The hysteroscope is used in modern gynecology to visualize the endometrial cavity. The device is inserted through the cervix, and the entire procedure may be performed in an office setting (Okohue, 2020). Hysteroscopy is especially important in evaluating both premenopausal and postmenopausal patients with abnormal uterine bleeding and is a strong alternative to hysterectomy (Mushambi & Williamson, 2002). Other indications for hysteroscopy include investigation of spontaneous or induced abortion, primary or secondary infertility, and location of intrauterine contraceptive devices (Murdoch & Gan, 2001). Hysteroscopy can also be used for endometrial ablation in the management of menorrhagia, treatment of septate uterus, and lysis of uterine adhesions (Cicinelli, 2010). A major benefit of this procedure is that it allows patients to be evaluated and treated in the outpatient setting and resume their day soon afterward (Salazar, 2018). Operative hysteroscopy provides a more effective and safer alternative to hysterectomy for most intrauterine disease treatment (Murdoch & Gan, 2001). Still, hysteroscopy poses risks, and surgeons and anesthesia providers must ensure to minimize risk of complications (Mushambi & Williamson, 2002).
The role of anesthesia in hysteroscopy depends on if hysteroscopy is employed for diagnostic or surgical purposes. Possible complications of hysteroscopy include fluid overload, uterine perforation, hemorrhage, infection, endometrial cancer, recurrent bleeding, and the need for reoperation (Murdoch & Gan, 2001). However, the ideal anesthesia regimen should minimize complications, provide comfort to the patient, and create an optimal operative environment. The options for hysteroscopic anesthesia are local anesthesia infiltration with or without sedation, paracervical block with or without sedation, regional anesthesia such as spinal, epidural or combined spinal-epidural anesthesia, and general anesthesia (Mushambi & Williamson, 2002).
Anesthesiologists are less involved in the setting of diagnostic hysteroscopy. (Murdoch & Gan, 2001). Anesthesia for diagnostic hysteroscopy can range from no anesthesia at all to a paracervical block. Some still debate if techniques such as simple infiltration of local anesthetic or paracervical block are valuable because these methods hold risks of infection and toxic reactions (Murdoch & Gan, 2001). In a short procedure such as diagnostic laparoscopy, hyperbaric lidocaine and mepivacaine are popular options (Murdoch & Gan, 2001). However, these methods may not be adequate for operative hysteroscopy.
Depending on the indications for operative hysteroscopy, anesthesia can be administered generally or regionally. Regional anesthesia allows early detection of fluid overload and other advantages over general anesthesia (Mushambi & Williamson, 2002). Important considerations gathered through a thorough preoperative assessment include the degree of uterine bleeding, symptoms of anemia, and associated coronary artery or cerebrovascular disease (Murdoch & Gan, 2001). There is a lack of consensus on what form of anesthesia is optimal for operative hysteroscopy. In some cases, hysteroscopic operations may escalate to a laparoscopy or laparotomy, and the anesthesia provider must be prepared for this situation (Mushambi & Williamson, 2002).
The need for and role of anesthesia in hysteroscopy is still a matter of debate (Cincinelli, 2010). However, this procedure is becoming increasingly used as an in-office technique for diagnosing and treating certain intrauterine pathologies. While hysteroscopy is a minimally invasive technique with low complication rates, the care team must be aware and ready to address any potential hazards (Cincinelli, 2010). Further research is needed to determine which techniques provide the most comfort to the patient and minimize risks of complications, especially in the setting of operative hysteroscopy.
References
Cicinelli E. Hysteroscopy without anesthesia: review of recent literature. J Minim Invasive Gynecol. 2010;17(6):703-708. doi:10.1016/j.jmig.2010.07.003
Murdoch JA, Gan TJ. Anesthesia for hysteroscopy. Anesthesiol Clin North Am. 2001;19(1):125-140. doi:10.1016/s0889-8537(05)70215-7
Mushambi MC, Williamson K. Anaesthetic considerations for hysteroscopic surgery. Best Pract Res Clin Anaesthesiol. 2002;16(1):35-52. doi:10.1053/bean.2002.0206
Okohue JE. Overview of Hysteroscopy. West Afr J Med. 2020;37(2):178-182.
Salazar CA, Isaacson KB. Office Operative Hysteroscopy: An Update. J Minim Invasive Gynecol. 2018;25(2):199-208. doi:10.1016/j.jmig.2017.08.009