Various instruments for hysteroscopic surgery have been designed in flexible, rigid, and semirigid forms. The flexible and semirigid instruments range in size from 6- to 9-French (2 to 3 mm) and can be slid through the operating channel of the hysteroscope for intrauterine surgery. These include grasping forceps, biopsy forceps, scissors, and electrodes (Fig. 12.1). The rigid or fixed instruments cannot be slid into the hysteroscopic channel but must be attached to the sheath itself; therefore the attached telescope and sheath must negotiate the cervical canal as a unit. Very few surgeons use rigid instrumentation.

Most manufacturing companies offer at least two different types of instruments (Fig. 12.2A, B). Generally speaking, the smaller, flexible instruments are for light-duty procedures, since they are rather fragile. They do have the advantage of being positioned at varying angles by means of the deflecting sheath. Practically speaking, the need for this type of maneuver is infrequent. The larger, semirigid instruments are preferred if the given hysteroscopic sheath can accommodate the wider diameter (3 mm) of these devices. The 2-mm instruments are small enough to fit through standard operating channels (Fig. 12.3A, B). They may be manipulated for close-up work near the terminus of the telescope or slid out away from the telescope to permit panoramic surgery. Essentially, the location of the operating instrument is relatively independent of the optical portion of the hysteroscopic system (Fig. 12.4). The 3-mm instruments are manufactured to serve as heavier-duty equipment compared with the 2-mm semirigid devices. The flexible design of the larger instruments is resistant to bending and breakage. The stout-hooked scissors are well suited for rapid section of septa and are particularly useful for broad septum resection. The small scissors are practical only for thin septa and fine adhesions.

Although free intrauterine devices may be removed by either 2-mm or 3-mm forceps, the former are totally unsuited for imbedded devices. Only the larger biopsy instruments supply a satisfactory specimen for the pathologist to evaluate. The jaws of smaller instruments are simply too small to obtain an adequate specimen for interpretation. When Hyskon is used as the distending medium, all accessory instruments must be immediately and thoroughly washed with hot water. If the Hyskon dries on the jaws of these accessories and an attempt is made to force them open by working the handles, it is likely that the instruments will break. These instruments may be steam or gas autoclaved. The rigid instruments are classified as heavy instruments (Fig. 12.5). They are permanently incorporated into the construction of the specialized sheath. The telescope in effect looks through the interior of the rigid operating sheath (Fig. 12.6). Thus the optical system provides a limited field of view and is permanently tied to the operating instrumentation at a fixed, unalterable distance (Fig. 12.7). In fact, this distance is very close to the end of the telescope and produces a magnified close-up view with a small field. The size of these instruments permits cutting large lesions and clearly allows greater traction to be applied to intrauterine lesions. As noted, the instruments must be slid through the cervix as an operating system, with the instruments protruding beyond the sheath. This makes for a more traumatic and difficult entry into the uterine cavity. Additionally, the cervical canal is not viewed during entry.