Before Your First: Hysteroscopy

Headed into the OR for your first hysteroscopy? In this episode, we walk through everything you need to know before you scrub in — from indications and pre-op preparation to OR equipment, distension media, fluid deficit management, and how to handle complications when they arise. I. Introduction & Learning Goals Purpose: Guidance for an intern's first hysteroscopy in the OR. Objectives: Review indications, pre-op preparation, OR setup/equipment, fluid media, and complications. II. Indications for Hysteroscopy Diagnostic Hysteroscopy: Abnormal uterine bleeding (AUB) or postmenopausal bleeding Infertility workup Evaluation of abnormal imaging findings Operative Hysteroscopy: Polypectomy (removal of polyps) Myomectomy (removal of submucosal fibroids) Septum resection Lysis of adhesions (Asherman syndrome) Foreign body removal (e.g., "lost" IUD) III. Pre-Operative Preparation Chart Review Checklist: Indication: Understand the clinical reason for the procedure Imaging (US/MRI): Confirm uterine size (to avoid over-dilating) and location of pathology Comorbidities: Check cardiac, renal, and pulmonary history to set fluid management thresholds Cervical History: Assess risk for stenosis (prior procedures or menopause) Menstrual Cycle: Check current phase (bleeding can obscure visualization) Patient Counseling (Benefits & Risks): Benefits: Superior diagnostic sampling and therapeutic symptom relief Standard Risks: Pain, bleeding, infection (low risk) Specific Risks: Uterine perforation (may require laparoscopy if energy was used or if there is concern for bowel injury) IV. Equipment & OR Setup The Hysteroscope Components: Telescope: The lens (0-degree for forward viewing vs. 30-degree for lateral angles) Sheaths: Inner and outer sheaths to house the telescope and allow fluid flow Inflow/Outflow Ports: For fluid delivery and drainage (use under-the-butt drapes to catch fluid for deficit calculation) Light Source: Warning — becomes extremely hot; keep away from drapes/patient Camera System & Monitor Working Channel: For operative instruments (graspers, scissors) V. Distension Media (Fluids) Isotonic Solutions (Preferred): Normal Saline: Compatible with bipolar electrosurgery; same osmolality as blood Hypotonic Solutions: Glycine (1.5%), Sorbitol (3%), Mannitol (5%) Used only for monopolar surgery; higher risk of hyponatremia Fluid Deficit Management: Definition: The difference between fluid into the uterus vs. fluid recovered ACOG Threshold: Max 2,500 mL for isotonic; however, many surgeons stop at 1,500 mL (or 750–1,000 mL for high-risk patients) VI. Procedural Steps & Tips Cervical Dilation: Can use mechanical dilators or "hydrodilation" using fluid pressure through the scope Tenaculum Tip: Take a "sturdy bite" of the cervix to prevent tearing/lacerations Pressure Management: Keep intrauterine pressure lower than the patient's Mean Arterial Pressure (MAP) to limit fluid extravasation into the body VII. Complications Uterine Perforation: Often occurs during dilation; recognized by a "loss of resistance" Fluid Overload: Can lead to hyponatremia, distributive shock, or flash pulmonary edema Hemorrhage: More common in operative cases (3% for myomectomy); manage with massage, uterotonics, or intrauterine balloons Vasovagal Reaction: Can occur during cervical manipulation or distensio...