Practical Manual of Hysteroscopy

Description

This book aims to provide readers with the latest information on application of hysteroscopy in diagnosis and treatment of gynaecological diseases. The first chapters systematically review current status, equipment and instruments, applied anatomy, preoperative treatment and anesthesia for hysteroscopic surgery. In the following chapters, details in aspect of hysteroscopy from diagnostic to hysteroscopic surgery are explained with clinical cases. After that, advanced techniques in hysteroscopy combined with laparoscopy and ultrasound monitoring hysteroscopic surgery are introduced with high-resolution illustrations. Written by experts with wealthy experience in the field, this book will be a valuable reference for gynecologists at hysteroscopy units, reproductive units, gynecological and oncological units. Foreword to the Third Edition Foreword to the Second Edition Foreword to the First Edition Preface Abstract Contents Editor and Contributors About the Editor Contributors Translators 1: History and Development of Hysteroscopy 1.1 The First Hysteroscope 1.2 Contact Hysteroscope and Modern Contact Hysteroscope 1.3 Hysteroscope with a Balloon at the End 1.4 Fluid Irrigation Mode (Original Continuous Irrigation System) and Uterine Distending Medium 1.5 Distention of Uterus with CO2 1.6 Invention of Fiber Hysteroscope 1.7 Continuous Flow Hysteroscope 1.8 A Clinical Review 1.9 Other Innovations Suggested Reading 2: Equipment and Instruments for Hysteroscopy 2.1 Equipment for Hysteroscopy 2.1.1 Power System 2.1.1.1 High-Frequency Current Generator 2.1.1.2 Nd-YAG Laser 2.1.2 Lighting System 2.1.2.1 Cold Light Source 2.1.2.2 Light Guide Bundle 2.1.3 Uterine Distention/Irrigation System 2.1.4 Camera Imaging System 2.1.4.1 Imaging System 2.1.4.2 Monitor 2.1.4.3 High Definition Digital Camera System 2.1.4.4 Other Application Systems 2.2 Instruments for Hysteroscopic Diagnosis and Treatment 2.2.1 Fiber Hysteroscope 2.2.1.1 Diagnostic Fiber Hysteroscope (Fig. 2.14) 2.2.1.2 Therapeutic Fiber Hysteroscope 2.2.2 Rigid Hysteroscope 2.2.2.1 Diagnostic Rigid Hysteroscope 2.2.2.2 Therapeutic Rigid Hysteroscope 2.2.2.3 Mini-Hysteroscope 2.2.2.4 Hamou Hysteroscope 2.2.3 Integrated Hysteroscope 2.3 Instruments for Hysteroscopic Surgery 2.3.1 Hystero-Resectoscope (Fig. 2.24) 2.3.1.1 Telescope (Fig. 2.25) 2.3.1.2 Working Element (Fig. 2.26) 2.3.1.3 Hysteroscopic Sheaths (Fig. 2.27) 2.3.1.4 Obturator 2.3.2 Active Electrodes 2.3.2.1 Wire Loop Electrode 2.3.2.2 Needle Electrode (Fig. 2.32) 2.3.2.3 Roller Ball Electrode 2.3.2.4 Roller Bar/Roller Barrel Electrode (Fig. 2.34) 2.3.2.5 Vaporizing Electrode/Vaportrode (Fig. 2.35) 2.3.2.6 Band Electrode (Fig. 2.36) 2.3.3 Accessory Instruments and Equipment 2.3.4 Plasma Bipolar Resectoscope (Fig. 2.37) 2.4 Cleaning, Sterilization, and Maintenance of Hysteroscopic Instruments 2.4.1 Cleaning and Inspection of Hysteroscopic Instruments 2.4.2 Sterilization Methods for Instruments of Hysteroscope 2.4.2.1 Autoclave Sterilization 2.4.2.2 Low Temperature Sterilization 2.4.3 Arrangement of Device and Instruments for Hysteroscopic Surgery 2.4.4 Maintenance of Hysteroscopic Equipment 2.4.4.1 Optical Lens 2.4.4.2 Electronic Equipment 2.4.5 Storage After Operation Suggested Reading Equipment for Hysteroscopy Instruments for Hysteroscopic Diagnosis and Treatment Instruments for Hysteroscopic Surgery Cleaning, Sterilization, and Maintenance of Hysteroscopic Instruments 3: Anatomy and Histology in Hysteroscopy 3.1 Anatomy of a Normal Uterus 3.1.1 Uterine Corpus 3.1.1.1 Endometrium 3.1.1.2 Myometrium 3.1.1.3 Serosa 3.1.1.4 Uterine Horn and Ostium of Fallopian Tube 3.1.2 Uterine Cervix 3.2 Cyclical Changes in Endometrium 3.2.1 The Menstruation Phase 3.2.2 Early Proliferative Phase 3.2.3 Late Proliferative Phase 3.2.4 Early Secretory Phase 3.2.5 Late Secretory Phase 4: Effects of Preoperative Medication for Hysteroscopy and Commonly Used Drugs in Gynecology on Endometrium 4.1 Preoperative Medication for Hysteroscopy 4.1.1 Mechanism of Pretreatment with Drugs Prior to Surgery 4.1.1.1 Pseudo-Pregnancy Therapy 4.1.1.2 Pseudo-Menopause Therapy 4.1.1.3 Medical Oophorectomy 4.1.1.4 Other Anti-Estrogen, Anti-Progesterone, and Endometrial Growth-Inhibiting Drugs 4.2 Nolvadex 4.3 Clomiphene 4.4 Levonorgestrel-Releasing Intrauterine System (LNG-IUS) Suggested Reading 5: Application of High Frequency Electricity in Hysteroscopic Surgery and Its Thermal Effects on Tissues 5.1 The Electronic Circuit Compositions and Current Types in Hysteroscopic Electrosurgery 5.1.1 The Electronic Circuit Compositions in Hysteroscopic Electrosurgery 5.1.2 Current Types in Hysteroscopic Electrosurgery 5.1.2.1 Cutting Current 5.1.2.2 Coagulating Current 5.1.2.3 Blended Current 5.2 Electrothermal Effects in Hysteroscopic Surgery and Its Impact on the Tissues 5.2.1 The Changes in Tissue Cells Caused by Electrothermal Effects 5.2.1.1 Influence of Electrothermal Effect on Protein 5.2.1.2 Influence of Electrothermal Effect on Enzymes 5.2.2 Influence of the Electrothermal Effect on Uterine Tissues 5.2.2.1 Influence of Current Wave Patterns on the Thermal Damage to Tissues 5.2.2.2 Influence of Electrode Powers and Action Times on the Thermal Damage to Tissues 5.2.2.3 Setting of Electrode Power 5.2.3 Histopathological Changes of Electrothermal Injury 5.2.3.1 Light Microscope 5.2.3.2 Findings Under Electron Microscope 5.3 Clinical Application of Hysteroscopic Electrosurgery 5.3.1 Application of Cutting Current in Hysteroscopic Electrosurgery 5.3.2 Application of Coagulating Current in Hysteroscopic Electrosurgery 5.3.3 Application of High Frequency Vaporization in Hysteroscopic Electrosurgery 5.3.4 Application of High Frequent Bipolar System in Hysteroscopic Electrosurgery Suggested Reading 6: Distention Medium in Hysteroscopy 6.1 CO2 Gas Insufflation 6.2 High Viscosity Distention Medium: Hyskon 6.3 Low Viscosity Distention Medium 6.3.1 Research on Complications Induced by Glycine Absorption 6.3.2 Research on the Complications Induced by Absorption of Sorbitol and Mannitol 6.3.3 Research on the Safety of 5% Glucose as Irrigating Fluid 6.4 Etiology and Clinical Presentation of TURP Syndrome 6.4.1 Etiology of TURP Syndrome 6.4.2 Clinical Presentation of TURP Syndrome 6.5 Treatment of TURP Syndrome 6.5.1 Treatment of Hyponatremia 6.5.1.1 Calculation of the Serum Sodium Deficit 6.5.1.2 Key Points in the Replacement of Sodium 6.5.2 Treatment of Acute Heart Failure 6.5.3 Treatment of Pulmonary Edema 6.5.4 Treatment of Cerebral Edema 6.5.5 Correction of Electrolyte Imbalance 6.6 TURP Syndrome: Prophylactic Measures 6.6.1 Prevention of Complications Caused by High Viscosity Distention Medium 6.6.2 Prevention of Complications Caused by Low Viscosity Distention Medium 6.7 Equipment for Uterine Distention with Fluids Suggested Reading 7: Anesthesia for Hysteroscopy 7.1 Pre-anesthetic Assessment 7.1.1 Preoperative Visits on Patients and Participation in Preoperative Discussions 7.1.2 Getting Familiar with the Patient’s Medical History and Conducting a Systematic Physical Examination 7.1.3 Examining and Checking the Essential Laboratory Parameters 7.1.4 Assessment of Anesthesia Risks 7.2 Anesthetic Methods and Choices for Hysteroscopy 7.2.1 Topical Anesthesia 7.2.2 Paracervical Nerve Block 7.2.3 Epidural Anesthesia and Subarachnoid Block 7.2.4 General Anesthesia 7.2.4.1 Intravenous Anesthesia 7.2.4.2 General Anesthesia Using Laryngeal Mask Airway 7.2.4.3 Inhalation Anesthesia 7.3 Intraoperative Surveillance During Hysteroscopic Surgery 7.3.1 Routine Monitoring 7.3.1.1 Electrocardiogram (ECG) 7.3.1.2 Blood Pressure 7.3.1.3 Monitoring of Pulse Oxygen Saturation (SpO2) 7.3.1.4 Auscultation in the Precordium and Inside the Esophagus 7.3.2 Special Monitoring 7.3.2.1 Monitoring of Electrolyte 7.3.2.2 Blood Glucose Monitoring 7.3.2.3 Monitoring of Central Venous Pressure (CVP) 7.3.2.4 Noninvasive Estimation of Extravascular Lung Water (EVLW) 7.4 Prevention and Treatment of Complications During Hysteroscopy 7.4.1 Mechanical Injury 7.4.2 Bleeding 7.4.3 Gas Embolism 7.4.4 TURP Syndrome Suggested Reading 8: Diagnostic Hysteroscopy 8.1 Hysteroscopy 8.1.1 Indications for Hysteroscopy 8.1.1.1 Abnormal Uterine Bleeding (AUB) 8.1.1.2 Abnormal Sonographic Findings in Uterine Cavity 8.1.1.3 Infertility 8.1.1.4 Physiological or Characteristic Changes Caused by Tamoxifen or Hormone Replacement Therapy (HRT) 8.1.1.5 Secondary Dysmenorrhea 8.1.1.6 After Complex Intrauterine Operations 8.1.1.7 Staging of the Endometrial Carcinoma 8.1.1.8 Uterine Myomas 8.1.1.9 Examination of Intrauterine Device 8.1.1.10 Abnormal Vaginal Discharge 8.1.2 Contraindications for Hysteroscopy 8.1.2.1 Absolute Contraindications 8.1.2.2 Relative Contraindications 8.1.3 Preoperative Evaluation 8.1.3.1 Patient’s History 8.1.3.2 Physical Examination 8.1.3.3 Laboratory Examination 8.1.3.4 Psychological Counseling 8.1.4 Uterine Distention System in Hysteroscopy 8.1.4.1 Fluid Medium for Uterine Distention Uterine Distending Equipment Distention Medium 8.1.4.2 Gas as Uterine Distention Medium 8.1.5 Timing of Hysteroscopy 8.1.6 Anesthesia and Analgesia in Hysteroscopy 8.1.6.1 Indomethacin Suppository 8.1.6.2 Kaflan 8.1.6.3 Paracervical Nerve Block 8.1.6.4 Surface Anesthesia of Cervical Mucosa 8.1.6.5 Endometrial Spraying Anesthesia 8.1.6.6 Intravenous Anesthesia 8.1.7 Procedures of Hysteroscopy 8.1.7.1 Preparation Before Hysteroscopy 8.1.7.2 Procedures Fiber (Flexible) Hysteroscopy Rigid Hysteroscopy Comparison Between Fiber Hysteroscopy and Rigid Hysteroscopy “No Touch” Technique 8.1.8 Hysteroscopy Combined with Ultrasonography 8.1.8.1 Indications for Hysteroscopy Combined with Ultrasonography 8.1.8.2 Procedures for Hysteroscopy Combined with Ultrasonography 8.1.8.3 Abnormal Findings in Hysteroscopy Combined with Ultrasonography Intrauterine Lesions Lesions on the Uterine Wall or Outside the Uterus 8.1.9 A Normal Uterus Under Hysteroscopy 8.1.9.1 Various Images Seen by Hysteroscopy 8.1.9.2 Normal Morphology of the Uterine Cavity Viewed by Hysteroscopy Cervical Canal Uterine Cavity Endometrium Endometrium of Women in Reproductive Age Endometrium of Women in Postmenopause Uterine Cornua and Fallopian Tubal Orifice Other Intrauterine Findings 8.1.10 Abnormal Findings Under Hysteroscope 8.1.10.1 Submucosal Myoma 8.1.10.2 Intrauterine Adhesions 8.1.10.3 Congenital Uterine Abnormalities 8.1.10.4 Intrauterine Foreign Bodies 8.1.10.5 Endometrial Polyps 8.1.10.6 Endometrial Hyperplasia 8.1.10.7 Atypical Endometrial Hyperplasia 8.1.10.8 Endometrial Carcinoma Hysteroscopic Findings Keypoints of Diagnosis Under Hysteroscope Precautions During Hysteroscopy Practicability of Hysteroscopy 8.1.10.9 Intrauterine Inflammatory Disease 8.1.10.10 Denomyosis 8.1.11 Principles of Endometrial Biopsy for Histopathologic Examination During Hysteroscopy 8.1.12 Causes of and Solutions to Hysteroscopic Failures 8.1.13 Management After Hysteroscopy 8.1.14 Prevention and Treatment of Complications in Hysteroscopy 8.1.14.1 Damage 8.1.14.2 Bleeding 8.1.14.3 Infection 8.1.14.4 Vaso-Vagal Syndrome 8.1.14.5 Allergic Reaction 8.1.14.6 Gas Embolism and Pneumoperitoneum 8.1.15 Experiences and Evaluation of Hysteroscopy 8.1.15.1 Comparisons of Hysteroscopy and HSG 8.1.15.2 Comparisons of Hysteroscopy and D&C 8.1.15.3 Comparisons of Hysteroscopy and Ultrasonography 8.1.15.4 Comparisons of Hysteroscopy and Transvaginal Color Doppler (TVCD) 8.1.15.5 Comparisons of Hysteroscopy and Sonohysterosalpingography (SHSG) or Saline Infusion Sonogram (SIS) 8.1.15.6 Comparisons of Hysteroscope and Magnetic Resonance Imaging (MRI) 8.1.16 Minimally Invasive Diagnostic Hysteroscope 8.1.17 Narrow Band Imaging Hysteroscopy 8.1.17.1 Principles of NBI 8.1.17.2 Clinical Applications of NBI 8.1.17.3 Characteristics of Intrauterine Pathology Under NBI Hysteroscopy 8.1.17.4 Clinical Applications of NBI Hysteroscopy 8.1.18 Does Diagnostic Hysteroscopy Facilitate the Dissemination of Tumor Cells? 8.2 Applications of Hysteroscopy in Gynecological Diseases 8.2.1 Abnormal Uterine Bleeding 8.2.1.1 AUB Among Indications for Hysteroscopy 8.2.1.2 Hysteroscopic Techniques Related to Uterine Bleeding 8.2.1.3 Hysteroscopy for AUB 8.2.1.4 Roles of Hysteroscopy in the Diagnosis of Non-pregnancy AUB Endometrial Polyps Diagnosis Values of Hysteroscopy Submucosal Myoma Diagnosis Values of Hysteroscopy Benign Endometrial Hyperplasia Diagnosis Values of Hysteroscopy Atypical Endometrial Hyperplasia and Endometrial Carcinoma Diagnosis Values of Hysteroscopy Chronic Endometritis Diagnosis Values of Hysteroscopy 8.2.1.5 Role of Hysteroscopy in Diagnosis of Postmenopausal Bleeding 8.2.1.6 Other Pathological Conditions Leading to AUB Endometrial Atrophy Adenomyosis AUB Caused by Contraception or Hormone Therapy Dysfunctional Uterine Bleeding (DUB) 8.2.2 Infertility 8.2.2.1 Indications of Hysteroscopy for Infertile Women 8.2.2.2 Infertility Factors Revealed by Hysteroscopic Examination Uterine Myoma Intrauterine Adhesion Endometrial Polyps Congenital Uterine Malformations Intrauterine Foreign Bodies Chronic Endometritis 8.2.2.3 Hysteroscopic Tubal Catheterization and Hydrotubation 8.2.2.4 Endometrial Changes in Patients with Infertility 8.2.3 Uterine Malformations 8.2.3.1 Formation and Classification of the Uterine Malformations Congenital Uterine Anomalies Co-existent Congenital Cervical Anomalies Co-existent Congenital Vaginal Anomalies 8.2.3.2 Clinical Manifestations of Uterine Malformation 8.2.3.3 Diagnosis of Uterine Malformation 8.2.3.4 Role of Hysteroscopy in Diagnosis of Uterine Malformation 8.2.4 Intrauterine Foreign Bodies 8.2.4.1 The Embedment or Residual Intrauterine Contraceptive Device (IUD) 8.2.4.2 Residual Fetal Bones or Osseous Metaplasia of the Endometrium 8.2.4.3 Residual Pregnancy Tissue 8.2.4.4 Ruptured Cervical Dilator or Residual Laminaria Tent 8.2.4.5 Residual Non-absorbable Sutures Following Cesarean Section 8.2.5 Intrauterine Adhesions 8.2.5.1 Formation and Classification of Intrauterine Adhesions 8.2.5.2 Clinical Manifestations of Intrauterine Adhesions 8.2.5.3 Diagnosis of Intrauterine Adhesions 8.2.5.4 Role of Hysteroscopy in Diagnosis of Intrauterine Adhesions 8.2.6 Endometrial Carcinoma 8.2.6.1 Diagnostic Methods of Endometrial Carcinoma 8.2.6.2 Hysteroscopic Diagnosis of Endometrial Carcinoma 8.2.6.3 Staging for Endometrial Carcinoma at Hysteroscopy 8.2.6.4 Screening for High-Risk Population with Endometrial Cancer by Hysteroscopy Suggested Reading Diagnostic Hysteroscopy Applications of Hysteroscopy in Gynecological Diseases 9: Operative Hysteroscopy 9.1 An Overview of Hysteroscopic Electroresection Surgery 9.1.1 Facilities of Operating Room and Patient’s Body Position 9.1.1.1 Operating Room 9.1.1.2 Gynecologic Operating Table: It Should Have the Following Functions 9.1.1.3 Positioning 9.1.1.4 Prevention of Infection 9.1.2 Irrigating Methods in Hysteroscopic Operation 9.1.2.1 High-Pressure Irrigating 9.1.2.2 Low-Pressure Irrigating 9.1.2.3 Selection of Irrigation Fluid 9.1.3 Cervical Ripening Before Operative Hysteroscopy 9.1.3.1 Osmotic Dilators 9.1.3.2 Misoprostol 9.1.3.3 Phloroglucinol 9.1.4 Techniques of Hysteroscopic Electroresection 9.1.4.1 Operating Procedures 9.1.4.2 Techniques of Resecting 9.1.4.3 Electrocoagulation Hemostasis 9.1.4.4 Weight Calculation of the Excised Tissue 9.1.4.5 Volume Assessment of Bleeding in Hysteroscopic Resection 9.1.4.6 Calculation Method of Blood Loss 9.2 Transcervical Resection of Endometrium and Endometrial Ablation 9.2.1 Indications and Contraindications of TCRE or EA 9.2.1.1 Indications 9.2.1.2 Contraindications 9.2.2 Preoperative Preparations 9.2.2.1 Inquiry of a Detailed History 9.2.2.2 Comprehensive Examinations 9.2.2.3 Consultation 9.2.2.4 Endometrial Pretreatment 9.2.2.5 Timing of Surgery 9.2.2.6 Preparation on the Day Before Operation 9.2.2.7 Preparation on Operation Day 9.2.2.8 Operator’s Preparation 9.2.3 Anesthesia 9.2.3.1 Choice of the Patients 9.2.3.2 Choice of the Operators 9.2.3.3 Operation Duration 9.2.3.4 Combined with Laparoscopy 9.2.3.5 Day Surgery 9.2.3.6 Complications 9.2.4 Operative Procedures 9.2.4.1 Transcervical Resection of Endometrium (TCRE) 9.2.4.2 Endometrial Ablation (EA) 9.2.5 Intraoperative Complicated Conditions and Managements 9.2.5.1 Inadequate Distension of Uterine Cavity 9.2.5.2 Slow Clearance of the Fragments and Clots Inside the Uterine Cavity 9.2.5.3 Insufficient Resection 9.2.5.4 Unclear Observation of the Endometrium and Uterine Cavity 9.2.5.5 Too Rapid Absorption of Irrigation Fluid 9.2.5.6 Intraoperative Bleeding 9.2.5.7 Postoperative Hemorrhage 9.2.6 Intraoperative and Postoperative Care 9.2.6.1 Intraoperative Monitoring 9.2.6.2 Postoperative Care and Managements 9.2.6.3 Postoperative Care 9.2.7 Detection and Management of Operational Complications 9.2.7.1 Intraoperative Complications 9.2.7.2 Postoperative Complications 9.2.8 Experience and Evaluation of TCRE 9.2.8.1 Effects of Operation 9.2.8.2 Endometrial Repair After TCRE/EA 9.2.8.3 One-Stage TCRE 9.2.8.4 TCRE in the Treatment of Uterine Bleeding Resulting from the Hormone Therapy and Blood Coagulation Disorders 9.2.8.5 TCRE in the Treatment of Uterine Bleeding Caused by Severe Medical Diseases 9.2.8.6 Uterine Malignant Lesions Detected During TCRE/EA 9.2.8.7 TCRE for Emergency Hemostasis 9.2.8.8 Endometrial Adenocarcinoma Found During TCRE 9.2.8.9 A Repeat TCRE/EA 9.2.8.10 Hormone Replacement Therapy After TCRE/EA 9.2.8.11 TCRE for Infertility 9.2.8.12 TCRE for Adenomyosis 9.2.8.13 TCRE Applied to Larger Uterus 9.2.8.14 Comparison of TCRE and Drug Therapy for the Treatment of Menorrhagia 9.2.8.15 Comparison Between TCRE and Transabdominal or Transvaginal Hysterectomy 9.2.8.16 Comparison Between TCRE and Other Methods of Endometrial Ablation 9.3 Transcervical Resection of Myoma 9.3.1 Classification of Uterine Myomas 9.3.2 Indications and Contraindications of TCRM 9.3.3 Preoperative Preparations 9.3.3.1 Case Selection 9.3.3.2 Preoperative Medical Pretreatment 9.3.3.3 Routine Laboratory Examination 9.3.3.4 Timing of Surgery 9.3.4 Anesthesia 9.3.5 Operative Equipment 9.3.6 Operative Procedures 9.3.6.1 Pedunculated Submucous Myomas 9.3.6.2 Sessile Submucosal Myoma 9.3.6.3 Intramural Myomas with Inward Protrusion or Close to the Uterine Cavity, and Transmural Myomas 9.3.6.4 Multiple Submucous and Intramural Myoma 9.3.6.5 Cervical Myoma 9.3.6.6 Simultaneous Resection of Endometrium and Myoma 9.3.6.7 Removal of Adenomyoma 9.3.6.8 Large Myomas >6 cm in Diameter 9.3.6.9 Diffuse Uterine Leiomyomatosis (DUL) 9.3.6.10 Operating Techniques of TCRM 9.3.7 Intraoperative Special Conditions and Management 9.3.8 Intra- and Postoperative Monitoring and Management 9.3.8.1 Intraoperative Monitoring 9.3.8.2 Postoperative Monitoring and Treatment 9.3.9 Identification and Treatment of Operative Complications 9.3.9.1 Bleeding 9.3.9.2 Uterine Perforation 9.3.9.3 Fluid Overload and Hyponatremia 9.3.9.4 Inversion of Uterus 9.3.9.5 Uterine Fistula 9.3.9.6 Uterine Myoma Malignancy 9.3.10 Experience and Evaluation of TCRM 9.3.10.1 Operating Process and Outcome of TCRM 9.3.10.2 Effects of TCRM 9.3.10.3 Fertility After TCRM 9.3.10.4 Repeat Operation After TCRM 9.3.10.5 Effects of Preoperative Application of GnRH Analogs on the Short- and Long-Term Outcomes Following TCRM 9.4 Transcervical Resection of Endometrial Polyps 9.4.1 Histopathological Classification 9.4.1.1 Originating from Mature Endometrium (Functional Polyp) 9.4.1.2 Originating from Immature Endometrium (Nonfunctional Polyp) 9.4.1.3 Adenomyoma Polyp 9.4.1.4 Postmenopausal Polyp 9.4.2 Indications and Contraindications of TCRP 9.4.3 Preoperative Preparation and Anesthesia 9.4.4 Operative Procedures 9.4.4.1 Clamping Under Hysteroscopy 9.4.4.2 Intercepting Under Hysteroscopy 9.4.4.3 Hysteroscopic Electroresection 9.4.5 Intra- and Postoperative Monitoring and Management 9.4.6 Identification and Management of Operative Complications 9.4.7 Experience and Evaluation of TCRP 9.4.7.1 Therapeutic Effect of TCRP 9.4.7.2 Postoperative Recurrence of Endometrial Polyps 9.4.7.3 TCRP Combined with TCRE to Improve Therapeutic Effect 9.4.7.4 TCRP and Infertility 9.4.7.5 Malignancy in Endometrial Polyp 9.5 Transcervical Resection of Septum 9.5.1 Embryology and Classification of Uterine Malformations 9.5.1.1 Septate Uterus 9.5.1.2 Bicornuate Uterus 9.5.1.3 T-Shaped Uterus 9.5.1.4 Unicornuate Uterus 9.5.1.5 Robert Uterus 9.5.1.6 Arcuate Uterus 9.5.1.7 Rudimentary Uterus 9.5.2 Indications of TCRS 9.5.3 Preoperative Preparation and Anesthesia 9.5.3.1 Preoperative Assessment 9.5.3.2 Timing of Operation 9.5.3.3 Operative Preparation 9.5.3.4 Anesthesia 9.5.4 Operative Procedures 9.5.4.1 Mechanical Resection with Scissors Under Hysteroscope 9.5.4.2 Transcervical Resection of Uterine Septum (TCRS) 9.5.4.3 Hysteroscopic Resection of Septum by Laser 9.5.4.4 Transcervical Uterine Incision (TCUI) 9.5.4.5 Uterine Unification for Bicornuate Uterus by Combined Laparoscopy and Hysteroscopy 9.5.5 Intraoperative Complex Conditions and Management 9.5.6 Intraoperative and Postoperative Monitoring and Management 9.5.6.1 Ultrasound Surveillance 9.5.6.2 Laparoscopic Monitoring 9.5.7 Identification and Treatment of Operative Complications 9.5.8 Experience and Assessment of Hysteroscopic Metroplasty 9.5.8.1 Septate Uterus 9.5.8.2 Bicornuate Uterus 9.5.8.3 T-Shaped Uterus 9.5.8.4 Unicornuate Uterus 9.5.8.5 Robert Uterus 9.5.8.6 Arcuate Uterus 9.6 Transcervical Resection of Intrauterine Adhesions 9.6.1 Operative Indications and Contraindications 9.6.1.1 Indications 9.6.1.2 Contraindications 9.6.2 Preoperative Preparations 9.6.3 Anesthesia 9.6.4 Surgical Procedures 9.6.4.1 Transcervical Resection of Intrauterine Adhesions (TCRA) 9.6.4.2 Hysteroscopic Lysis of Adhesions with Scissors 9.6.4.3 Lysis of Adhesions with Fiber Optic Lasers 9.6.5 Intraoperative Complicated Conditions and Cautions 9.6.6 Intraoperative Monitoring 9.6.6.1 Ultrasonography 9.6.6.2 Laparoscopy 9.6.7 Postoperative Management and Adjunctive Therapy 9.6.7.1 Hormone Treatment 9.6.7.2 Intrauterine Placement of Barriers 9.6.7.3 Prophylactic Antibiotics 9.6.7.4 Second-Look Hysteroscopy 9.6.8 Diagnosis and Management of Operative Complications 9.6.9 Experiences and Evaluations of TCRA 9.6.9.1 Success Rate of Operations 9.6.9.2 Postoperative Menstruations 9.6.9.3 Postoperative Recurrence of Adhesions 9.6.9.4 Postoperative Conception and Reproductive Outcomes 9.6.9.5 Factors Affecting Reproductive Prognosis After TCRA 9.7 Transcervical Removal of Uterine Foreign Body 9.7.1 Intrauterine Device (IUD) 9.7.2 Retention of Fetal Bone 9.7.3 Endometrial Ossification and Cervical Ossification 9.7.4 Residual Trophoblastic Remnants 9.7.5 Cervical Pregnancy 9.7.6 Cesarean Scar Pregnancy 9.7.7 Fragmented Cervical Dilator or Laminaria Tent 9.7.8 Surgical Suture Threads 9.8 Other Hysteroscopic Operations 9.8.1 Transcervical Uterine Incision (TCUI) 9.8.1.1 Indications 9.8.1.2 Operative Procedures 9.8.1.3 Experience and Evaluation of the Operation 9.8.2 Transcervical Resection for Biopsy (TCRB) 9.8.2.1 For Diagnosis of Adenomyosis 9.8.2.2 For Diagnosis of Endometrial Tuberculosis 9.8.3 Hysteroscopic Resection of Cystic Adenomyosis 9.8.3.1 Indications 9.8.3.2 Operative Procedures 9.8.3.3 Experience and Evaluation of the Operation 9.8.4 Transcervical Resection of Cervical Lesion (TCRC) 9.8.4.1 Indications 9.8.4.2 Operative Procedures 9.8.4.3 Experience and Evaluation of the Operation 9.9 Other Techniques of Endometrial Ablation 9.9.1 Uterine Balloon Thermo-Ablation (UBT) 9.9.2 Hydrothermo Ablation (HTA) 9.9.3 Multi-Electrode Balloon Ablation (MEBA) 9.9.4 Microwave Endometrial Ablation (MEA) 9.9.5 Bipolar Radiofrequency Endometrial Ablation (RFEA) 9.9.6 Cryo-Endometrial Ablation 9.9.7 Endometrial Laser Intrauterine Thermotherapy (ELITT) 9.9.8 Micro-Hysteroscopy Versapoint Bipolar Electrosurgery Intrauterine System (Versapoint) Suggested Reading An Overview of Hysteroscopic Electroresection Surgery Transcervical Resection of Endometrium and Endometrial Ablation Transcervical Resection of Myoma Transcervical Resection of Endometrial Polyps Transcervical Resection of Septum Transcervical Resection of Intrauterine Adhesions Transcervical Removal of Uterine Foreign Body Other Hysteroscopic Operations Other Techniques of Endometrial Ablation 10: Combined Hysteroscopy and Laparoscopy 10.1 Indications for Combined Hysteroscopy and Laparoscopy 10.2 Contraindications for Combined Hysteroscopy and Laparoscopy 10.3 Operative Procedures of Combined Hysteroscopy and Laparoscopy 10.3.1 Step 1: The Joint Examination of Hysteroscopy and Laparoscopy 10.3.2 Step 2: Hysteroscopic Surgery Under Laparoscopic Monitoring 10.3.2.1 Endometrial Resection 10.3.2.2 Resection of Broad-Based Sessile Submucosal Myomas and Inward-Protruding Intramural Myomas 10.3.2.3 Surgical Correction of Uterine Septum 10.3.2.4 Lysis of Severe Intrauterine Adhesions 10.3.3 Step 3: Laparoscopic Surgery and Hysteroscopic Surveillance 10.3.4 Step 4: Laparoscopic Exploration and Surgery 10.4 Application of Combined Hysteroscopy and Laparoscopy 10.4.1 Diagnosis and Treatment of Infertility 10.4.1.1 Combined Hysteroscopy and Laparoscopy in Diagnosis and Treatment of Uterine Malformations 10.4.1.2 Diagnosis and Treatment of Tubal Infertility 10.4.2 Etiological Diagnosis and Treatment of Chronic Pelvic Pain 10.4.3 Monitoring Complicated Hysteroscopic Surgery 10.4.4 Metroplasty for Complete Bicornuate Uterus 10.4.5 Laparoscopic Uterine Artery Ligation and Hysteroscopic Surgery for Intrauterine Lesions with High Risk of Hemorrhage 10.4.6 Diagnosis and Treatment of the Coexistent Pelvic and Intrauterine Lesions Suggested Reading 11: Ultrasonography Monitoring During Hysteroscopic Surgery 11.1 Techniques of Ultrasonography Guidance 11.2 Ultrasonography Guidance for Intraoperative Operation 11.2.1 Ultrasonography Guidance for TCRE 11.2.2 Ultrasonography Guidance for Endometrial Ablation 11.2.3 Ultrasonography Guidance for TCRM 11.2.4 Ultrasonography Guidance for TCRS 11.2.5 Ultrasonography Guidance for TCRA 11.2.6 Ultrasonography Guidance for TCRF 11.2.6.1 Removal of the Residual IUD 11.2.6.2 Removal of Complete or Broken Metal Ring 11.2.6.3 Removal of Fetal Bones 11.2.6.4 Removal of Residual Placental Tissues 11.3 Ultrasonography Guidance and Uterine Perforation 11.3.1 Causes of Uterine Perforation 11.3.1.1 Intrauterine Myomas 11.3.1.2 Adenomyosis 11.3.1.3 Placenta Residues 11.3.1.4 Intrauterine Retention and Embedment of Fetal Bones 11.3.1.5 Severe Intrauterine Adhesions 11.3.1.6 Old Injuries in the Uterine Wall 11.3.1.7 The Position of the Uterus 11.3.2 Sonographic Features of Uterine Perforation 11.3.3 Intraoperative Monitoring and Uterine Perforation 11.4 The Value of Ultrasonography Guidance in Hystersocopic Surgery Suggested Reading 12: Complications of Hysteroscopic Surgery 12.1 Organ Injury 12.1.1 Uterine Perforation 12.1.1.1 Incidence 12.1.1.2 Factors for Occurrence of Uterine Perforation 12.1.1.3 Identification of Uterine Perforation 12.1.1.4 Seriousness of Uterine Perforation 12.1.1.5 Treatment of Uterine Perforation 12.1.1.6 Prevention of Uterine Perforation 12.1.1.7 Long-Term Prognosis of Uterine Perforation 12.1.2 Injury to Adjacent Organs Induced by Uterine Perforation 12.1.3 Large Vessel Injury Following Uterine Perforation 12.1.4 Other Injuries 12.2 Fluid Overload 12.2.1 Physiology of Low-Viscosity and Electrolyte Fluid 12.2.2 Fluid Overload and Dilutional Hyponatremia 12.2.3 TURP Syndrome 12.2.4 Prevention of TURP Syndrome 12.2.5 Treatment of TURP Syndrome 12.2.6 Monitoring Device for the Prevention of Fluid Overload (Portable) 12.2.7 New Operative Device: Imitated Bipolar System 12.2.8 Conclusion 12.3 Intra- and Postoperative Bleeding 12.3.1 Factors and Mechanisms of Intra- and Postoperative Bleeding 12.3.1.1 The Cutting Depths of TCRE, TCRA, and TCRP Reaching the Uterine Vascular Layer 12.3.1.2 Bleeding from the Myometrium of the Fundus Because of the Injury of the Vessels When TCRS Reaches the Fundus 12.3.1.3 Bleeding from the Base of Myomas with Large Size and Special Location 12.3.1.4 Bleeding from the Damaged Vessels During Hysteroscopic Operations on Intrauterine Conception in Special Locations 12.3.1.5 Disturbed Contractility of the Uterus with Adenomyosis or Myoma 12.3.1.6 Uterine Arteriovenous Fistula 12.3.1.7 Coexisting with Relevant Medical Diseases 12.3.2 Intraoperative Bleeding of Hysteroscopic Surgeries 12.3.2.1 Identification of Intraoperative Bleeding 12.3.2.2 Prevention and Treatment of Intraoperative Bleeding 12.3.3 Bleeding in the Early Postoperative Period 12.3.3.1 Identification of Bleeding in the Early Postoperative Period 12.3.3.2 Prevention and Treatment of Bleeding in the Early Postoperative Period 12.3.4 Bleeding in the Late Postoperative Period 12.3.5 Prolonged Bleeding in the Postoperative Period 12.4 Infection 12.4.1 Characteristics of Female Genital Organs 12.4.2 Factors Causing Postoperative Infection 12.4.2.1 Factors Related to Procedures 12.4.2.2 Changes in the Internal Environment of Reproductive Tract 12.4.2.3 Factors Related to Instrument 12.4.3 Microbiological Characteristics of Infections After Hysteroscopy 12.4.4 Diagnosis and Treatment of Postoperative Infection 12.4.4.1 Clinical Symptoms 12.4.4.2 Physical Signs 12.4.4.3 Auxiliary Examination 12.4.4.4 Treatment 12.4.5 Reports of Infections After Operative Hysteroscopy 12.4.6 Preventive Measures Against Infection 12.4.6.1 Strict Sterilization of Instruments 12.4.6.2 Strict Sterile Operation 12.4.6.3 Improvement in Patient Status 12.4.6.4 Application of Prophylactic Antibiotics 12.5 Venous Air Embolism 12.5.1 Incidence 12.5.2 Etiology 12.5.3 Pathogenesis 12.5.4 Pathophysiology 12.5.5 Clinical Manifestations 12.5.6 Diagnosis of VAE 12.5.6.1 Symptoms and Signs 12.5.6.2 Laboratory Tests 12.5.6.3 Imaging Examination 12.5.6.4 Electrocardiogram Examination 12.5.7 Monitoring of VAE 12.5.8 Emergency Managements 12.5.9 Prevention and Treatment of VAE 12.6 Intrauterine Adhesions 12.6.1 Incidence of Postoperative Intrauterine Adhesions 12.6.1.1 Hysteroscopic Endometrial Surgery 12.6.1.2 Hysteroscopic Resection of Myomas 12.6.1.3 Hysteroscopic Surgery on Uterine Malformations 12.6.1.4 Hysteroscopic Lysis of Intrauterine Adhesions 12.6.1.5 Other Hysteroscopic Surgeries 12.6.2 Mechanisms of Occurrence of Postoperative Intrauterine Adhesions 12.6.3 Symptoms of Postoperative Intrauterine Adhesions 12.6.3.1 Menstrual Disorders 12.6.3.2 Pregnancy Disorders 12.6.3.3 Hematometra 12.6.4 Diagnosis of Postoperative Intrauterine Adhesions 12.6.4.1 Gynecologic Ultrasonography 12.6.4.2 Second-Look Hysteroscopy 12.6.5 Prevention of Postoperative Intrauterine Adhesions 12.6.5.1 Reduction of the Surgical Trauma During Hysteroscopic Surgery 12.6.5.2 Artificial Cyclic Hormone Treatment After Hysteroscopic Surgery 12.6.5.3 Intrauterine Insertion of Barriers After Hysteroscopic Surgery 12.6.5.4 Prophylactic Antibiotics 12.6.5.5 Second-Look Hysteroscopy After Hysteroscopic Surgery 12.6.6 Treatment of Postoperative Adhesions 12.6.6.1 Division of Adhesions During Second-Look Hysteroscopy Under Ultrasonography Guidance 12.6.6.2 Hysteroscopic Lysis of Adhesions 12.6.6.3 Hysterectomy 12.7 Postoperative Pregnancy 12.7.1 Possibility of Pregnancy After TCRE 12.7.2 Risk of Pregnancy After TCRE 12.7.2.1 Abnormal Placenta Implantation 12.7.2.2 High Incidence of Ectopic Pregnancy 12.7.2.3 High-Risk Population Related to Induced Abortion 12.7.3 Diagnosis and Management of Pregnancy After TCRE 12.7.3.1 Diagnosis 12.7.3.2 Management 12.8 Postablation-Tubal Sterilization Syndrome 12.8.1 Etiology of PASS 12.8.2 Diagnosis of PASS 12.8.3 Treatment of PASS 12.8.4 Prevention of PASS 12.9 Accidental Electrical Injuries 12.9.1 Electrical Burn Accidents 12.9.1.1 Burns Around the Negative Plate 12.9.1.2 Burns Outside the Site of Negative Plate 12.9.2 Electric Shock Accidents 12.9.3 Accidents Caused by Electromagnetic Interference 12.9.4 Accidents Caused by Sparks 12.10 Other Complications 12.10.1 Hematometra 12.10.2 Abdominal Pain 12.10.3 Iatrogenic Uterine Adenomyosis 12.10.4 Treatment Failure and Recurrence of Symptoms 12.10.5 Malignant Lesions of the Uterus 12.10.6 Uterine Necrosis 12.10.7 Pulmonary Hemorrhage 12.10.8 Transient Blindness 12.10.9 Nerve Injury 12.10.10 Death 12.10.11 Complications of the Second Generation Endometrial Ablation Suggested Reading Organ Injury Fluid Overload Intra- and Postoperative Bleeding Infection Venous Air Embolism Intrauterine Adhesions Postoperative Pregnancy Postablation-Tubal Sterilization Syndrome Accidental Electrical Injuries Other Complications 13: Hysteroscopy for Other Purposes 13.1 Vaginoscopy 13.1.1 Indications of Vaginoscopic Diagnosis and Operation 13.1.2 Contraindications of Vaginoscopic Diagnosis and Operation 13.1.3 Procedures of Vaginoscopic Diagnosis and Operation 13.1.3.1 Vaginoscopic Examination 13.1.3.2 Vaginoscopic Diagnosis and Operation 13.1.3.3 Vaginoscopic Removal of Vaginal Foreign Bodies 13.1.3.4 Vaginal Wall Biopsy Under Vaginoscopy 13.1.3.5 Hysteroscopic Resection or Coagulation Vaginoscopically 13.1.4 Applications of Vaginoscopic Examination and Operation 13.2 Hysteroscopy in Place of Culdoscopy in Fertiloscopy 13.3 Hysteroscopy in Place of Laparoscopy 13.4 Hysteroscopy in Place of Cystoscopy 13.4.1 Indications for Hysteroscopy in Place of Cystoscopy 13.4.2 Contraindications for Hysteroscopy in Place of Cystoscopy 13.4.3 Matters Need Attention for Using a Hysteroscope as a Cystoscope Suggested Reading 14: Hysteroscopy Training 14.1 Training Procedures 14.2 Requirements for an Operator 14.3 How to Teach Beginners 14.4 How to Cut Tissues Suggested Reading 15: The Future of Hysteroscopy Suggested Reading 16: Digital Storage and Application of Endoscopic Image 16.1 Basic Concept 16.2 Storage and Application of Static Images 16.3 Storage and Application of Dynamic Images 16.4 Concept and Composition of Nonlinear Editing System 16.5 Clinical Applications of Digital Video Image Data Appendix 1: Routine Orders in a Hysteroscopic Ward Doctor’s Orders on Admission Standing Orders Stat Orders Hysteroscopic Operations Orders on the Day Before Operation Postoperative Orders Special Management After TCRS and TCRA Conditions on Discharge Precautions After Hysteroscopic Operation Laparotomy Surgery Orders on the Day Before Operation Postoperative Orders Precautions After Operation Conditions on Discharge Routine Orders of Diagnostic or Operative Laparoscopy Orders on the Day Before Operation Bowel Preparation Methods of Bowel Preparation (See Table- Appendix 1) Three Days Before Operation Two Days Before Operation On the Day Before Operation Postoperative Orders Conditions on Discharge Routine Orders of Transvaginal Surgery Preoperative Preparation for Transvaginal Surgery Orders on the Day Before Operation Standing Orders After Transvaginal Surgery Documents Provided to the Patients on Discharge Clinical Medication Antibiotics in Common Usage Fluid replacement Addendum Appendix 2: A Practical Manual of Hysteroscopic Surgery Facilities of Operating Room and Patient’s Body Position Preoperative Preparations Transcervical Resection of Endometrium (TCRE) Indications Contraindications Timing of Operation Anesthesia Operating Procedures Intraoperative Ultrasonography Monitoring and Guidance Postoperative Precautions Transcervical Resection of Myoma (TCRM) Indications Contraindications Preoperative Preparations Timing of Operation Anesthesia Operating Procedures Postoperative Management Postoperative Precautions Transcervical Resection of Endometrial Polyp (TCRP) Indications Contraindications Preoperative Preparation Timing of Operation Anesthesia Operating Procedures Postoperative Management Postoperative Precautions Transcervical Resection of Uterine Septum (TCRS) Indications Preoperative Preparations Operating Procedures Postoperative Precautions Transcervical Resection of Adhesions (TCRA) Indications Preoperative Preparations Operating Procedures Postoperative Precautions Transcervical Removal of Uterine Foreign Body (TCRF) Removal of IUD Indications Methods Removal of the Residual Trophoblastic Remnants Removal of Residual Fetal Bone Removal of Remaining Sutures Monitoring of TCRF Transcervical Resection of Cervix (TCRC) Preoperative Preparations Operating Procedures Postoperative Precautions Appendix 3: Patient Consent Form for Hysteroscopic Operation in the Hysteroscopy Center of Fuxing Hospital, Capital Medical University Appendix 4: Patient Consent Form for Hysteroscopic Diagnosis in the Hysteroscopy Center of Fuxing Hospital, Capital Medical University Appendix 5: Report of Diagnostic Hysteroscopy