History of the development of hysteroscopy

Hysteroscopy was first performed in 1869 by Pantaleoni using a device similar to a cystoscope. A polypous growth was discovered in a 60-year-old woman, which caused uterine bleeding.

In 1895, Bumm reported on the results of an examination of the uterine cavity using a urethroscope at the Vienna Congress of Gynecologists. Lighting was provided by a light reflector and a forehead mirror.

Subsequently, the examination conditions were changed (preliminary removal of blood from the uterine cavity, stretching of the uterine walls), as well as the quality of the examination devices due to the improvement of lenses, selection of their optimal position and increased illumination.

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

In 1927, Miculicz-Radecki and Freund constructed a curetoscope - a hysteroscope that allowed biopsy under visual control. In an animal experiment, Miculicz-Radecki first performed electrocoagulation of the mouths of the fallopian tubes for the purpose of sterilization.

Granss was also involved in hysteroscopy. He created a device of his own design, equipped with a flushing system. Granss proposed using hysteroscopy to determine the fertilized egg in the uterus, diagnose placental polyps, uterine body cancer, endometrial polyposis, submucous nodes, and also to sterilize women by electrocoagulation of the fallopian tube orifices.

B.I. Litvak (1933, 1936), E.Ya. Stavskaya and D.A. Konchiy (1937) used isotonic sodium chloride solution to stretch the uterine cavity. Hysteroscopy was performed using the Mikulich-Radeckiy and Freund hysteroscope and was used to detect remnants of the ovum and diagnose postpartum endometritis. The authors published an atlas on the use of hysteroscopy in obstetrics.

However, hysteroscopy has not become widespread due to the complexity of the technique, insufficient visibility and lack of knowledge to correctly interpret the results of the examination of the uterine cavity.

In 1934, Schroeder placed the lens on the end of the hysteroscope rather than on the side, which increased the field of view. The flushing fluid entered the uterine cavity under the force of gravity from a reservoir located above the patient. To reduce endometrial bleeding, several drops of adrenaline were added to it. The fluid was injected at a rate sufficient to maintain the uterine cavity in a stretched state. Schroeder used hysteroscopy to determine the phase of the ovarian-menstrual cycle and to detect endometrial polyposis and submucous nodes of uterine fibroids, and also proposed using hysteroscopy in radiology to clarify the localization of a cancerous tumor before performing targeted irradiation. He was the first to attempt sterilization of two patients by electrocoagulation of the mouths of the fallopian tubes through the uterine cavity. However, these attempts were unsuccessful.

The conclusions of Englunda et al. (1957) were important, showing from the results of hysteroscopy of 124 patients that during diagnostic curettage even a fairly experienced specialist completely removes the endometrium only in 35% of cases. In the remaining patients, areas of the endometrium, single and multiple polyps, and submucous myomatous nodes remain in the uterine cavity.

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

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

Of great importance in the development of hysteroscopy was Wulfsohn's proposal to use a cystoscope with direct optics for examination and a rubber inflatable balloon for dilating the uterine cavity. This method was later improved and widely used in the Silander Clinic (1962-1964). The Silander device consisted of two tubes: an internal (viewing) tube and an external (for fluid intake). A light bulb and a balloon made of thin latex rubber were attached to the distal end of the external tube. First, the hysteroscope was inserted into the uterine cavity, then fluid was pumped into the balloon with a syringe, which made it possible to examine the walls of the uterus. By changing the pressure in the balloon and using a certain mobility of the hysteroscope, it was possible to examine the inner surface of the uterus in detail. Using this method of hysteroscopy, Silander examined 15 patients with uterine bleeding that arose against the background of endometrial hyperplasia and 40 women suffering from uterine cancer, and indicated the high diagnostic value of the method for identifying malignant processes in the uterine mucosa.

After Silander's proposal, many gynecologists both in the USSR and abroad began to use this method to detect intrauterine pathology. The possibility of diagnosing submucous nodes of uterine myoma, polyps and endometrial hyperplasia, cancer of the uterine body, remnants of the fertilized egg, and uterine developmental anomalies was demonstrated. At the same time, it was not possible to identify the nature of the hyperplastic process using such a hysteroscope.

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

The advantages of using optical fiber: good illumination of the object, its significant magnification during examination, the ability to examine each wall of the uterine cavity without its expansion using balloons.

Devices designed on the basis of optical fiber deliver cold light to the object, i.e. they do not have the disadvantages of previous endoscopes: the electric bulb and its frame, located at the distal end of the endoscope, heated up during prolonged operation, which created a risk of burning the mucous membrane of the cavity being examined.

Working with fiber optics is safer, since the possibility of electric shock during examination of a patient is practically excluded.

Another advantage of modern hysteroscopes is the ability to take photographs and films.

Since the advent of modern endoscopes, intensive research has begun to find optimal media introduced into the uterine cavity for its expansion, and to select diagnostic criteria, as well as to determine the possibility of performing various intrauterine manipulations.

A mandatory condition for performing hysteroscopy is the expansion of the uterine cavity, for which certain media (gaseous and liquid) are introduced into it.

Air and carbon dioxide are used as gaseous media. Most researchers prefer the introduction of the latter, since gas embolism is possible when introducing air. Introduction of carbon dioxide is possible when using small-diameter hysteroscopes (from 2 to 5 mm), which does not require dilation of the cervical canal. Authors working with CO ₂ note good visibility of the uterine walls, convenience of photography and filming. However, Cohen et al. (1973), Siegler et al. (1976) and others point out significant disadvantages of introducing gas into the uterus, including discomfort in patients when gas enters the abdominal cavity and the possibility of gas embolism. Carbon dioxide began to be widely used after Lindemann proposed using a special adapter (cervical cap) for vacuum fixation of the hysteroscope to the cervix.

Of the liquid media used to stretch the uterine cavity, isotonic sodium chloride solution, 5% glucose solution, 1.5% glycine, polyvinylpyrrolidone and 30% dextran solution are used. The latter solution has high viscosity, due to which it does not mix with blood and mucus and, therefore, provides good visibility and the ability to photograph the hysteroscopic picture, and also remains in the uterine cavity longer, which allows for an increase in the examination time). On the other hand, this is a fairly sticky solution, so there are certain mechanical difficulties in introducing the liquid under the required pressure and in caring for the hysteroscope.

Porto and Gaujoux used hysteroscopy to monitor the effectiveness of radiation therapy for cervical cancer (1972). Transcervical catheterization of the fallopian tubes during hysteroscopy was successfully used by Lindemann (1972, 1973), Levine and Neuwirth (1972), and others. This technique was further improved for therapeutic purposes in 1986 by Confino et al. (transcervical balloon tuboplasty).

Dissection of intrauterine adhesions under hysteroscopy control using endoscopic scissors was proposed and successfully applied by Levine (1973), Porto 0973), March and Israel (1976). Sterilization of women using hysteroscopy by electrocoagulation of the fallopian tube orifices was performed by Menken (1971), Нерр, Roll (1974), Valle and Sciarra (1974), Lindemann et al. (1976). However, this sterilization technique turned out to be associated with a high frequency of complications and failures. According to Darabi and Richart (1977), in 35.5% of cases, sterilization was ineffective, and 3.2% of women had serious complications (uterine perforation, intestinal injury, peritonitis).

In 1980, in order to improve hysteroscopic sterilization, Neuwirth et al. proposed the introduction of methyl cyanoacrylate glue into the fallopian tube orifices. Hosseinian et al. proposed the use of polyethylene plugs, Erb et al. proposed the introduction of liquid silicone, and Hamou in 1986 proposed a model of an intratubal spiral.

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

In 1978, David et al. used hysteroscopy to examine patients with cervical polyps.

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

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

Further development of operative hysteroscopy was facilitated by the proposal to use the Nd-YAG laser (neodymium laser) in various operations in the uterine cavity: dissection of intrauterine adhesions (Newton et al., 1982), intrauterine septum (Chloe and Baggish, 1992). In 1981, Goldrath et al. first performed vaporization of the endometrium with a laser using a contact method, and Leffler in 1987 proposed a method of contactless laser ablation of the endometrium.

In 1990, Kerin et al. proposed falloposcopy, a method of visual examination of the intratubal epithelium using a hysteroscopic approach.

The invention of the fibrohysteroscope and microhysteroscope (Lin et al., 1990; Gimpelson, 1992; Cicinelli et al., 1993) marked the beginning of the development of outpatient hysteroscopy.

The works of L.S. played a major role in the development of hysteroscopy in Russia. Persianinova et al. (1970), A.I. Volobueva (1972), G.M. Savelyeva et al. (1976, 1983), L.I. Bakuleva et al. (1976).

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

Hysteroresectoscopy began to develop rapidly in Russia in the 1990s, and was the subject of works by G.M. Savelyeva et al. (1996, 1997), V.I. Kulakov et al. (1996, 1997), V.T. Breusenko et al. (1996, 1997), L.V. Adamyan et al. (1997), A.N. Strizhakova et al. (1997).

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