O&G · gynae-surgery
Operative hysteroscopy — distension media, fluid management, energy and complications
Also known as Hysteroscopic surgery · Resectoscopy · Hysteroscopic polypectomy · Hysteroscopic myomectomy · Office hysteroscopy · See-and-treat hysteroscopy · Fluid overload in hysteroscopy · OHIA · Mechanical hysteroscopic tissue removal
Exam-exhaustive FRANZCOG fellowship reference on operative hysteroscopy — distension media and the fluid-deficit stop points (1000 mL hypotonic, 2500 mL isotonic; lower for the comorbid), bipolar versus monopolar energy, the resectoscope and mechanical tissue-removal systems, outpatient see-and-treat versus operating-room day-case, and the complications that kill (fluid overload, hyponatraemia, gas embolism, perforation). Grounded in the AAGL distending-media report, the BSGE/ESGE fluid guideline, ACOG Committee Opinion 800, the Cochrane review of distension media, and the bipolar-technology literature. RANZCOG-primary, globally tagged to MRCOG, ABOG and FRCSC.
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Target exams
Red flags
- A rising fluid deficit with an electrolyte-free hypotonic medium — hyponatraemia and cerebral oedema can follow; stop at 1000 mL (750 mL if comorbid)
- Sudden cardiovascular collapse with falling end-tidal CO2 during CO2 distension — gas embolism, stop the gas and go to Durant's position
- Fever, pain or peritonitis after hysteroscopy — a perforation with visceral or vascular injury until proven otherwise
- Matching the wrong medium to the energy — electrolyte-rich saline with monopolar current disperses energy outside the field; use saline only with bipolar or for diagnostic use
- Perforation with the resectoscope or active energy in situ — the high-stakes event that may injure bowel or broad-ligament vessels and needs laparoscopic assessment
- Choosing the office for a large, deeply invasive lesion in an anxious patient without the skill, personnel or equipment to finish safely
It is a busy day-case list and your next patient is a 64-year-old with postmenopausal bleeding and a 2 cm polyp. You plan a hysteroscopic polypectomy with a resectoscope and glycine. The numbers on the fluid pump are climbing faster than you like, and the anaesthetist mentions the sodium on the gas machine. Hysteroscopy looks gentle — it is transvaginal, small, quick — but the distending medium you need to see is the same medium that can drop a sodium and swell a brain. This topic is your rehearsal for the cavity, the pump and the sodium.[13][14]
Overview and definition
Hysteroscopy inserts a rigid or flexible scope through the cervix and distends the uterine cavity with a medium so you can see and operate — the gold standard for evaluating and managing intrauterine pathology, from abnormal uterine bleeding to infertility, retained products and müllerian anomalies.[14][15] Polypectomy is the most common hysteroscopic procedure worldwide.[14]
The operative spectrum runs from the resectoscope (a loop electrode for monopolar or bipolar resection) to the mechanical hysteroscopic tissue-removal (mHTR) systems that morcellate without energy, and the mini-hysteroscope that needs no dilation for office work.[14] Two settings bookend the practice: the outpatient "see-and-treat" office and the operating-room day-case under anaesthesia.[8][15]
References15ShowHide
- [1]Munro MG, Storz K, Abbott JA, et al. AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media J Minim Invasive Gynecol, 2013.PMID 23465255
- [2]Abdallah KS, Gadalla MA, Breijer M, Mol BWJ Uterine distension media for outpatient hysteroscopy Cochrane Database Syst Rev, 2021.PMID 34826139
- [3]Umranikar S, Clark TJ, Saridogan E, Miligkos D, Arambage K, Torbe E, Campo R, Di Spiezio Sardo A, Tanos V, Grimbizis G BSGE/ESGE guideline on management of fluid distension media in operative hysteroscopy Gynecol Surg, 2016.PMID 28003797
- [4]Aydeniz B, Gruber IV, Schauf B, Kurek R, Meyer A, Wallwiener D A multicenter survey of complications associated with 21,676 operative hysteroscopies Eur J Obstet Gynecol Reprod Biol, 2002.PMID 12206931
- [5]Calabrese S, DE Alberti D, Garuti G The use of bipolar technology in hysteroscopy Minerva Ginecol, 2016.PMID 26928415
- [6]De Silva PM, Stevenson H, Smith PP, Clark TJ Pain and Operative Technologies Used in Office Hysteroscopy: A Systematic Review of Randomized Controlled Trials J Minim Invasive Gynecol, 2021.PMID 34089888
- [7]Cooper NA, Smith P, Khan KS, Clark TJ Does cervical preparation before outpatient hysteroscopy reduce women's pain experience? A systematic review BJOG, 2011.PMID 21797959
- [8]Bennett A, Lepage C, Thavorn K, Fergusson D, Murnaghan O, Coyle D, Singh SS Effectiveness of Outpatient Versus Operating Room Hysteroscopy for the Diagnosis and Treatment of Uterine Conditions: A Systematic Review and Meta-Analysis J Obstet Gynaecol Can, 2019.PMID 30528838
- [9]Lethaby A, Penninx J, Hickey M, Garry R, Marjoribanks J Endometrial resection and ablation techniques for heavy menstrual bleeding Cochrane Database Syst Rev, 2013.PMID 23990373
- [10]Vitale SG, Sapia F, Rapisarda AMC, Valenti G, Santangelo F, Rossetti D, Chiofalo B, Sarpietro G, La Rosa VL, Triolo O, Noventa M, Gizzo S, Laganà AS Hysteroscopic Morcellation of Submucous Myomas: A Systematic Review Biomed Res Int, 2017.PMID 28948169
- [11]Haber K, Hawkins E, Levie M, Chudnoff S Hysteroscopic morcellation: review of the manufacturer and user facility device experience (MAUDE) database J Minim Invasive Gynecol, 2015.PMID 25128851
- [12]Luerti M, Vitagliano A, Di Spiezio Sardo A, et al. Effectiveness of Hysteroscopic Techniques for Endometrial Polyp Removal: The Italian Multicenter Trial J Minim Invasive Gynecol, 2019.PMID 30528831
- [13]Sethi N, Chaturvedi R, Kumar K Operative hysteroscopy intravascular absorption syndrome: A bolt from the blue Indian J Anaesth, 2012.PMID 22701213
- [14]Moore JF, Carugno J Hysteroscopy StatPearls, 2026.PMID 33232015
- [15]American College of Obstetricians and Gynecologists (ACOG) The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion, Number 800 Obstet Gynecol, 2020.PMID 32080054