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 distension • Gas Embolism: Rare; more common with older CO₂ distension methods Resources: • ACOG Technology Assessment: Hysteroscopy (https://www.acog.org/clinical/clinica...) • UpToDate: Hysteroscopy – Managing Fluid and Gas Distending Media (https://www.uptodate.com/contents/hys...) • AAGL – Advancing Minimally Invasive Gynecology Worldwide (https://www.aagl.org/) About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Mahima Krishnamoorthi, MD – Gyn/Ob resident at Johns Hopkins Hospital. She attended Stanford University for un...