Andrea Tinelli - Atlas of Hysteroscopy

The history of vaginal examination dates back to ancient times and has, hitherto, been a rite of passage into womanhood. Revolutions in this gateway field have been few and far between, with the most notable of which coming from J. Marion Sims in 1845 when he fashioned the first crude speculum from a pewter spoon []. This method, however, still did not allow full examination of the vagina due to the inability to maintain distension of the potential space (vagina). The proposal of a new modification to inspect the vagina was proposed by Osama Shawki dubbed the Shawki technique which includes approximation of the vulva to avoid leakage and ballooning of the vagina exposing all the vaginal walls, fornices as well as the portio vaginalis of the cervix. This technique bears all the advantages of the aforementioned technique in terms of pain relief and gains a more effective view of the vaginal canal and ectocervix. It has also been revolutionary for the treatment of vaginal pathology such as OHVIRA syndrome for the obstructed hemi-vagina to be re-connected to the menstruating vagina.

These patients tend to present around the age of puberty when the menstrual cycle begins. Patients complain of severe cyclic lower abdominal pain during menstruation often requiring hospitalisation. As one hemi-vagina is communicating with the vulval orifice, there is no suspicion of Mullerian anomalies until further investigations are performed which include ultrasound examination and MRI.

These advanced studies would show a fluid collection in the vagina. The condition is most commonly associated with a bicornuate bicollis uterus, otherwise known as didelphys.

Another common association is ipsilateral renal agenesis on the same side as the obstructed hemi-vagina; thus a urological examination would prove prudent.

These cases were previously misdiagnosed and subjected to exploratory laparotomies which may have ended in a hemi-hysterectomy, removing the obstructed sides uterus. The fact that a lot of the patients are virgins proved a difficult point to navigate any vaginal approach in certain cultures where the hymen is of great importance.

With the new vaginoscopy technique implemented, exposure of the vagina is possible and the obstructed vagina can be accessed by utilising a resectoscope with a Collins knife inserted trans-hymenal and incising through the obstructing vaginal septum. This unification is a minimally invasive approach which respects the hymen and avoids the abdominal route whilst providing an instant cure for the condition.

Similarly, a longitudinal non-obstructing vaginal septum can be tackled by the vaginoscopic route as well.

This pathology, which is usually associated with a cervico-uterine septum, was previously treated surgically by clamping and excising the vaginal septum. This was then followed by hysteroscopic release of the uterine septum with or without incision of the cervical septum [].

In the vaginoscopic approach, the vaginal septum is tackled in a similar way to a uterine septum, again utilising the resectoscope with Collins knife inserted and incising the septum from caudal to cephalad until reaching the external cervical os.

In this technique the tissues retract and there is no need for any further excision. Progression to resecting the cervical and uterine septa is then possible hysteroscopically.