Hysteroscopy  Module
To Hysteroscopy Prep
The overall educational goal of the Hysteroscopy Module is to  understand the value of hysteroscopy and hysteroscopic surgery and how to apply the various hysteroscopic systems safely and effectively.
Objectives
By the end of this session, the resident will be able to:
  1. Demonstrate proper assembly and disassembly of the different hysteroscopic systems available in the session
  2. Perform different hysteroscopic tissue removal techniques using a hands-on tissue simulation systems
  3. Demonstrate manipulation of the various parameters impacting the intrauterine distending media pressure 
  4. Describe strategies to improve the chance of successful access to the endometrial cavity.
STATION 1. Endometrial Polyps, Hysteroscopic Polypectomy 1
Tasks
  1. Assemble an operative hysteroscopic system including endoscope, sheath, inflow and outflow, camera and light source.
  2. Access the simulated endometrial cavity
  3. Remove the polyp using scissors and grasper
  4. Assemble a Bipolar RF resectoscope including the endoscope, internal and external sheaths, electrode, element and electrical, light and fluid connections and camera.
  5. Access the simulated endometrial cavity and remove the polyp using RF electricity.
Clinical Vignette 1
65yo P-0000 with a single episode of postmenopausal bleeding presents to your office referred by her primary care provider. Transvaginal US shows an EEC of 10 10mm and sonohysterogram demonstrates a 12 X 7 mm polyp. Endometrial biopsy shows minute fragments of hypotrophic benign endometrium and tissue consistent with a benign endometrial polyp. You plan a hysteroscopic polypectomy.
Questions
  1. What are special considerations when performing hysteroscopy on a postmenopausal patient?
  2. What is the chance of cancer if the endometrial biopsy is normal?
STATION 2. Endometrial Polyps, Hysteroscopic Polypectomy 2
Tasks
  1. Assemble the manual mechanical morcellating system including input and output connections (Hologic Myosure Manual)
  2. Perform hysteroscopic polpyectomy with the manually operated mechanical device
  3. Assemble the electromechanical hysteroscopic morcellating system including hysteroscope, morcellating probe and fluid management components.
Clinical Vignette 2
45 year old P-3003 with the symptom of random intermenstrual bleeding superimposed upon normal volume, predictable q 29 day menses with a duration of 4 days. You perform a Day 5 transvaginal ultrasound and find a EEC thickening to about 22 mm. Sonohysterogram demonstrates findings consistent with an endometrial poyp 27 X 19 mm in greatest dimensions. What are your options for cuff closure? Endometrial biopsy at the time of the SHG shows proliferative endometrium.
Questions
  1. How would you provide analgesia or anesthesia for this patient in the office setting?
  2. How would you remove this polyp if it was 8 X 5 mm?
  3. What do you know about the chances of recurrence of polyps?
  4. What do you understand about the cost of the instrumentation that you have used at this station?
STATION 3. Endometrial Biopsy, Hysteroscopic Transection of a Class V/U-2a, C-0, V-0 Septum
Tasks
  1. Assemble the hysteroscopic system comprising the operative sheath with a 5 Fr Channel, the endoscope, the fluid attachments and the medical camera. 
  2. Access the simulated endometrial cavity, perform hysteroscopically guided biopsy of the tiny polyps using the 5 Fr biopsy forceps or graspers, 
  3. Use the scissors to transect a “septum”.
Clinical Vignette 3
25yo P 0000 with the symptom of random intermenstrual bleeding, predictable q 25-day cycles with normal menstrual volume lasting 3 days, and primary infertility for 13 months. Day 18 transvaginal US shows an echogenic EEC of 12 mm, come central irregularity, and a possible septum involving the corpus. Sonohysterogram demonstrates two fundal polyps, one 8 mm long, the other 12 mm long.
Questions
  1. What role do failures of Mullerian absorption have on fertility?
  2. What additional information do you need when contemplating and counseling about surgery?
STATION 4. Hysteroscopic Myomectomy, Electromechanical Morcellation and Removal
Tasks
  1. Assemble the hysteroscopic system comprising the hysteroscope with integrated channel, the outflow channel, the fluid management system and tubing, and the medical camera.
  2. Understand the components of the fluid management system
  3. Insert a morcellating cannula
  4. Perform electromechanical morcellation of the simulated leiomyoma
Clinical Vignette 4
37yo P-2002 with the symptom of heavy menstrual bleeding (HMB) for 18 months, a Hb of 10.5 and a ferritin of 13. You perform a transvaginal ultrasound and find a uterus that is 9 cm long with a central 2.5 cm mean diameter mass consistent with a leiomyoma. Sonohysterogram demonstrates a (FIGO Type 0, Type 1, Type 2, Type 3, Type 4) leiomyoma. She has a strong desire for future fertility. 
Questions
  1. What are the different type of fibroids and what fibroids affect fertility?
  2. What are the factors that should be considered when considering and preparing this patient for hysteroscopic myomectomy?
  3. What preop/intra op measures can be taken to reduce blood loss?
  4. What is the maximum allowable fluid deficit for the distending media in use?
  5. How can you minimize the amount of distending media “absorbed” systemically.
  6. What postop measures can you consider given that she desires fertility?
  7. How long should she wait before attempting pregnancy?
Share by: