Instrumentation and set-up

Setting up a hysteroscopy service

Infrastructure

This involves a multidisciplinary set up. The ability to perform ultra­sound scans is important, particularly transvaginal scanning in the same clinic.

Ideal setting

Due to the intimate nature of the procedure, women attending the hysteroscopy clinic are likely to be anxious (57). Outpatient hysteroscopy should be conducted in a well-organized clinic with calm, competent, and experienced doctors and nursing staff. Women should receive appropriate information, providing them with details of the procedure. Background music may act as a complementary adjuvant for anxious patient (58). It is important for patients to be as comfortable as possible and have private changing facilities, a toilet, and refreshments (59). Facilities should be available in the case of unexpected responses, for example, vasovagal responses, with either a bed or recliner accessible.

Equipment

The necessary equipment includes the following:

• Gynaecological couch/chair: positioning the patient comfort­ably on the examination couch/chair will help the patient to relax during the procedure. It should be possible to manoeuvre the couch if the preference is for an electronically powered modern gynaecological chair. Positioning the patient to perform both diagnostic and operative hysteroscopy is important, particularly in morbidly obese patients. The provision of a good couch helps the operator and also reduces strain on both the arm and hands of the surgeon during both diagnostic and operative procedures.

• Video camera and monitor: it is important to get high-quality im­ages with printing and storage facilities; increasingly both video cameras and monitors are being miniaturized which is helpful in space utilization. Ideally the video camera and monitor should be housed on a single video cart.

• Light source and cable: most hysteroscopes require a cold xenon light source (175 watt).

• Pressure cuff for fluid distension medium: generally normal sa­line is preferred to carbon dioxide as this allows an improved image quality, a quicker procedure, and allows the use of bipolar energy for operative hysteroscopy. There is no significant differ­ence in pain perceived with using either of the distention media for hysteroscopy (60). Normal saline bags 1-3 L should be used, these should be warmed to room temperature. Pressure bags can be used to achieve uterine distention pressure of 80-120 mmHg. A fluid management system is recommended for fibroid resection for a clear view intraoperatively and to accurately monitor fluid balance

• Carbon dioxide insufflator and tubing if using gas distention: if carbon dioxide is used as a distention medium, a carbon dioxide insufflator apparatus is used to achieve a flow rate of 100 mL/min.

• Additional basic instruments: include Cusco Speculum, ten­aculum, forceps, sterile cleaning solution, Hegar cervical dilator (1/2 mm onwards).

• Inflow and outflow tubing, dental syringe, local anaesthetic, Pipelle endometrial biopsy sampler, scissors, and silver nitrate sticks.

• Hysteroscope: a range of hysteroscopes, diagnostic and opera­tive, can be used. These vary from rigid diagnostic 3 mm and operative 5 mm.

■ The size of the hysteroscope plays an important role in the ac­ceptance and success of hysteroscopy (61). Randomized control trials compared the effect of size of the outer sheath on pain and success rate of ambulatory hysteroscopy (61-65).

■ Hysteroscopes with an outer sheath diameter of less than 3.5 mm were associated with significantly less intraoperative pain (62-64). Most diagnostic hysteroscope are 30 degrees allowing a thorough inspection of uterine walls, with min­imal movement of the shaft. Both diagnostic and operative hysteroscopy clinics should consider investing in more rigid hysteroscopes as the Versapoint bipolar electrode and most miniature mechanical and electrosurgical devices require rigid hysteroscopes with size 4 Fr operative channels.

• Morcellators: the most recent development in operative hysteroscopy is the advent of mechanical miniature hysteroscopic morcellators. There are currently three different products on the market: Truclear, MyoSure, and the Intrauterine Bigatti Shaver.

■ This technology is particularly advantageous for treating mul­tiple endometrial polyps or large polyps. Investing resources in morcellation hysteroscopes can still prove to be cost-effective in terms of the safety, speed, patient acceptability, and complete removal of the polyp/fibroid (66, 67).