[Room air as the etiology of gas embolism in diagnostic CO2 hysteroscopy]

During a diagnostic CO2-hysteroscopy in general anesthesia, a manifest gas embolism with a resulting drop of the endexpiratory CO2 partial pressure occurred upon insertion of the instrument. By ending the procedure and through appropriate anesthesiological measures, the occurrence was brought under control and the embolism had no clinical consequences. The incidence encouraged us to reconsider the CO2-hysteroscopy examination technique. As a result, we describe an up to now neglected mechanism which may lead to air embolism in gas hysteroscopy: Similar to hysteroscopy with fluid distension, the whole system has to be purged from air by insufflating CO2 prior to examination. If this step is neglected, up to 40 cm3 of room air may be insufflated into the patient, considering a connective tubing of 200 cm length and 0.5 cm lumen. The scientific organisations as well as the endoscopic training centers and the manufacturers of hysteroflators are challenged to deal with this newly described potential cause of complications.

The future of hysteroscopy

Hysteroscopy is rapidly becoming a common examination for every gynecologist. As an office procedure, it is one of the most valuable ways to detect intrauterine lesions. Benign and malignant changes in the endometrium can be diagnosed at an early stage, and problems in the uterine cavity that can cause sterility can be recognized and treated.

[Gynecologic endosonography: initial experiences]

Basing on our research work in hysteroscopy, we used recently developed small endosonographic sounds for intrauterine and later vaginal approach, for the first time in 1981. We call this method endosonography. The equipment used so far is described, the procedure explained, and the efficacy of this new technique demonstrated via several endosonograms. The advantage to transabdominal sonography is the close contact of the ultrasound transducer with the organ to be examined. This enables the use of high frequencies with correspondingly good resolution. Finally, our own experience is discussed.

Carbon dioxide hysteroscopy immediately after second trimester abortion

The use of hysteroscopy has been restricted a.o. by the need for general anesthesia. This applies in particular to the pre- or post-partum period, because the hyperemic atonic uterus is easily over-inflated to a dangerous level. Over-inflation did not occur following 50 aspirotomy D & E procedures in the second trimester, using a para- and intracervical block with lidocaine 1% with adrenaline 1:200,000 only. The uterine cavity was always thoroughly evacuated in these cases in which final check suction had been performed. We recommend that postabortum hysteroscopy should be performed preferably under local anesthesia.

[Experiences with 3120 outpatients sterilized by laparoscopic tubal bipolar coagulation (author's transl)]

3120 patients have been sterilized by laparoscopic tubal bipolar coagulation. The operations were performed in an outpatient procedure. 0.096% severe complications during surgery were caused. The pregnancy rate was 0.06%. Our experiences and results confirm the low risk outpatient way of laparoscopic sterilization as reported in Anglo-American literature.

CO2-hysteroscopy today

A survey of intra-uterine endoscopy over the last years is given showing the increased demand for hysteroscopy for diagnosis and therapy of intra-uterine diseases. Its indications include the search for unknown causes of uterine bleeding or sterility. It is also applied for various therapeutic reasons such as for example the search and removal of lost or embedded intra-uterine devices. The different methods of hysteroscopy--particularly the CO2 hysteroscopy, which we developed, are described. The new examination procedures such as for example the extensive penetration test applied in cases of sterility and others, which through the advances made in technology are now possible, are also discussed.

[Prenatal diagnosis of a double fissure malformation (author's transl)]

By Sonography changes of the non-osseous parts of the fetal body are just as recognizable as any malformation of the skull and skeleton. We report about a severe case of double cleft formation. The prenatal diagnosis pre-determined our intranatal care and method of delivery.

[Outpatient termination of pregnancy in the first trimester during paracervical blockade with Carticain (author's transl)]

Sparing termination of pregnancy with a low incidence of complications, using the drainage method in local anaesthesia, can be effected on an outpatient basis. Carticain, which is a rapidacting anaesthetic with good analgesic effect, enables practically painless dilatation of the cervical channel with subsequent evacuation, when combined with good psychological guidance of the patient. When questioned postoperatively, practically all patients were in favor of local anaesthesia. Another positive aspect, in their opinion, was the fact that they could be discharged after brief hospitalization. Furthermore, treatment on an outpatient basis is cost-saving.

A preliminary report about transcervical embryoscopy

Transabdominal amniocentesis and occasionally fetoscopy are used as a means of early diagnosis of fetal damage or abnormality after the 14th week of pregnancy. For medical reasons a still earlier method of diagnosis is desirable. We report about the transcervical approach- using CO2-gas-hysteroscopy to visualize the amnion sac and its contents.

[A comparative study of the suction and customary curettage methods in the termination of pregnancy (author's transl)]

90 hysteroscopies using CO2 were performed to evaluate differences in effectiveness between the customary curettage and the suction methods in terminating pregnancy during the first trimenon. Following suction, the uterine cavity was nearly always thoroughly evacuated. Very seldom is there any residual tissue seen. On the contrary, the uterine cavity following termination by customary curettage was almost never completely evacuated. Very often rest tissue of decidua, usually chorionic, in some cases with villous structures, were found. Tissue remnants following termination by either method were removed by target biopsy or curettage and examined histologically. Having made the above observations and comparison, it must be concluded that the suction method is clearly the more advantageous. If applied correctly, it becomes unnecessary to perform curettage right after the suction.

[Physical and physiological principles of CO2 hysteroscopy (author's transl)]

Various possibilities of developing the uterine cavity for hysteroscopy were presented together with their advantages and disadvantages. The authors consider CO2 gas insufflation to be the method of choice. The physical, physiological and technical principles and data of the procedure were discussed. The construction and function of the Hysteroflators 1000 S, a special gas insufflation apparatus for hysteroscopy were also discussed.

[Methods of sterilization of the female. Possibilities of hysteroscopic sterilization]

Present-day procedures for the sterilization of women are discussed. In particular, the possibilities of inpatient and ambulant treatments and their efficacy and risks are gone into. The hypsteroscopic transuterine tubal sterilization is reported as a new method which is still in the experimental stage. If the same sucessful results are achieved as with the sterilization methods already known, its advantages would be: a short ambulant procedure; local anesthesia, therefore no risk from the anesthetic point of view; avoiding the abdominal cavity, consequently no complications involving the peritoneal space such as are usually encountered with all other sterilization procedures; low risk of morbidity; the patients are not disabled; very low cost factor.

The Hysteroflator 1000S

A new electrical apparatus for CO2 hysteroscopy is described. It adds an electric suction pump to the insufflator to fix the cervical cup securely and maintain the seal indefinitely. The apparatus was used in 257 patients without any untoward effects.

[Experimental and clinical investigations on the effects of carbon dioxide gas during hysteroscopy (author's transl)]

The acute toxicity, lethal dosage and mechanical effects of carbon dioxide gas were studied in the waking dog by intravenous and intra-arterial insufflation. The threshold dosage for toxicity was 400 ml per minute in the dog. The important factor in the toxicity was not the total volume of carbon dioxide but the volume per unit of time. Metabolic acidosis was responsible for changes in the EKG, the heart rate and the respiratory rate. These findings are discussed in relationship to the usage of carbon dioxide gas for hysteroscopy in the human female. During carbon dioxide gas hysteroscopy blood gas analyses were done in 40 patients. 28 patients had a hysteroscopy under general anaesthesia and 12 patients under local anaesthesia. It was found that the volume of carbon dioxide used for the creation of a pneumometra in hysteroscopy has no side effect. The necessary gas flow is too small for toxic side effects or mechanical side effects such as a gas embolisation.