Ultrasound Guided Hysteroscopy in the Complex Uterine Isthmus

Abstract

<h3>Study Objective</h3> To demonstrate clinical considerations, operative setup and techniques for a reproducible method of achieving safe hysteroscopic access to the endometrial cavity using multimodal imaging techniques to navigate the complex uterine isthmus. <h3>Design</h3> Educational and stepwise instructional narrated surgical video. <h3>Setting</h3> Community Gynecologic Surgery Referral Practice <h3>Patients or Participants</h3> A 31-year-old G1P1 patient with severe cervical stenosis and high-grade isthmocele is referred for assistance with cervical dilation prior to planned embryo transfer. <h3>Interventions</h3> The patient underwent combined simultaneous hysteroscopic and ultrasonographic visualization to safely access the endometrial cavity. <h3>Measurements and Main Results</h3> A reproducible procedural setup and workflow is described in depth including positioning of patient, assistants and technology as well as detailed stepwise procedure instructions to obtain endometrial access without perforation. <h3>Conclusion</h3> As recognition of isthmocele and other anatomic pathology increases alongside high rates of cesarean section, the gynecologic surgeon must command careful perioperative planning, multimodal imaging techniques and a firm grasp of instrumentation safety parameters as part of the advanced endoscopic skill set required to navigate this complex anatomic area.