Operative hysteroscopy is a valuable tool in the treatment of non-malignant conditions of the uterine cavity. As technology progresses some of the complications occur less frequently when small barrel hysteroscopes are used, both in operative out patient procedures and when small barrel resectoscopes are used. The procedure in general has a low risk of adverse effects with an incidence of 0,28% in 13,600 procedures (1). A German study including 21,676 operative procedures found an incidence of 0,24 (2) Indications for endoscopic surgery become wider therefore safety protocols become more important in the prevention of complications. This is particularly important as most complications do occur during the learning curve of the surgeons mastering the technique and in specific procedures i.e. hysteroscopic myomectomy, where the risk of complications can be as high as 10% (3).

It is advisable that a surgeon embarking in hysteroscopic surgery should have performed at least 250 diagnostic hysteroscopies. The recommendation is also for hysteroscopic surgery to be graded according to the difficulty. There are different classifications. The author works with the classification issued by the Accreditation Taskforce of the International Society for Gynecologic Endoscopy (ISGE) (Tab 1). It is also advisable to use abdominal ultrasound over a full bladder – liquid covering the uterine fundus – to guide the operator in difficult cases, as there are myomectomy, adenomyosis, uterine septa –to preserve enough fundal myometrium – and severe adhesions. (van Herendael B. personal communication FIGO 2012 Rome). This has two advantages first the uterus is stretched in its longitudinal axis and second the instruments are visible in the uterine cavity whilst the direction and the thickness of the myometrium can objectively be measured during the intervention.