Ambulatory hysteroscopy

A reproducable examination with minimal discomfort for the patient


When Stefano Bettocchi came to the department in 1990 I had been experimenting with carbon dioxyde gas using only a speculum and the the Hamou I scope -still my favorite because of its reduced length. I did not use any local anaesthesia and no tenaculum in over 70% of my patients. Because of the +/- 5 mm diameter of the scope I could not perform the exam in most of the peri-menopausal women and most of the nulligravidae.
We then started a trial with a semirigid single fiber scope of some 2mm outer diameter and were able to perform hysteroscopy in over 92 % of the patients. The problem now became the distension medium as carbon dioxyde did not give a good visibility in 24 % of the patients. So we had to convert to fluid distension in casu "physiologic" solution. 
Fig. 1 gives an example of the single fiber. The images are good for routine diagnosis but are not clear enough to satisfy the trained eye. 
The images obtained by the single fiber were not that good, qualitywise spoken. Bringing more fibers in the rigid scope resulted in better images but a larger outer  diameter and a very high temperature at the final lens, capable of causing burns.
So we had to look for other solutions. It is the merit of Stefano to have had the idea to reduce the Hopkins rod lens system to its maximum as to have a rigid scope with excellent images and an outer diameter, with 5 French working channel, of 3.8 mm. Stefano had also the stroke of genius to keep the 30 degree final lens and to use the vagina as a first distension chamber, VAGINOSCOPY. So now we are able to visualise the outer cervix from within the vagina and start our hysteroscopy from there. The use of liquid distension medium is a must but the combination of these modifications made that Stefano and we in a later phase were now able to perform ambulatory hysteroscopy in over 98% of the patients with a minimal discomfort in over 85% of our patients.
Fig. 2  proves that the small diameter does not mean poor quality of vision as seen here in the vascularisation of an adenocarcinoma of the endometrium, seen by contact hysteroscopy at 60 X magnification.
The recent evolution is now that the outer diameter of the scope is even more reduced to 2.8 mm still with the 5 French operating channel. This channel allows for operative procedures without anaesthesia. We were so excited with these developments that we edited a book on "ambulatory hysteroscopy" Stefano, Raphael Valle and myself . We organised it in a way that we invited co-authors from all over the globe as to get a good idea of what is going on in the world of ambulatory hysteroscopy at this moment in time. ( more information to be obtained on the FAQ section).
Fig.3 shows the images called "strawberry" seen in office setting. The white dots are the glands, pseudo hypertrophic due to the reduction in height of the inter-glandular tissue. This tissue has suffered the effects of chronic infection. The red colour is due to the rupture of the capillaries and the injection of the inter-glandular tissue with red blood cells. Note that the normal pattern of the distribution of the glands is disturbed.
Fig.4 gives a picture of the ostium on the right side. The intra-mural part is clearly not affected by the infection of the endometrium. We see the "strawberry" appearance of the cornual endometrium.


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ZNA STER Site Stuivenberg
Department Gynaecological Surgery
Department General Surgery

Lange Beeldekensstraat, 267
B-2060 Antwerp - Belgium
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