Hysteroscopy is a minimally invasive diagnostic and therapeutic procedure that allows direct visualization of the uterine cavity using a specialized endoscope called a hysteroscope. It has revolutionized the management of intrauterine pathologies, enabling precise diagnosis, targeted treatment, and improved outcomes in gynecological practice. Dr. R. K. Mishra, a pioneer in minimally invasive surgery, emphasizes understanding the fundamentals of hysteroscopy to ensure safety, efficacy, and optimal patient outcomes.

Introduction to Hysteroscopy

Hysteroscopy provides direct visualization of the endometrium, uterine cavity, tubal ostia, and cervical canal. It allows gynecologists to diagnose conditions such as fibroids, polyps, adhesions, congenital anomalies, and endometrial hyperplasia, and to perform therapeutic procedures like polypectomy, myomectomy, adhesiolysis, and endometrial ablation.

Hysteroscopy can be classified into:

Diagnostic Hysteroscopy – Primarily for evaluating abnormal uterine bleeding, infertility, or recurrent pregnancy loss.

Operative Hysteroscopy – Includes procedures for intrauterine pathologies, often performed using miniature instruments introduced through the hysteroscope.

Indications for Hysteroscopy

According to Dr. Mishra, proper patient selection is critical for success. Common indications include:

Abnormal uterine bleeding (AUB), especially when imaging studies are inconclusive

Recurrent pregnancy loss or infertility, for evaluation of uterine factors

Suspected intrauterine lesions such as polyps, fibroids, or adhesions

Congenital uterine anomalies like septate uterus

Retained products of conception or foreign bodies

Endometrial ablation or biopsy for therapeutic purposes

Types of Hysteroscopes

Hysteroscopes can be rigid or flexible and vary in diameter and working channels. Key components include:

Optical System – Provides magnified visualization of the uterine cavity.

Working Channel – Allows insertion of instruments such as scissors, graspers, biopsy forceps, and electrosurgical devices.

Light Source and Camera – Provides illumination and allows video recording for documentation and teaching.

Distension System – Maintains the uterine cavity using fluid (saline, glycine, sorbitol) or carbon dioxide gas for better visualization.

Preoperative Preparation

Proper preparation is essential for safety and optimal visualization:

Patient Assessment – Includes medical history, physical examination, and relevant investigations (ultrasound, hysterosalpingography).

Informed Consent – Discusses the purpose, procedure, risks, benefits, and alternatives.

Bowel and Bladder Preparation – Some surgeons prefer empty bladder; bowel preparation may be needed in specific cases.

Anesthesia – Can be performed under local, regional, or general anesthesia, depending on patient comfort and complexity of the procedure.

Preoperative Medications – Misoprostol may be used for cervical ripening in nulliparous women or difficult cervical canals.

Surgical Technique Fundamentals

Dr. Mishra emphasizes meticulous technique and adherence to safety principles during hysteroscopy:

Cervical Access

Gentle dilation of the cervix may be performed using mechanical dilators or pharmacological agents.

A speculum is used to visualize the cervical os, and the hysteroscope is inserted under direct vision.

Uterine Cavity Distension

The uterine cavity is distended using fluid or gas, which provides adequate visualization of the endometrium and allows manipulation of instruments.

Continuous monitoring of intrauterine pressure is essential to avoid fluid overload or embolism.

Diagnostic Inspection

Systematic inspection of the cervical canal, uterine walls, endometrium, and tubal ostia is performed.

Any abnormal findings, such as polyps, fibroids, or adhesions, are documented.

Operative Procedures

Instruments can be introduced through the working channel for:

Polypectomy – Removal of endometrial polyps

Myomectomy – Excision of submucosal fibroids

Adhesiolysis – Division of intrauterine adhesions (Asherman’s syndrome)

Endometrial Ablation or Biopsy – For therapeutic or diagnostic purposes

Completion and Hemostasis

After completing the procedure, the uterine cavity is inspected for bleeding.

Distension medium is aspirated, and the hysteroscope is withdrawn carefully.

Advantages of Hysteroscopy

Minimally Invasive – Avoids large incisions and reduces postoperative pain

Diagnostic Accuracy – Direct visualization allows precise diagnosis compared to ultrasound or MRI alone

Therapeutic Capability – Simultaneous treatment of intrauterine lesions reduces the need for multiple procedures

Short Recovery Time – Most patients are discharged on the same day

Improved Fertility Outcomes – Removal of polyps, fibroids, or adhesions enhances reproductive potential

Risks and Complications

Though hysteroscopy is generally safe, potential complications include:

Uterine Perforation – Rare but serious, requiring immediate recognition

Bleeding – Usually mild; severe cases may need intervention

Fluid Overload or Electrolyte Imbalance – From distension media absorption

Infection – Rare; prophylactic antibiotics may be indicated in select patients

Cervical Trauma – From dilation or instrumentation

Dr. Mishra emphasizes prevention through gentle technique, proper instrument handling, and continuous monitoring.

Conclusion

Hysteroscopy is a fundamental tool in modern gynecology for both diagnosis and treatment of intrauterine pathologies. Mastery of its principles, proper patient selection, meticulous surgical technique, and awareness of potential complications are essential for achieving optimal outcomes. According to Dr. R. K. Mishra, understanding the fundamentals of hysteroscopy empowers gynecologists to provide minimally invasive, precise, and safe care, improving patient outcomes in both fertility and general gynecological practice.

If you want, I can also create a step-by-step illustrated guide showing hysteroscope insertion, uterine cavity inspection, and operative procedures, perfect for surgical teaching or lecture videos.