As an office standard for diagnostic work, I will put a little bag of LR on a pressure cuff, pump it up and there it is not an issue. As soon as we go to operative work, where we are using glycine or sorbitol, I have a problem with using a pressure bag. It becomes hard for my nurses to be able to see what I put in. You also don’t know how much pressure you are using and how much pressure you really need. So what I have gone to in most cases with those specific media, is hanging the bag up at 6 foot or so; that will generally give you enough of a pressure head that you will be able to adequately distend the cavity, your nurses can follow the I&O’s and you will be able to track it in the way that it should be tracked, which is at a minimum, every 10 to 15 minutes and if you get above 700 cc over, more often than that.
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Sonohysterogram has done more for me as a preoperative test than probably any test. A lot of you have ultrasounds in your office, which makes it so easy. I use the same kind of catheter that I use for intrauterine inseminations. I catheterize, take 10 cc of saline, remove the speculum, put the vaginal probe in and it lights up intracavitary masses so well. What it has done for me is to allow me to figure out just how much of the mass is in the cavity. If I look at myoma and ten percent of it is sitting in the cavity, while eighty to ninety percent of it is sitting back behind the cavity, that is a terrible patient for a resectoscopic procedure.
Prior to surgery, I don’t tend to use laminaria unless a patient has profound cervical stenosis. If they have significant cervical stenosis, I will put in one laminaria and let it sit overnight. It isn’t necessarily going to dilate them, but it will allow the cervix to soften, so when you go to dilate, it will be a little bit easier. The problem is, if you stick a bunch of laminaria in somebody, you may end up with a vastly over-dilated cervix and then your problem is going to be fluid flowing out that you will have trouble keeping track of and problems with keeping good distention.
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I limit my medical treatment now to really treating for fibroids. In the past, we had done this for endometrial ablation. I think a lot of people are moving towards balloon ablations, and this may become less of an issue. Hemoglobin can be markedly altered in patients with submucous fibroids. For diagnostic hysteroscopy patients, those seen in the office or even in the O.R., the ideal time to bring these patients in and hysteroscope them is after they have finished their periods, when you have a very low, very basal endometrium. There is very little vascularity at that point in time. It is very forgiving. If you hit the side wall or fundus, there isn’t much there to cause a problem. As you start to get out further, you build up the lining. As you get out even further, you risk the potential in patient who at risk for pregnancy for disrupting pregnancy.