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Archive August 2000 I, No. 8

How and Why to Add Hysteroscopy

Yasmine Iqbal, Contributing Editor


If you are searching for growth opportunities and have not done so already, consider adding hysteroscopy to your suite of services. Demand for this procedure, which involves examining and treating the uterus with a thin telescope inserted through the cervix, is likely to grow significantly in the coming years, particularly since hysteroscopic procedures can often offer a kinder, gentler alternative to full-blown hysterectomy. Reimbursements for the procedure are likely to rise, at least in the ambulatory surgery center setting. In the June 1998 proposed ASC payment rates, the Health Care Financing Administration proposed raising the facility fee for diagnostic hysteroscopy by more than 50 percent and for hysteroscopy with myoma removal 27 percent. The procedure lends itself well to an ambulatory setting, as skilled surgeons can perform diagnostic hysteroscopy with little or no sedation in as little as 15 minutes, and simple operative procedures with epidural or general anesthesia in less than an hour. Finally, adding the hardware may be less expensive than you think, particularly if you already do urology, GI or orthopedics.

In this article, we'll briefly examine the types of hysteroscopic procedures, discuss surgeon qualifications, and provide some advice on how to add this procedure to your facility.

Types of Hysteroscopy
The Accreditation Council for Gynecologic Endoscopy, which was established to elevate standards in gynecologic endoscopy and recognize surgeons with advanced skills (about 1,000 surgeons have ACGE certification), divides hysteroscopy into three categories:

Diagnostic hysteroscopy involves using a thin (usually around 3 mm) hysteroscope to evaluate patients with abnormal uterine bleeding by obtaining a panoramic view of the uterus. It's possible to do these types of procedures in the office.

Minimally therapeutic hysteroscopy uses a slightly thicker (around 5.5 mm) hysteroscope with a working channel (similar to a gastrointestinal endoscope) through which the surgeon can insert thin instruments to remove small polyps, perform biopsies, cut adhesions, and perform other minor procedures. Both diagnostic and minimally therapeutic procedures can be performed with local anesthesia or, in some cases, with no anesthesia at all.

Advanced hysteroscopy, nearly always done in an OR setting with local, epidural, or general anesthesia, uses an operative hysteroscope to remove significant adhesions, remove large fibroids, or perform endometrial ablations.

Who Performs Hysteroscopy
The most difficult challenge in adding hysteroscopy may be finding qualified surgeons. Although most GYN surgeons who completed their residencies in the last decade received training in hysteroscopy, fewer than 5 percent of gynecologic surgeons perform advanced hysteroscopic procedures, says Anthony Luciano, MD, a gynecologic surgeon at New Britain General Hospital in New Britain, Conn. Even if some gynecologic surgeons do not feel comfortable doing advanced hysteroscopic procedures in the ambulatory outpatient setting, they may be quite willing to do the diagnostic and minimally invasive procedures, which represent the vast majority of hysteroscopic procedures performed in your facility, notes Mark Davis, MD, an Atlanta-based gynecologic surgeon.

The American Association of Gynecologic Laparoscopists (AAGL), which provides training, sponsors research, and builds awareness of gynecologic endoscopy and laparoscopy, has developed surgeon training guidelines that may be useful when you are examining a surgeon's credentials. According to the AAGL, physicians seeking hysteroscopic training should be board-certified in gynecology, have unsupervised gynecologic privileges for patient care, or be in an accredited residency program in obstetrics and gynecology. A surgeon's hysteroscopic training should include a CME-approved program which should cover the following:
- Uterine anatomy.
- Options of distension media.
- Management of distension media.
- Energy sources.
- Instrumentation.
- Surgical indications and techniques for:

-diagnostic hysteroscopy;
-polycystic ovary;
-fibroid resection/vaporization; andendometrial ablation.

- Prevention and management of hysteroscopic complications.

The AAGL also advises at least four hours of hands-on training and highly recommends case observation and preceptorship.

Before allowing surgeons to perform hysteroscopy in your facility, it may be a good idea to make sure they have satisfied all of these requirements. In untrained hands, a hysteroscope may cause severe complications, including uterine perforation, bowel, or bladder injury.

Equipment and Staffing
If you're already hosting certain procedures in your facility, you may already have some of the equipment necessary for offering hysteroscopy. Gastroenterology, arthroscopy, and general surgery in particular are procedures that tend to "mix well" with hysteroscopy, because these procedures require the same kinds of high-resolution monitors and video equipment, says Dr. Luciano. Another particularly good concomitant procedure is urology; in fact, the resectoscope, which is a hysteroscope with an electrosurgical loop for cutting and coagulating tissue, was originally designed for use in prostate surgery.

Besides the hysteroscopes and related instruments and accoutrements, here are two other important parts of your OR setup:

An automatic, user-friendly OR table: "Some of the newer tables have stirrup configurations that allow the surgeon to move the patient from the low lithotomy to high lithotomy positions easily and without redraping," says Thomas Lyons, MD, a gynecologic surgeon at the Advanced Surgery Center of Georgia in Canton, Ga. "This allows the surgeon to place the patient in almost any position with minimal trouble."

An insufflator or fluid distension system: A key part of hysteroscopy is distending the uterus with either carbon dioxide or fluid. Your surgeons can use CO2 insufflation in diagnostic hysteroscopy, but according to Frank Loffer, MD, a Phoenix-based gynecologic surgeon, using a fluid distension system for both diagnostic and therapeutic cases may be the best choice, for several reasons. CO2 insufflators, which must be dedicated hysteroscopy units (laparoscopic insufflators have different pressure and flow rates) are more expensive and may create bubbles; also, in his experience, the gas frequently leaks from the rubber gasket on the forceps channel, causing distension to be lost. Fluid distension systems, on the other hand, make use of low-viscosity fluids to distend the uterus; Dr. Loffer feels that they're more reliable and allow him to get a better view of the uterine cavity.

A potential, if rare, complication of using fluid distension systems is fluid overload, which can lead to excessive intravasation and pulmonary edema. To avoid this, the AAGL recommends purchasing a fluid distension system that automatically monitors fluid inflow and outflow. If you don't have fluid monitoring capability, it's imperative that a staff person be dedicated to monitoring and informing the surgeon and anesthesiologist of the fluid intake, output, and potential deficit.

Don't allow an automatic system to lull you into complacency, warns Dr. Lyons, who feels that having a staff person dedicated to fluid monitoring is always necessary. "There is no good type of (automatic) fluid monitoring," he says. "The key is having motivated people that can ensure fluid management, no matter what system you use."

Indeed, having trained staff is essential for all aspects of hysteroscopy, experts say. "The nurses are as important as the doctors," stresses Harry Hassan, MD, a Chicago-based GYN surgeon. "They need to be familiar with the procedure and know how to troubleshoot the equipment."

Don't be surprised, says Dr. Lyons, if adding hysteroscopy has a "snowball" effect on your GYN caseload. "GYN procedures are uniquely amenable to a minimally invasive approach, and outpatient facilities, particularly ambulatory surgery centers, are the ideal settings to perform them," says Dr. Lyons. "They enable the surgeon to provide a very high level of care in a comfortable, patient-friendly environment."

Hysterectomy Alternatives: Services Worth Considering?

Traditionally, endometriosis and fibroid tumors have been the leading indications for hysterectomy, a procedure done some 600,000 times per year, almost always on an inpatient basis. Now many of these women can choose less-invasive alternatives that may allow them to return to activities more quickly, be less costly, and sometimes even preserve their fertility. Could any of these work in your facility?

Women with excessive bleeding or fibroid tumors may be candidates for hysteroscopic myomectomy. This procedure can allow the woman to remain fertile. It's also faster, incurs fewer complications, requires less analgesia and allows a faster return to normal activities than hysterectomy, according to a 1999 study performed at the Royal Free Hospital in London.

Another less invasive technique for the same indications is endometrial ablation-removal of the lining of the uterus rather than the entire uterus. One technique involves manually removing the uterus lining. Another involves inserting a soft, flexible balloon via a catheter and either inflating it with hot fluid or activating electrodes impregnated within the balloon. After treatment with either technique, the lining sloughs off in the next few days. Like hysteroscopic procedures, endometrial ablation allows the woman to return to normal activities much more quickly. It is also significantly less expensive than hysterectomy; in a 1996 study performed at the University of Vermont, the mean cost of an endometrial ablation was $5,159 compared to around $8,500 for a vaginal or abdominal hysterectomy. It is also generally easier than hysteroscopic myomectomy. However, there are several disadvantages. It does not preserve fertility, it may be less successful for stopping bleeding than hysteroscopic ablation, and it may not be effective in women whose bleeding is caused by large fibroids.


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