History of development of hysteroscopy

Hysteroscopy was first performed in 1869 by Pantaleoni with a device similar to a cystoscope. A 60-year-old woman managed to detect polypoid growth, which caused uterine bleeding.

In 1895, at the Vienna Congress of Gynecologists, Bumm reported on the results of the examination of the uterine cavity with the help of a urethroscope. Lighting provided a light reflector and a frontal mirror.

Later, the conditions of the examination (preliminary removal of blood from the uterine cavity, stretching of the uterus walls), as well as the quality of the viewing instruments, were improved by improving the lenses, selecting their optimal position and increasing the illumination.

To remove blood in 1914, Heineberg applied a washing system, which was then used by many researchers. There were attempts to stretch the walls of the uterus with carbon dioxide injected under pressure into its cavity; this improved the results of the examination (Rubin, 1925), but when gas hit the abdominal cavity caused pain in the patients.

In 1927, Miculicz-Radecki and Freund constructed a curetoscope - a hysteroscope, providing the possibility of biopsy under the control of vision. In an animal experiment, Miculicz-Radecki first performed electrocoagulation of the uterus of the fallopian tubes for sterilization purposes.

At the same time, hysteroscopy was handled by Granss. He created a device of his own design, equipped with a washing system. Granss suggested using hysteroscopy to identify the fetal egg in the uterus, diagnose placental polyps, uterine cancer, endometrial polyposis, submucosal nodes, and also for sterilization of women by electrocoagulation of the uterus of the fallopian tubes.

B.I. Litvak (1933, 1936), E.Ya. Stavskaya and D.A. The croups (1937) used an isotonic solution of sodium chloride to stretch the uterine cavity. Hysteroscopy was performed with a Mikulich-Radetsky and Freund hysteroscope and used to detect fetal egg residues and diagnose postpartum endometritis. The authors released an atlas on the use of hysteroscopy in obstetrics.

However, hysteroscopy has not become widespread due to the complexity of the technique, insufficiently good review and lack of knowledge for the correct interpretation of the results of the study of the uterine cavity.

In 1934 Schroeder placed a lens on the end of the hysteroscope, and not on the side, which increased the field of view. In this case, the washing liquid entered the uterine cavity by gravity from the reservoir located above the patient. To reduce the bleeding of the endometrium, several drops of adrenaline were added to it. The fluid was injected at the rate necessary to maintain the uterine cavity in the stretched state. Schroeder applied hysteroscopy to determine the phase of the ovarian-menstrual cycle and the detection of endometrial polyposis and submucous uterine fibroids, and also proposed the use of hysteroscopy in radiology to clarify the localization of a cancerous tumor prior to directional irradiation. He first attempted to sterilize 2 patients by electrocoagulation of the uterus of the fallopian tubes through the uterine cavity. However, these attempts were unsuccessful.

Important conclusions were Englunda et al. (1957), who, according to the results of hysteroscopy, showed 124 patients that even with a diagnostic curettage, even an experienced specialist completely removes the endometrium only in 35% of cases. The rest of the patients in the uterine cavity are endometrial sites, single and multiple polyps, submucous myomatous nodes.

Despite the imperfection of the method, many authors believed that hysteroscopy would undoubtedly help in the diagnosis of intrauterine diseases such as hyperplastic processes, endometrial cancer, uterine mucosa polyps and submucous myomatous nodes. Particularly emphasized was the importance of this method for targeted biopsy and removal of the pathological focus from the uterine cavity.

In 1966 Marleschki proposed a contact hysteroscopy. The hysteroscope he created had a very small diameter (5 mm), so there was no need to expand the cervical canal to insert the device into the uterine cavity. The optical system of the hysteroscope gave an increase in the image of 12.5 times. This made it possible to see the vascular pattern of the endometrium and to judge by its change the nature of the pathological process. Addition of the device with an instrumental channel allowed the introduction of a small curette into the uterine cavity and a biopsy under visual control.

Of great importance in the development of hysteroscopy was the suggestion of Wulfsohn to use a cystoscope with direct optics for examination, and to apply a rubber inflatable balloon to expand the uterine cavity. Later this method was improved and widely used in the clinic Silander (1962-1964). The Silander device consisted of two tubes: internal (viewing) and external (for fluid intake). At the distal end of the outer tube, a light bulb and a ball of fine latex rubber were reinforced. First the hysteroscope was inserted into the uterus cavity, then a liquid was injected into the balloon with a syringe, which made it possible to examine the walls of the uterus. Changing the pressure in the balloon and using a certain mobility of the hysteroscope, it was possible to examine in detail the inner surface of the uterus. Using this method of hysteroscopy, Silander examined 15 patients with uterine bleeding that appeared against the background of endometrial hyperplasia and 40 women with uterine cancer and pointed out the high diagnostic value of the method for detecting malignant processes of the uterine mucosa.

After the proposal of Silander, many gynecologists in the USSR and abroad began using this method to detect intrauterine pathology. The possibility of diagnostics of submucous nodes of uterine fibroids, polyps and endometrial hyperplasia, uterus cancer, fetal remains, anomalies of the uterus was demonstrated. At the same time, it was not possible to reveal the nature of the hyperplastic process with the help of such a hysteroscope.

A new stage came after the introduction into medical practice of fiber optics and rigid optics with an air lens system.

Advantages of using optical fiber: a good illumination of the object, a significant increase in the object during examination, the possibility of examining each wall of the uterine cavity without expanding it with cylinders.

Devices constructed on the basis of optical fiber, send cold light to the object, i.e. Do not have the disadvantages of the preceding endoscopes: the electric bulb and its frame, located at the distal end of the endoscope, heated up during prolonged operation, which created a threat of a burn of the mucous membrane of the examined cavity.

Work with fiber light guides is safer, as the examination of the patient virtually eliminates the possibility of electric shock.

Another advantage of modern hysteroscopes is the possibility of photo and filming.

Since the advent of modern endoscopes, intensive research has begun to find the optimal media introduced into the uterine cavity for its expansion, and the selection of diagnostic criteria, as well as the determination of the possibility of various intra-uterine manipulations.

An obligatory condition for carrying out hysteroscopy is the expansion of the uterine cavity, for which it introduces certain media (gaseous and liquid).

Air and carbon dioxide are used as gaseous media. Most researchers prefer the introduction of the latter, since with the introduction of air gas embolism is possible. Introduction of carbon dioxide is possible when using small diameter hysteroscopes (from 2 to 5 mm), which does not require the expansion of the cervical canal. Authors working with CO ₂, note the good visibility of the walls of the uterus, the convenience of producing photo and filming. However, Cohen et al. (1973), Siegler et al. (1976) and others point to significant disadvantages of introducing a gas into the uterus, including unpleasant sensations in patients with gas entering the abdominal cavity and the possibility of gas embolism. Carbon dioxide was widely used after Lindemann's proposal to use a special adapter (cervical cap) to vacuum fix the hysteroscope to the cervix.

Of liquid media for stretching the uterine cavity isotonic sodium chloride solution, 5% glucose solution, 1.5% glycine, polyvinylpyrrolidone and 30% dextran solution. The latter solution has a high viscosity, so that it does not mix with blood and mucus, and therefore provides good visibility and the possibility of photographing the hysteroscopic pattern, and also retains longer in the uterine cavity, allowing longer study times). On the other hand, it is a sufficiently sticky solution, so there are certain mechanical difficulties in introducing the fluid under the desired pressure and in the care of the hysteroscope.

Porto and Gaujoux used hysteroscopy to monitor the effectiveness of radiotherapy for cervical cancer (1972). Transcervical catheterization of the fallopian tubes during hysteroscopy was successfully applied by Lindemann (1972, 1973), Levine and Neuwirth (1972), and others. Later, this method was perfected with a curative purpose in 1986 by Confino et al. (transcervical balloon tuboplasty).

Dissection of intrauterine synechia under the control of hysteroscopy using endoscopic scissors was proposed and successfully used by Levine (1973), Porto 0973), March and Israel (1976). Sterilization of women with hysteroscopy by electrocoagulation of the uterine tubes was carried out by Menken (1971), Nerr, Roll (1974), Valle and Sciarra (1974), Lindemann et al. (1976). However, this method of sterilization has been associated with a high incidence of complications and failures. According to Darabi and Richart (1977), sterilization was ineffective in 35.5% of cases, 3.2% of women had serious complications (perforation of the uterus, bowel injury, peritonitis).

In 1980, in order to improve hysteroscopic sterilization, Neuwirth et al. Proposed the introduction of methyl cyanide glue in the mouth of the fallopian tubes. Hosseinian et al. Proposed the use of polyethylene plugs, Erb et al. - the introduction of liquid silicone, and Hamou in 1986 proposed a model of an in-tube spiral.

In 1976 Gabos noted that hysteroscopy is a more accurate diagnostic method than hysterosalpingography, especially with adenomyosis.

In 1978, David et al. Hysteroscopy was used to study patients with cervical polyp.

An important stage in the development of hysteroscopy was the creation of the Hamou in 1979 of a microhysteroscope - a complex optical system with the combination of a telescope and a complex microscope. Currently, it is produced in two versions. The microhysteroscope is an integral part of the operating hysteroscope and resectoscope.

The era of electrosurgery in hysteroscopy began with the first report of Neuwirth et al. In 1976 on the use of a modified urological resectoscope for the removal of the submucosal node. In 1983, De Cherney and Polan proposed the use of a resectoscope for resection of the endometrium.

Further development of operative hysteroscopy was promoted by the proposal to use an Nd-YAG laser (neodymium laser) for various operations in the uterine cavity: dissection of intrauterine synechia (Newton et al., 1982), intrauterine partition (Choe and Baggish, 1992). In 1981, Goldrath et al. For the first time, the endometrial vaporization of the endometrium with a contact laser was performed, and in 1987 Leffler proposed a technique for contactless laser ablation of the endometrium.

In 1990, Kerin et al. Suggested phalloposcopy - a technique for visual inspection of the inside-tube epithelium by hysteroscopic access.

The invention of a fibrogysteroscope and a microhysteroscope (Lin et al., 1990, Gimpelson, 1992, Cicinelli et al., 1993) marked the beginning of the development of ambulatory hysteroscopy.

A major role in the development of hysteroscopy in Russia was played by LS. Persianinova et al. (1970), A.I. Volobueva (1972), G.M. Savelieva et al. (1976, 1983), L.I. Bakuleva et al. (1976).

The first domestic manual on hysteroscopy using fiber optics and endoscopic equipment of Storz was the monograph Endoscopy in Gynecology, published in 1983 under the editorship of G.M. Savelieva.

Hysteroresectoscopy began to develop rapidly in Russia in the 90s, the works of G.M. Savelieva et al. (1996, 1997), V.I. Kulakov et al. (1996, 1997), BT. Breusenko et al. (1996, 1997), L.V. Adamyan et al. (1997), A.N. Strizhakova et al. (1997).

[1], [2], [3], [4], [5], [6]