An automatic electronic defibrillator is optional, but it certainly is a good piece of relatively inexpensive equipment for any medical office to have, and I encourage its inclusion in any in-office hysteroscopy setup. A pulse oximeter is mandatory only for level II procedures. With office hysteroscopy, you likely will never use one (we have not), but it is nice to know it's there to use if a patient has a change in consciousness.
When level II procedures are being performed using parenteral narcotics and/or sedatives, a fully stocked crash cart is required, and an ACLS (advanced cardiac life support)-certified staff member who is not performing the procedure must be present to monitor the patient.
Anesthesia and Patient Comfort
At the Kaiser Permanente San Rafael (Calif.) Medical Center, we have performed more than 12,000 gynecologic office procedures—from diagnostic hysteroscopies to hysteroscopic sterilizations and endometrial ablations—under local anesthesia with minimal oral sedation, over a 25-year period.
For diagnostic and minor operative hysteroscopy, we generally instruct patients to take 400–800 mg ibuprofen at home 1 hour before the procedure. We administer a paracervical block consisting of 5–10 mL of 1% lidocaine to the cervical vaginal junction superficially through the mucosa at 3:00 and 9:00.
Whenever a tenaculum is used, we also inject the anterior lip of the cervix with approximately 1–2 mL of local anesthetic before the tenaculum is applied, and then leave the room for 5–10 minutes to allow the block to set properly.
Remember, as with any office gynecologic procedure, it is important to use a “no-touch” technique, as the uterine wall is innervated by both sympathetic and parasympathetic fibers. It is unnecessary to sound the uterus; the old but still common practice of sounding is uncomfortable for the patient and may provoke uterine contractions that make distention of the uterus difficult. It may also cause perforation and is simply unnecessary.
Our oral premedication regimen for HTA and Essure procedures consists of 800 mg ibuprofen (Motrin), 10 mg diazepam (Valium), and two hydrocodone/acetaminophen (Vicodin) tablets taken at home 1–2 hours before the procedure. Patients are instructed to arrive 30 minutes prior to their scheduled appointment, at which time they are given an intramuscular injection of 30 mg ketorolac (Toradol) and 0.4 mg atropine.
Toradol is a prostaglandin synthetase inhibitor and has a peripheral effect as well. Atropine is used to prevent vasovagal reactions. The patient should be warned that she may experience dry mouth, but that this is preferable to the extreme discomfort felt during a vasovagal episode.
We then administer a paracervical/intracervical block with 1% mepivacaine (Carbocaine, Polocaine), which is longer acting than lidocaine. We inject 2 mL in the anterior lip of the cervix before it is grasped with a tenaculum; we place the needle against the cervix and ask the patient to cough, which results in self-injection. We then inject 10 mL in the cervicovaginal junction on each side at 3:00 and 9:00. These injections are given superficially, just under the mucosa, to raise a weal.
We inject an additional 5 mL intracervically about 1–2 cm deep at 8:00 and 4:00, and 5 mL submucosally at 6:00 between the uterosacrals. The total amount of mepivacaine given is 37 mL, or 370 mg (the recommended maximum dose is 400 mg).
Again, it is important to leave the room for 10–15 minutes to allow the block to set properly. We recommend that the physician leave while the nurse stays to monitor the patient and help her relax.
The Essure procedure can be done with less oral anesthesia and a smaller paracervical or intracervical block than endometrial ablation requires, but because our patients tolerate our ablation anesthesia regimen so well, we use it for both procedures.
In a study of 249 endometrial ablations performed at Kaiser Permanente San Rafael over 5.5 years using the HTA system, only one procedure was discontinued because of pain, and two patients were admitted overnight for cramping and nausea. The overall success rate was 90.6%, despite 40% of our patients having submucous myomas. The only complications were four cases of postoperative endometritis, with two of those patients requiring hospitalization for intravenous antibiotics, and two cases of procedure failure due to false passages.
We have not had any adverse anesthetic reactions in our patients who have undergone HTA over the years, or in any of the thousands of other women who were given similar paracervical blocks for office gynecologic procedures.
Postprocedure recovery is rarely necessary for these level I procedures. Our nurses monitor patients' blood pressure for 10–15 minutes after the procedures are completed and ensure that patients are feeling well and are ambulatory. This monitoring is done in the procedure room. Patients who don't feel well enough to leave in that time period are brought into another exam room and are discharged when they are ready. This is very rare.