Cytotec

Here's some great news. I was recently informed that we have funding for another Clinical Pearls contest. This year we will be giving away nine portable DVD players, complete with car kits. So please take a few minutes to think about those little tips you like to use in the office and hospital and send them in. The deadline is May 15, 2005. (See complete contest rules on page 5.)

Now on to some tips for performing hysteroscopy.

Get It Straight

Roland Baiza Jr., M.D., Colorado Springs, has a tip for introducing a hysteroscope if the uterus is retroflexed, particularly in a postmenopausal patient. First place a tenaculum on the anterior cervical lip and pull gently to straighten out the uterus.

If this is unsuccessful, place a finger in the rectum and lift the uterus to the mid-position while the surgery technician or scrub nurse places traction on the cervix. Now the scope will enter easily.

Scan It

When Steven R. Daube, D.O., of Hinsdale, Ill., encounters cervical stenosis in a patient requiring D & C or hysteroscopy, and he can't enter the uterine cavity, even with small dilators, he places a tenaculum on the posterior lip of the cervix, thus changing the angle of the cervix.

If this is unsuccessful, he performs an intraoperative ultrasound and watches the dilator penetrate the cavity under direct visualization.

Flush It

Anne Radley, M.D., St. Louis, notes that when doing a hysteroscopy on a bleeding patient, it can be impossible to see the endometrial cavity. Either overdilate the cervix and flush the cavity with normal saline through the scope, or use an operative scope and open the accessory port to irrigate. The picture clears right up.

Open Wide

At times during hysteroscopy the uterine walls flop closed and make adequate visualization impossible. Edmund Kim, M.D., of Lawrenceville, Ga., says to try closing the outflow valve slightly. This strategy can increase the intrauterine pressure just enough to open the endometrial cavity.

Leak Detector

When doing hysteroscopy or resectoscope work, if you have any concern that you may have perforated the uterus, Scott Hayworth, M.D., of Mount Kisco, N.Y., says to try this pearl. Just close the outflow tract on the hysteroscope.

If fluid continues to run into the hysteroscope after about 30 seconds, you probably have perforated the uterus. If the inflow of fluid stops, the probability of perforation is extremely low.

Cytotec Tip

Several doctors, including J. Michael Scarff, M.D., of Las Vegas, and Joseph G. Capecchi, M.D., of St. Paul, suggested that a pearl we published for helping with the difficult endometrial biopsy also works with hysteroscopy.

Have the patient place one or two 200-mcg misoprostol (Cytotec) tablets in her vagina the night before surgery. This may "ripen" a stenotic cervix so that the procedure can be easily performed.

BY BRUCE L. FLAMM, M.D.

DR. FLAMM is area research chairman and a practicing ob.gyn. at the Kaiser Permanente Medical Center in Riverside, Calif.

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Dr. Bruce L. Flamm

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Riverside, CA 92503

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