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For answering the question at which hysteroscopical procedures an intraoperative screening method is necessary to avoid a fluid overload and whether a beginning fluid absorption can be diagnosed early by adding ethanol to the distension medium, a prospectively randomised comparative study of ablative versus non-ablative operative hysteroscopy with differing ethanol concentrations was performed (n = 120). Purisole (a mannit/sorbit solution) was used a distension medium. The measuring parameters (breath alcohol, amount of absorbed fluid, haematocrit and haemoglobin values, central venous pressure, heart frequency) were intraoperatively determined at 5-minute intervals. The results of the study show that with those hysteroscopical procedures during which the endometrium is not or only minimally injured (e.g. syneciolysis, hysteroscopic proximal tubal catheterisation). Intraoperative screening is not necessary due to the low absorbing amounts. With hysteroscopical procedures such as resection of myoma, endometrium ablation and septum resection, however, an addition of ethanol of 2% to the distension medium has proved useful, because with this method absorption amounts of 400 ml and more can be detected by positive values of breath alcohol. As the result of a further absorption of fluid, delayed in time compared to the first positive value of breath alcohol, there is an increase in central venous pressure and hyponatraemia. Intraoperative ethanol monitoring is a non-invasive procedure which can be performed during ablative-operative hysteroscopies and has no negative influence on the course of the intervention and the general condition of the patients.

The present study reports first experiences with falloposcopy for extended diagnosis in tubal sterility. In a total of 38 patients, n = 62 tubes were to be examined falloposcopically. Catheterization was successful in 85.5%. After successful catheterization, optically interpretable images were obtained in 93.6%. The overall success rate was therefore 80%. Considering the anatomical segments of the tube, no differences were found neither for catheterization nor for visualization. The spectrum of intratubal findings extended from normal in 25% to partly obstructive, nodular or non-nodular pictures, together with various degrees of mucosal alteration with or without synechia formation.

A hysteroscopic endometrial ablation (HEA) under maximal anesthesiologic surveillance was performed on 34 high-risk patients (group I: chronic anticoagulant therapy n = 26; group II: endogenous coagulopathy n = 8) with therapy resistant meno-metrorrhagia to avoid a hysterectomy (HE). Total amenorrhea, or a least hypomenorrhea respectively cyclic spotting could be attained primarily in 22 patients (group I: 19; group II: 3), after a repeat procedure in further 6 patients (4 in group I, 2 in group II). Subjective evaluation of surgical results (overall 22 patients primarily satisfied, 6 secondarily) also differed between the two subgroups (group I: p < 0.01 primarily satisfied; p < 0.05 secondarily satisfied vs. p < 0.05 and p < 0.01 in group II). A HE had to be performed on two patients due to extensive adenomyosis uteri interna (group II). The significantly better results in the anticoagulation group were probably due to the basic illness. Larger groups will, however, be necessary before any conclusions from this difference can be drawn. No surgical or anesthesiological complications occurred. There also were no major postoperative complications (1 endomyometritis, 2 cervical stenoses). Endometrial ablation was found to be a valuable treatment alternative for this specific group of patients with severe coagulopathy, thrombo-embolic or thrombotic disease.

Hysteroscopy has become an integral part of operative gynecology, with rates of major complications of 1%. To avoid serious, even lethal, complications, an intensive, well-structured training program for practicing surgeons is necessary. In response to these educational requirements. The HysteroTrainer was developed to provide in vitro simulation training for diagnostic and operative hysteroscopy, including laser and high-frequency electrosurgery.

A comparative study on thermal, mainly laser and high frequency electrosurgical techniques, was conducted. Indications, handling and morphometric results were correlated. Morphometrical findings suggest that minimal thermal tissue damage is associated by a decrease in the hemostatic effect. Additional bipolar coagulation is necessary when using the carbon dioxide laser or high frequency electrodes. As thermal tissue lesion is concerned, the two techniques differ only slightly, by fractions of millimeters. Concerning clinical handling and practicability at our department, as well as in the centers participating at the European Consensus Study on Lasers in Gynaecology, high frequency electrosurgery has proven the method of choice for endoscopic ablative procedures. The carbon dioxide laser (at laparoscopy) and the Nd:YAG contact laser (at hysteroscopy) are preferentially employed for reconstructive surgery (e.g. the carbon dioxide laser for treatment of distal tubal pathology or endometriosis, the Nd:YAG contact laser for hysteroscopic synechiolysis).

Hysteroscopy has become an integral part of the overall gynaecological surgical concept. On the one hand the experience of our study group as well as a literature survey have demonstrated that results of hysteroscopic metroplasty, resection of submucous myoma and synechiolysis are at least comparable to those of conventional procedures, the advantages of minimal invasive surgery being evident. However, increasing complications, even with a lethal outcome, due to deficient technical equipment or insufficient training of the surgeon are reported. Yet, a survey of complications in literature and in our own series of hysteroscopies (n = 200), shows a median complication rate below 1%. Knowledge of possible complications, symptoms and management alternatives is, however, a first requirement for application of these minimal access procedures. The second major precondition being a well structured training program for surgeon and assisting team. With the recently developed in-vitro-simulation trainer, the HysteroTrainer, training of the entire spectrum of hysteroscopic procedures, including laser and high frequency electrosurgical applications, is now feasible. The simulator may also be employed for security checking of the complex hysteroscopic equipment.

To date, the therapy of first choice in case of proximal tubal pathology is resection of the occluded segment and microsurgical reconstruction. Essential disadvantage of this rather successful method consists in the need of a laparotomy. According to the concept of minimal invasiveness a pilot study has been undertaken to evaluate hysteroscopic proximal tube catheterization (HPTC) and balloon dilatation for recanalization. This attempt has proven intraoperatively successful in more than 80% of the cases and the first pregnancy and birth following HPTC can yet be reported.