Operative hysteroscopy involves «operating» in the uterus, with the surgeon's movements controlled by a direct view into the cavity, thanks to an endoscopic camera connected to the hysteroscope.
Operative hysteroscopy is performed on an outpatient basis, meaning that the patient is hospitalized for only a few hours, and goes home the same evening (with a few exceptions related to general condition (chronic or incapacitating illnesses), long distances from home, absence of an accompanying person, etc.).
The procedure is performed in the operating theatre of a health care facility, usually under light general anaesthesia (without intubation or assisted ventilation) or pure local anaesthesia (cervical infiltration with xylocaine), more rarely locoregional anaesthesia (epidural or rachia),
Post-operative care is generally straightforward, with little or no pain and only a little bleeding.
This procedure is therefore indicated whenever it is necessary and possible to correct certain anomalies internally (i.e. through the natural route without «opening»), such as :
- Polyps: The endometrium is a small outgrowth of the lining of the uterus, varying in size from a few millimeters to several centimeters.
In general, these lesions are responsible for bleeding outside the menstrual period (metrorrhagia). They can also contribute to infertility when they are large or when they are placed in an area of the uterus where the embryo implants (at the bottom of the cavity).
They very rarely degenerate (become cancerous), except in the peri- or post-menopausal period, when they need to be checked more precisely by histological analysis.
- Myoma or «fibromyoma» or «leiomyoma», also known as a «fibroid», is a benign tumour formed by the proliferation of muscle cells from the lining of the uterus. It has the consistency of a golf ball but varies in size from a pea to a tennis ball, and even more rarely (grapefruit or larger).
Fibroids or myomas are always benign, but it is important to ensure that there are no associated lesions that could be malignant in nature, especially after the menopause.
A myoma is a benign muscular tumor of the uterus that can cause pain, bleeding or difficulty in getting pregnant.
If the fibroma or myoma grows inside the uterine cavity, it is said to be sub-mucosal, making it accessible by hysteroscopy, and can therefore also be removed naturally.
- Synechiae: Normally, the uterus is like a hollow cavity lined with a mucous membrane (a kind of carpet), which prevents one side from sticking to the other. If the mucous membrane is damaged and disappears, the 2 sides of the cavity may stick together, reducing the size of the cavity and compromising implantation and pregnancy. In very extensive forms, they can even affect the volume of menstruation, which is then absent.
This can occur after mucosal alteration secondary to miscarriage, uterine surgery or infection such as genital tuberculosis.
Synechia is best treated hysteroscopically, with the fibrous bridges being cut precisely under visual control.
- Endometrialctomy: This procedure consists of removing the endometrium (the mucous membrane lining the uterus) to reduce bleeding during menstruation (in the case of haemorrhagic or very long periods, also known as menorrhagia).
Endometrectomy can be considered whenever menstrual bleeding is too heavy and medical treatment has been insufficient. It's an interesting alternative to hysterectomy, since the procedure is performed on an outpatient basis, requiring just a few hours’ hospitalization, and you can resume your professional activities the very next day.
Like all hysteroscopic operations, the procedure is performed under general anaesthetic. The after-effects are not painful, but are generally marked by some minor bleeding.
- Removing an IUD: sometimes after IUD insertion, the threads are no longer visible on the cervix.
This is because the threads are usually left outside the cervix, so that they can be grasped and the IUD removed if necessary, particularly for changing after a few years.
But sometimes, over time, the IUD shifts or moves up into the uterine cavity and the wires are no longer seen or wound higher up, so it's not possible to remove it easily because the wires are no longer accessible.
Thanks to hysteroscopy, it's possible to reach into the cervix, then into the uterine cavity, to visualize the IUD and its thread, to grasp it, lower it and remove the intra-uterine device (IUD or coil) without any anaesthetic, as the endoscopy is painless.
- Tubal ligation or tubal sterilization:When a couple no longer wishes to have children, and traditional methods of contraception such as the pill or IUDs are poorly tolerated or contraindicated, tubal sterilization, i.e. «ligation» of the fallopian tubes, is an option.
This procedure consists of «plugging» the Fallopian tubes to prevent sperm from meeting the eggs and thus creating a pregnancy.
Traditionally, tubal «ligation» has been performed surgically (with an open abdomen), or by laparoscopy. Recently, hysteroscopy has made it possible to visualize the beginning of the tubes and slide an Intra Tubal Device (ITD) into the tube (without any incision or scarring).
This DIT will progressively block the fallopian tube, preventing sperm and egg cells from meeting and thus providing definitive but also irreversible contraception.
- Uterine septum : Diagnosis is made by ultrasound, which enables us to assess the height of the septum, its thickness and vascularization. Above all, it enables us to differentiate between septate uteri and double uteri, which are contraindications to hysteroscopic treatment.
