative that women are properly evaluated and surgeons properly trained and experienced in performing these procedures. Indeed, essentially all hysteroscopic procedures can be performed in an office environment without systemic opiates or anxiolytics, an approach that further decreases risk and cost, both to the healthcare system and the patient.

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