Lecture at the Global Congress on Hysteroscopy (2-5 May 2017 - Barcelona, Spain).

1. Barcelona, Spain
2-5 May 2017
Dr. Antonio Simone Laganà
Unit of Gynecology and Obstetrics, Department of
Human Pathology in Adulthood and Childhood “G.
Barresi”- University of Messina (Italy)
European Society of
Human Reproduction
and Embryology
Italian Association
of Endometriosis
International Society
Of Gynecological
Endocrinology
Society for Reproductive
Investigation
How to set up a Hysteroscopy Unit
Italian Society of
Gynecological Endoscopy

2. Disclosure
I have no actual or potential conflict of interest,
including commercial or financial relationship,
regarding this presentation.

3. Some of the innovations that we are currently using in daily practice were
almost unimaginable few years ago.
These milestone changes were achieved step-by-step thanks to many
brave, countercurrent and sometime visionary Colleagues, which were able
to see over the horizon and conjugate new views with evidence-based
medicine.
Philip Bozzini Isidor Clinton Rubin Jacques Hamou Stefano Bettocchi
Back to the basic!

4. What will we discuss?
Intracavitary vision:
1. Video camera
2. Cold light
sources
3. Light cable
4. Endoscope
5. Video monitor
and data
archiving
Intracavitary
distension:
Non-electrolyte
solutions
Electrolyte solutions
Supply methods
Hysteroscopes for
diagnostic and
operative “office”
procedures
Resectoscopes
… and few elements about new devices, ergonomic setting and
maintenance of the equipment

5. Video camera
1. The definition of the image depends in direct proportion by the number of pixels
(image picture elements) that are contained on the charge-coupled device (CCD).
2. The sensitivity is expressed in lux, which is inversely proportional to the sensitivity,
and is intended as the minimum quantity of light necessary to obtain the image.
3. The resolution depends by the number of vertical lines displayed on the video
monitor.
4. The Signal/Noise Ratio (SNR) is defined as the ratio of the power of a signal
(meaningful information) and the power of background noise (unwanted signal).
5. The zoom allows the magnification of the image.

6. Cold light sources
The development of cold light sources allowed to get a clear view of the
uterine cavity despite the intrinsic high light absorption due to the
natural red tonality.
There are two main types of cold light
sources: xenon and halogen.
Xenon light sources are usually preferred:
- very long lifespan (around 500 working
hours);
- emit white light and have a “colour
temperature” that fit human eye (5000–6400
Kelvin).

7. Light cable
There are two main types of light cables:
• Fiber-optic cables: the light transmission is
based on the total internal reflection on the inner
surface. These cables are flexible and bendable,
but very fragile.
• Liquid crystal cables: they are filled by a liquid
medium (usually cholesteric salts), which is able
to transmit the light. They transmit higher intensity
of light and are more durable, but are also less
flexible.

8. Endoscope
These optical lenses are integrated in a sheath which allows the flowing of
distension medium to the uterine cavity.
It is formed by an optical lens system which allows the transmission of the light to
the anatomical site that should be investigated and back to the camera.
The introduction of cylindrical lenses by Harold Horace
Hopkins has dramatically enhanced the image definition
and reduced optical aberrations, due to the favourable ratio
between air spaces and lenses.
There are several endoscopes with different view angles: 0°, 12°, 30/45°, 70°: the
use of 12° and 30/45° optics allows to obtain the same visualizations of the 0°
optic just rotating the endoscope without any additional lateral movement.

9. Video monitor and data archiving
To date, the most common systems are able to record and store still
images, video sequences and audio comments during the procedure,
activating the command by keypad, foot pedal, camera buttons or voice.
In case of a hospital data network system, it is also possible to share the
information in real time and get also other patient’s records (ultrasound
images, x-rays).
 Request of images and videos by patients
+  Medical litigations
=  Data archiving
It is advisable to have a high resolution monitor with an
adequate overall dimension of the screen.

10. Intracavitary distension media
• They allow a complete overview of inner surface of uterine walls and
tubal ostia;
• They avoid unnecessary contact between the endoscope and the
endometrial mucosa, that is extremely fragile and may start to bleed.
There are two main classes of distension media: gaseous and liquid.
The only available gaseous distension medium is carbon dioxide (CO2),
limited only for diagnostic hysteroscopy. The usual insufflation pressure is
around 100–120 mmHg and a flow of 30–60 mL/min, in order to maintain
an intracavitary pressure of 40–80 mmHg.
Regarding liquid media, they are divided in high and low molecular
weight. The only high molecular weight distension medium, Hyskon, is
not currently used anymore (high risk of adverse reactions!)

11. Low molecular weight liquid distension media
They are the most used distension media in modern hysteroscopy:
• The non-electrolyte solutions (glycine and sorbitol-mannitol).
They do not contain any anion or cation and, therefore, do not conduct
electricity. For this peculiar characteristic, they are used in case of
operative hysteroscopy performed with unipolar electrosurgical
instruments. WARNING: risk of intravascular absorption syndrome
and consequent dysbalance of serum electrolytes.
• The electrolyte solutions, such as normal saline solution 0.9%.
This distension medium is often used during diagnostic hysteroscopy
and seems to offer a balanced cost-effectiveness. In addition, it is
mandatory to use this type of distension medium in case of operative
hysteroscopy performed with bipolar instruments, in order to prevent
electrosurgical damage.

12. Devices to supply the liquid distension medium
• 3 or 5 L bag positioned 90-100 cm above the patient’s
pelvis, in order to obtain about 70 mmHg of irrigation
pressure. In addition, it is possible to increase the irrigation
pressure until 80-120 mmHg through the squeeze-bulb.
• Dedicated microprocessor-controlled irrigation and
suction pumps, which are usually set to have
intrauterine pressure of about 30–40 mmHg, a flow
rate of 200 mL/min, an irrigation pressure of 50–75
mmHg and a suction pressure of 0.25 bars. In
particular, this low intrauterine pressure prevents the
passage of distension medium from the uterine cavity,
through the tubes, to the peritoneal cavity and reduces
the risk of vagal syndrome and pain.

13. Hysteroscopes for diagnostic and operative “office” procedures
They are designed with an operative channel and a system of continuous flow
irrigation. This allowed the “revolution” of hysteroscopic techniques, since it
was possible to perform several procedures in ambulatory setting.
Bettocchi Hysteroscope: there are two versions of this hysteroscope. The first
one consists of a 2 mm scope and an outer diameter of 4 mm (A); the second
one consists of a 2.9-mm scope with 30° forward-oblique view and an outer
diameter of 5 mm (B). Both of them have a double sheath, one of irrigation and
the other for suction (in order to allow a continuous flow), and a 5 French
operating channel.

14. Hysteroscopes for diagnostic and operative “office” procedures
TROPHYscope (designed by Rudi Campo): it has a diameter of 2.9 mm and
the possibility to use two different outer sheaths. The first one is a 3.7 mm
continuous-flow sheath, the second one is a 4.4 mm sheath with 5 French
operating channel. The particular design of this scope allows two positions of the
outer sheath: a “passive” position (A) with lower diameter, specific for diagnostic-
only procedure, and an “active” position (B).
A
B

15. Ambulatory setting: “cold” mechanical instruments
They are inserted through the operative channel of
the hysteroscope, in order to perform several
procedures, including biopsies, lysis of adhesions or
septa, polypectomies, lost-IUD retrieval.
Among the most commonly used instruments, there
are grasping forceps with teeth (the so-called
“alligator forceps”), the biopsy or spoon forceps, the
pointed scissors (extremely useful for the metroplasty
in case of a small septum) and tenaculum grasping
forceps (for the removal of polyps or small myomas
fragments).

16. Bipolar instruments
These instruments can be used with electrolyte solutions (normal saline
solution 0.9%):
Versapoint: it consists of a high-frequency
bipolar generator that works in combination
with three types of 5 French electrodes
(the Twizzle, widely used for fine-regulated
and precise tissue vaporization; the Spring,
useful for the vaporization of larger portion
of tissue; the Ball, extremely useful for
coagulation).
Autocon II 400: this high-frequency bipolar
generator is similar to Versapoint, but the
electrodes are reusable so it could be a
valid option in order to reduce the cost of
the procedure.

17. Hysteroscopic instruments in operation room: resectoscopes
The most used are of 22 Fr (7.3 mm), 26 Fr (8.7 mm), and 27 Fr (9 mm)
and can equip unipolar o bipolar energy.
The typical resectoscope consists of a working element, two sheaths
(inner and outer, for continuous-flow irrigation) and the loop (active or
cold). The most important of the previous parts is the working element,
which is formed by a mechanical device that allows the fine-regulated
advance or retraction of the loop.

18. Unipolar or bipolar instruments? Some considerations…
In unipolar systems (with glycine and sorbitol-mannitol), the
electrons flow directed from the electrosurgical unit to the active
electrode (e.g. cutting loop or knife electrode), pass through the tissue to
the neutral electrode and then come back to the electrosurgical unit: this
may cause burning damage to the surrounding tissue, even at some
distance from the active electrode, because it is not possible to predict
exactly the pathway that the electrons will follow.
In the bipolar systems (with normale saline solution), the generator
produces an electrical arc between the two bipolar electrodes: this arc
converts the conductive solution of sodium chloride to plasma containing
sodium particles (the so-called “plasma effect”). Afterwards, the contact
with the activated sodium ions causes tissue disintegration (breaking of
the carbon-carbon and carbon-hydrogen bonds and dissociation of the
water molecules to H+ and OH- ions) and thus “cutting effect”.

19. New devices: a brief overview
Intrauterine
morcellators
Hysterobasket
by Zizza
Tenaculum by Di
Spiezio Sardo
Intrauterine palpator
by Bettocchi and Di
Spiezio Sardo New integrated
workstation
Portable diagnostic
devices

20. Preparation of ambulatory setting and operating room
• These environments should be spacious
and ergonomic.
• All the instruments should be checked
before to start any procedure by a
nurse/midwife.
• Use of detailed protocols and flow-
charts.
• Use of log book to summarize all the
procedures, to prepare a report of costs
and future planning.
• Dedicated area of the ambulatory setting
for drugs.
• Cleaning, sterilization and maintenance
of the instruments should be performed
only by qualified nurses/midwives.

21. Thanks for your
attention!