CHAPTER 106 To perform operative hysteroscopy as well as panoramic diagnostic hysteroscopy, the potential uterine cavity must be distended to allow the operator to see. Although a large number and variety of instruments are available, the critical implements required to perform manipulative hysteroscopic examinations and procedures are few. The first and most important device is the telescope, which permits vision within the uterine space. Typically, rigid telescopes measure 4 mm in outer diameter (O.D.) and contain optical rod lenses as well as fiberoptic light–transmitting elements (Fig. 106–1A through C). The second element is the hysteroscopic sheath, which transmits the distention medium into the uterine cavity. For simple viewing, the sheath measures 5 mm O.D.; however, larger sheaths ranging in size from 7.5 to 9.0 mm O.D. are required for operative hysteroscopy (Fig. 106–2A, B). Contemporary sheaths should have isolated inflow and outflow channels to properly and continuously flush the uterine cavity (Fig. 106–3A through D). Some sheaths are specialized, for example, the resectoscopic sheath is specifically designed for electrosurgery (Fig. 106–4A through C). Third, a high-powered (and preferably xenon) light generator is required to provide high-intensity light (Fig. 106–5). Coupled with the light generator is a video camera and monitor, because most if not all modern hysteroscopy is performed with the surgeon and assistants viewing the operative field via a video monitor (Fig. 106–6A, B). Recording equipment for still, video, or digital photography should be available to memorialize findings and to supplement the dictated operative report (Fig. 106–7). Accessory instruments may be divided into conventional devices and energy-delivered implements. Among the conventional tools are scissors, grasping forceps, biopsy forceps, and suction cannulas (Fig. 106–8A, B). The energy devices include bipolar and unipolar needles, coagulating ball electrodes, and laser fibers (Fig. 106–9A, B). A specialized sheath commonly utilized for hysteroscopic surgery is the resectoscope. This consists of a flushing sheath, a number of double-armed monopolar electrodes, and a spring-loaded trigger mechanism to move the electrode out of the sheath and then return it back to the sheath (Fig. 106–10). The most convenient consolidation of the myriad pieces of equipment is the mobile, multilevel, storage cart (see Fig. 106–5). Finally, hysteroscopic infusion media (e.g., 32% dextran-70 [Hyskon], glycine, mannitol, saline) are vasoactive substances, which, because of pressure differentials, gain entry into the patient’s vascular space (Figs. 106–11 and 106–12
Hysteroscopic Instrumentation
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