Feasibility and Pain Tolerance of 19Fr Mechanical Hysteroscopic Morcellation under Local Anesthesia: A Retrospective Case Series

Abstract

Objective: The paradigm shift from inpatient surgery to ambulatory settings represents a major trend in modern gynecology. However, the use of larger-diameter instruments like the 19Fr Bigatti Shaver (IBS®) under local anesthesia remains debated due to the need for cervical dilation. This study aims to evaluate the feasibility, pain tolerance, and safety of 19Fr mechanical morcellation performed under a standardized local anesthesia protocol. Methods: We conducted a retrospective monocentric case series of 80 patients treated at the Centre Hospitalier des 4 Villes (France) between 2022 and 2024. All patients underwent operative hysteroscopy for benign pathologies (polyps, myomas <25mm, RPOC) using the 19Fr IBS system. The anesthetic protocol included oral multimodal premedication (NSAIDs, Paracetamol, Hydroxyzine) and a Paracervical Block (PCB), followed by mechanical dilation to Hegar 6. The primary outcome was pain tolerance assessed by the Visual Analog Scale (VAS, 0-10). Results: The surgical success rate was 100% (defined as the complete removal of the pathology in a single session). The anesthetic feasibility rate was 97.5% (78/80); only two patients required conversion to sedation, both of whom were nulliparous. The mean operative time ranged from 5–15 minutes depending on pathology. The mean pain score was ≤ 3/10. No complications (perforation, infection, fluid overload) were recorded. Conclusion: Operative hysteroscopy with a 19Fr shaver is feasible and well-tolerated under paracervical block, offering a safe and efficient alternative to general anesthesia. While highly effective for multiparous women, nulliparity was identified as a critical risk factor for pain intolerance, suggesting the need for tailored management in this subgroup.