{"paper_id":"6196c8d9-60f7-498d-b18d-705c25444b6a","body_text":"482\nAmbulatory or office endoscopy procedures are opti-\nmally suited to enhance effectiveness and efficiency of\nhealth care delivery systems. All the advantages of en-\ndoscopy as a diagnostic or surgical modality are main-\ntained with a minimization of time spent in a healthcare\nsetting. The savings in terms of time, admission, nurs-\ning and facility maintenance costs can be substantial.\nThey could be utilized as important components of\n“one-stop” clinics for conditions like abnormal uterine\nbleeding, infertility and pain management. Office en-\ndoscopy procedures have been in practice in other spe-\ncialties such gastroenterology and otorhinolaryngology\nsince a couple of decades and are well established in\nthese fields. In gynecology, endoscopic procedures\nsuch as colposcopy are routinely practiced as office\nprocedures. A number of hysteroscopies (diagnostic\nand operative) have the potential to be converted from\nhospital to office settings. Endoscopy techniques such\nas tranvaginal hydrolaparoscopy (TVHL) and microla-\nparoscopy have been described for office\nsettings.\n1 These procedures have become possible due\nto the advances in technology related to endoscopic\nequipment making, especially small-diameter optics,\nhigh intensity light sources and digital cameras to cap-\nture and store images.\nPatient selection is paramount for successful office en-\ndoscopy. Women with obvious pathology requiring\ncomplex surgical interventions and medically unfit pa-\ntients who may need supportive care are not suitable\nfor office procedures. One of the challenges of office\nendoscopy procedures is to manage apprehensiveness,\nanxiety and pain. Counseling women and preparing\nthem mentally are important to reduce anxiety. Premed-\nication with oral ibuprofen reduces pain perception and\noral sedation with agents such as lorazepam may be\nused. Atropine reduces the risk of vasovagal symptoms.\nThe procedure may be carried out without anesthesia,\nunder local anesthesia or with intravenous sedation\ntechniques depending on the procedure and comfort\nlevels of the patient and physician.\n2\nHysteroscopy in the office can be performed using car-\nbon dioxide or saline as distension medium. Carbon\ndioxide has the advantage of being non-messy. A spe-\ncial hysteroflator is needed for this. The insuffulator\nused for laparoscopies cannot be used due to the very\nlarge pressures it generates. Most gynecologists practic-\ning office hysteroscopy perform it using the standard\ntechnique as used under general anesthesia. The proce-\ndure is likely to be painful and not tolerated well in\nthese situations. This is especially true when the patient\nis nulliparous or menopausal. Some modifications sug-\ngested to the standard technique are the use of a 3.5 mm\nhysteroscope (as compared to a 5 mm sheath), local\nanesthesia (paracervical block), avoiding holding the\nanterior lip of the cervix and avoiding dilatation of the\ncervix.\n1 Bettocchi et al have pioneered the vaginoscopic\napproach to hysteroscopy. No instruments are intro-\nduced into the vagina except for the hysteroscope. A\nspecial Bettocchi hysteroscopy system has been de-\nsigned to allow complex procedures to be performed in\noffice settings. A recent review describes the successful\napplication of office hysteroscopy in a wide variety of\nhysteroscopic procedures including biopsy, polypec-\ntomy, sterilization, metroplasty and myomectomy.\n3 It\nshould be borne in mind that this group has a vast op-\nerative experience. The generally encountered prob-\nlems include vasovagal episodes (<1%) and inability to\ncomplete the procedure due to technical difficulties or\npain (~ 5%).\n1\nTransvaginal hydrolaparoscopy is using a culdoscopic\ntechnique was described by Grodts et al.\n4 The V eress\nJ Obstet Gynecol India V ol. 60, No. 6 :November / December 2010 Pg 482 - 483\nEditorial\nOffice Endoscopy in Gynecology\n\n\n483\nStress Urinary IncontinenceJ Obstet Gynecol India November / December 2010\nneedle-cannula system was inserted in the midline ap-\nproximately 15 mm below the insertion of the vagina\nwall on the cervix. Progressively, the dilator and can-\nnula were inserted transvaginally into the pouch of\nDouglas, after which the dilator and V eress needle were\nremoved and replaced by a 2.7 mm, 30° rigid, wide-an-\ngled optical system that was placed in a 3.5 mm shaft\nsystem ensuring irrigation with saline during the proce-\ndure. This can be followed by chromopertubation. In a\nseries of more than 150 women, there were no failed\nprocedures or procedures interrupted due to pain. Vi-\nsualization of both adnexae was confirmed in over 90%\nof women. Standard laparoscopy is recommended\nwhen there are abnormal findings requiring operative\nintervention. It is estimated that about 75% of women\nwould avoid a standard laparoscopy if this approach is\nused.\n1\nMicrolaparoscopy under local anesthesia is done using\na standard V erres needle insertion intraumbilically. The\nsheath of the V erres needle is left in place and a 2.7mm\nrigid laparoscope is introduced through it. Carbon diox-\nide is insuffulated under vision to the quantity required\nto visualize the structures of interest. Generally 800 ml\nof gas is sufficient. The relatively smaller quantity of\ngas minimizes patient discomfort. Ancillary ports of\n2mm diameter and correspondingly small hand instru-\nments can be used for minor operative interventions.\nThe accuracy of narrow diameter laparoscopy has been\nverified in a number of studies.\n5 The procedure is sim-\nilar to standard laparoscopy in terms of risks of injuries\nand gas related complications but port sites are smaller\nand pain is significantly lesser.\nSophisticated equipment and newer techniques have\nnow brought into reality a variety of procedures which\nare even less invasive than standard endoscopy.\nNeedless to say, equipment costs, restructuring of\ninfrastructure in the office setting, appropriate staffing,\nfacilities to deal with emergencies and surprises are\nmandatory before initiating these services. Surgeons\nshould familiarize themselves with these modified tech-\nniques to increase the repertoire of procedures that they\ncan offer.\nReferences\n1. Marana R, Marana E, Catalano GF. Current prac-\ntical applications of office endoscopy. Curr Opin\nObstet Gynecol 2001;13:383-387.\n2. Society of American Gastrointestinal and Endo-\nscopic Surgeons. SAGES Guidelines for office\nendoscopic services. Los Angeles, November\n2008. Available at http://www.sages.org/publica-\ntion/id/09. Accessed on: 28 November 2010.\n3. Di Spiezio Sardo A, Bettocchi S, Spinelli M, et\nal. Review of new office-based hysteroscopic pro-\ncedures 2003-2009. J Minim Invasive Gynecol.\n2010; 17:436-48.\n4. Gordts S, Campo R, Brosens I. Office transvagi-\nnal hydrolaparoscopy for early diagnosis of pelvic\nendometriosis and adhesions. J Am Assoc Gy-\nnecol Laparosc 2000; 7:45-49.\n5. Faber BM, Coddington CC. Micro-laparoscopy: a\ncomparative study of diagnostic accuracy. Fertil\nSteril 1997; 67:952-954.\nDastur Adi E\nMD FICOG FCPS DGO DFP FICMU FICMCH A TMF (USA)\nHonorary Professor Emeritus and Dean\nSheth G S Medical College & Nowrosjee Wadia Mat.\nHospital, Mumbai, India.","source_license":"CC0","license_restricted":false}