Figure 23.25 Office hysteroscopy instruments. An assembled continuous ﬂow operating hysteroscope with a 5.5-mm diameter external sheath is shown in (A). A 5-French semirigid scissors occupies the working channel. An additional biopsy forceps is shown in (B). Tubing transporting media to the system is shown in (C) going into a 3-mm external diameter ﬂexible and steerable hysteroscope (D). A medical video camera is attached to the hysteroscope (F) and the light source is attached at (E). An open speculum (G) facilitates removal with instruments in place. A small dilator (H) or series of dilators will be necessary for a large number of patients. A tenaculum (I) attached to the cervix frequently facilitates both dilation and entry of the hysteroscope into the endometrial cavity.
Anesthesia The anesthetic requirements for hysteroscopy vary greatly, depending on the patient’s level of anxiety, the status of her cervical canal, the procedure, and the outside diameter of the hysteroscope or sheath. In some patients, diagnostic hysteroscopy is possible without anesthesia, especially if the patient is parous or if narrow-caliber (<3 mm in outside diameter) hysteroscopes and sheaths are used (208). In many instances the pain of cervical dilation can be avoided or minimized with the preprocedural use of oral or vaginal misoprostol (see below) or by inserting a laminaria “tent” in the cervix 3 to 8 hours before the procedure. Laminaria are thin rods of natural (slippery elm) or synthetic construction that, when passed through the internal os, expand over several hours thereby dilating the cervix. However, if laminaria are left in place too long (e.g., longer than 24 hours), the cervix may overdilate, which is can be counterproductive for CO2 insufﬂation.