Insertion of the hysteroscope without a tenaculum requires a great deal of dexterity and comfort with the instrument. The surgeon needs to understand the correlation between what is seen on the screen and the exact position of the hysteroscope so that the instrument does not rub against the cervix or the uterine tissue and cause trauma and pain.
With an angled hysteroscope, the image displayed on the screen reflects what is actually above the tip of the instrument. If the opening to the cervical os looks like it's straight ahead, for instance, it is actually above the direction in which the scope is being guided, and the scope must therefore be angled to enter the canal. Understanding the correlation and being comfortable with this 12- or 30-degree fore-oblique view takes some practice, as does visualizing the cervix correctly when pulling back from the posterior fornix. For most gynecologic surgeons, the necessary skills and comfort levels fall into place after just a few vaginoscopic procedures.
I have not found any difference in difficulty based on the axis of the uterus. I fact, I have found that utilizing a vaginal speculum in conjunction with a cervical tenaculum to straighten the uterine axis has limited my hysteroscope manipulation for extreme ante- or retroversion, increasing patient discomfort.
Just as with traditional hysteroscopy, operative hysteroscopy is possible right after or even at the same time as a diagnostic hysteroscopy performed with a vaginoscopic approach. The gynecologic surgeon can remove polyps that are visualized during a diagnostic procedure, for instance; perform adhesiolysis for Asherman's syndrome and tubular cannulation for blocked proximal tubal obstruction; retrieve lost IUDs; and perform tubal occlusion using the Essure system. My most recent tubal occlusion procedure took less than 5 minutes from start to finish, and the patient drove herself home within 15 minutes after completion of the procedure.
I do nothing differently when performing an operative hysteroscopy utilizing the vaginoscopic approach than I would using the traditional approach, except for not using the speculum and tenaculum.
I recommend fluid monitoring when performing operative hysteroscopy especially. I generally monitor fluid outflow in my practice, with a nurse checking fluid levels and monitoring the deficit while I explain to the patient what I am doing and visualizing. Because diagnostic procedures are fairly short, the likelihood of fluid intravasation at high volumes is low, however.
Vaginoscopy can be extremely helpful for evaluating patients who are morbidly obese and for whom standard office instruments are not adequately sized for visualization of the cervix. I recently tried to obtain a Pap smear and do an endometrial biopsy in a patient who was morbidly obese and had a large fibroid uterus, but with conventional methods I was unable to do so using our instruments. I brought the patient to the operating room to use larger instruments, but even these were insufficient. I finally performed the Pap smear successfully by palpating the cervix and os, and used vaginoscopy to visualize the entire cervix. I then continued with the hysteroscopy and endometrial biopsy.
After the diagnostic—and sometimes operative—procedure, our nurses will check patients' vital signs and ensure that they are feeling well and are ambulatory. Most of the time, patients leave the office within 15 minutes or so, happy to have had their procedure done in the office as opposed to the hospital.
Vaginoscopy also has been shown to be effective, fast, and easy for managing gynecologic problems in pediatric and adolescent patients. In a report published in 2000, Dr. Abraham Golan and his colleagues in Israel reported that they were able to complete the procedure successfully in 22 patients aged 3–16 years who were evaluated for vulvovaginitis, vaginal trauma, bleeding, or genital malformation (J. Am. Assoc. Gynecol. Laparosc. 2000;7:526–8). Gynecologic surgeons who build skills and experience with the vaginoscopic approach to hysteroscopy could also serve the pediatric/adolescent community well.
The hysteroscope is guided into the posterior vaginal fornix.
Source IMAGES COURTESY DR. AARATHI CHOLKERI-SINGH
Then it is pulled back while the external cervical os is visualized anteriorly.
Then the scope is guided through the endocervical canal.
Vaginoscopy's Approach to Hysteroscopy
Over the past several years, the number of office-based gynecologic surgical procedures has skyrocketed. Factors cited in this trend toward in-office surgery are better reimbursement, greater efficiency for both patient and physician, as well as the ability to provide a familiar environment for the patient. Both diagnostic as well as operative hysteroscopy are two such procedures that easily can be converted to the office setting.