Video Transcript: Hysteroscopic Management of a Stenotic Cervix
The authors have no conflicts of interest to disclose. We present an approach for the surgical management of a stenotic cervix in an outpatient hysteroscopy setting, with video demonstrations.
Gynecologists require intrauterine access for a number of procedures. An outpatient hysteroscopy suite has a number of advantages over the operating theatre and typically uses hysteroscopes with a smaller operative canal than traditional instruments.
Even experienced practitioners can have difficulty with a stenotic cervix. This formidable opponent is encountered when a cervical canal is too narrow to allow the insertion of a 2.5 mm Hegar or a Pratt dilator. We present the ease of a see-and-treat approach in an outpatient hysteroscopy setting to manage a stenotic cervix.
As in all aspects of surgery, patient positioning is a key component, and stirrups should be used. Surgical lighting improves visualization. Patient discomfort can be minimized with routine oral analgesia and if required, a paracervical block or conscious sedation. Although not routinely required, applying a tenaculum to the cervix can help straighten the angle and improve surgical technique. Oftentimes, these simple steps can allow passage through what was previously described as a stenotic cervix.
Vaginoscopy is the first step to the no-touch hysteroscopy technique. It decreases the patient’s discomfort by avoiding both the speculum and tenaculum. The hysteroscope is inserted under direct visualization into the vagina, and the distension medium retracts the walls of the vagina.
By following the posterior wall, as shown here, the posterior fornix is eventually visualized. By slowly retracting the hysteroscope, the external cervical os will be seen. Cervical mucus or glands found in the transformation zone can help localization.
By advancing slowly, the distension medium dilates the cervical canal ahead, and even a tortuous path through the cervix can be navigated. Adjusting the angle of the camera prevents damage to delicate vasculature within the canal, which decreases patient discomfort and improves visualization. Careful techniques can be almost pain-free and allow excellent assessment of the uterine cavity.
A stenotic cervix can be the result of thick adhesions at the external os, internal os or throughout the length of the canal. The cause is commonly due to a sharp curettage or previous treatment for cervical dysplasia. Microscissors can be used for the revision of the cervical canal. They pass through the operative canal of the hysteroscope and can sharply dissect tissue.
For these thick adhesions at the external os, the familiar push-spread technique can be adapted to allow a safe dissection. The fibrous adhesions usually allow only a small amount of distension but enough to visualize the direction of the cervical canal, as shown here.
In the awake patient, feedback is extremely helpful, as a division of fibrous scar tissue is pain-free, whereas increased pain would suggest a division of normal cervical or uterine tissue. Progressive division of adhesions allows further distension of the cervical canal ahead and eventually access into the uterine cavity.
This technique of sharp dissection can be adapted to the division of intrauterine adhesions as well. Microscissors and micrograspers can be used to remove specimens both within the cervical canal and uterine cavity.
Another similar technique uses micrograspers to push and spread, which bluntly slices the adhesions. One advantage is that injury to normal cervical or uterine tissue is minimized, but this technique is limited to a cervix that is only partially stenosed and to adhesions that are not only fibrotic, as shown in this video here.
A stenotic cervix can be narrowed to the point that even a mini hysteroscope cannot be inserted. In these patients, aggressive, blind dilation can significantly increase their risk of uterine perforation.
The width of a cutting loop electrode is significantly smaller than a hysteroscope and can oftentimes be advanced into a stenotic canal. By removing a small amount of the cervical depth, the overall cross-sectional area of the cervical canal is increased and can permit the advancement of a larger hysteroscope. By progressively removing a small amount of cervical depth, increasing the cross-sectional area and further extending the cervical canal ahead, we can access the uterus.
These particular cases are performed in the main operating theatre. The loop excision can be performed in the outpatient setting as well. Safe excision of tissue can be performed as long as the operating instrument is kept within the visual field.
We presented here an approach to the stenotic cervix, which includes optimizing the environment, no-touch hysteroscopy and revision of the cervical canal with micro instruments or a loop electrode. These techniques can be applied in an outpatient hysteroscopy setting and also adapted for use in an operating theatre.
This video was brought to you by the Ottawa Minimally Invasive Gynaecology team.