Hysteroscopy is an outpatient minimally invasive procedure designed to remove uterine fibroids or polyps that may be the cause of abnormal bleeding. The ultimate goal of the procedure is complete cessation of abnormal bleeding and inspection of the tissue removed to rule out the presence of cancer. This procedure is an outpatient procedure, meaning that patients are discharged to home directly from the recovery room when they are deemed “stable”, usually after 1-1 ½ hours.
Hysteroscopy is accomplished by inserting a long tubular camera scope called a hysteroscope through the cervix into the uterus. Through this instrument we can visualize the inside lining of the uterus, called the endometrial cavity. The hysteroscope has an attached wire loop electrode that can cut through the tissue attaching the fibroid or polyp to the lining of the uterus, thus allowing easy removal of the tissue. The base of the connecting tissue is then cauterized. This prevents regrowth of the tissue and controls bleeding.
The following will describe the events leading up to the surgery, as well as the procedure itself so that you will feel more comfortable and less anxious.
On the night before surgery, eat a light meal. Do not eat or drink anything after midnight on the day of your surgery if your surgery is in the morning. If it is in the afternoon, don’t eat or drink anything 8 hours prior to the scheduled time of your surgery.
When you arrive at the surgery center (either the outpatient surgery center or main hospital – we’ll tell you exactly which location), you will need to register. At John Muir Medical Center, you may register in the main hospital lobby. Sometimes in the very early morning, the registration area is closed. In this case, walk over to the Emergency Room and register there. If you are having your procedure at Aspen Surgery Center located on the first floor of the new parking structure on the side of John Muir Medical Center, enter through the main entrance and turn left down the hallway. You will see the signs to the registration area on the left. You will then proceed to the “pre-op” area where you will be asked to fill out paperwork, change into a hospital gown, and recline in a hospital gurney. Labs may or may not be drawn, depending on the reason for the D&C and whether or not they were drawn previously. An I.V. line will be placed into a vein in your hand or arm either in the “pre-op” area or the operating room itself.
Next you will be interviewed briefly by your attending nurse and subsequently the anesthesiologist. I will arrive just when we are scheduled to go back to the Operating Room. Feel free to ask any last minute questions at that time. Next, it’s time to head into the Operating Room, where you will notice it to be quite chilly. We will move you from the gurney to the operating table and will cover you with warm blankets. The anesthesiologist will place a blood pressure cuff around an arm, and place EKG electrodes on your chest to continuously monitor your blood pressure and heart rate and rhythm throughout the surgery. At this time the anesthesiologist will then give you a medication through your I.V. that will make you very sleepy and you will then drift off to sleep.
Once you are asleep under anesthesia, your legs will be placed in supportive stirrups and the vaginal area will be cleansed with an iodine containing solution. A speculum will be placed into the vagina and the cervix is grasped with a clamp to stabilize it. Smooth tipped metal rods of incrementally increasing size are inserted into the cervix, dilating the cervix to allow placement of the main device, a special type of hysteroscope called a resectoscope. Using the optical part of the resectoscope, the entire lining of the uterus (endometrial cavity) can be inspected. When fleshy polyps or fibroids are noted, they are then removed with a wire electrode that can cut and remove the tissue. Once the entire endometrium cleared of fibroids or polyps and bleeding is controlled the procedure is complete. Instruments are removed and you will be transferred to the recovery room. Hysteroscopic myomectomy or polypectomy usually takes about 45 minutes to accomplish (about 60 minutes of “under anesthesia” time including going to sleep and waking up).
Following the procedure you will be taken to the recovery room where you will remain for about 1 – 1 ½ hours. When you are discharged to home, you will still feel groggy and should go directly to bed. The effects of the anesthesia will wear off in about 24 hours. The post-operative course following this procedure is variable, but in general you can expect to be fully recovered within 2-3 days. It may take longer if the procedure was complicated. You will need to restrain from vigorous physical activity for 24 hours following the procedure.
We will discharge you from the surgery center with instructions to take pain medication designed to minimize postoperative discomfort. This medication (Motrin or if needed Vicodin) will be called into a pharmacy for you to pick up or we will have given you the prescription prior to the surgery. Post-operative pain is usually very mild, and may not require more than Motrin. The bleeding you will experience should be no more than a normal period and will last for about 4-5 days. Anything more than this should prompt you to call my office. Additionally, call if you have a temperature greater than 100.4 degrees or increasing abdominal or pelvic pain. Please call my office several days after the procedure for a follow-up examination to be performed 2 weeks following the ablation.
Every time we perform surgery on a patient, and even though for us this is routine, we are always cognizant of the risks involved. When we perform an endometrial ablation, the risks are straightforward: Initially we put sharp instruments into a “blind” cavity, and are doing so by feel, not by direct visualization. As such, the greatest risk present is the risk of perforation of the uterus. That means placing the dilators through the wall of the uterus. After dilation is accomplished, perforation can also occur with the hysteroscope, although this happens even less frequently than with the dilators. When perforation occurs, there is a risk of damaging other pelvic structures such as bowel, bladder, or blood vessels. Although extremely rare, any surgeon who has performed enough procedures will invariably encounter this complication. Usually, there is no significant sequela. When perforation is diagnosed, laparoscopy (placing a camera through a small incision in the navel to inspect the pelvic structures) is performed and if all is normal, and the patient is still discharged to home from the recovery room. Additional risks associated with this procedure is infection and increased blood loss. Both are managed with medications. If bleeding is profuse, blood transfusion would be considered. I must emphasize that these risks are very uncommon but should, in the course of providing information, be included in discussion.
I welcome any questions you may have about the procedure, risks & benefits, or pre- or post-instructions. Please contact me as soon as possible for any questions you may have.