Graded, Vision-Controlled Access to the Difficult Cervix During Operative Hysteroscopy: Development and Preliminary Evaluation in 973 Procedures

Background/Objectives: Blind mechanical dilatation is the conventional response to a cervix that cannot be negotiated during operative hysteroscopy and is often implicated in perforation. We evaluated a graded, vision-controlled strategy for difficult cervical access. Methods: Retrospective single-surgeon cohort of 973 eligible no-touch vaginoscopic operative hysteroscopies (2023–2026) using a 7.25 mm mechanical tissue removal system. Each difficult cervix was graded 1–4 from first-approach morphology; four escalating vision-controlled techniques were selected intraoperatively, not by grade, with blind dilatation as rescue. The primary outcome was uterine access. Results: Difficult access occurred in 139 procedures (14.3%). Access was achieved in all 128 grade 1–3 patients (100%, 95% CI 97.2–100) and in 5 of 11 with grade 4 (45.5%, 16.7–76.6); overall 133/139 (95.7%, 90.8–98.4). Among successful passages, cervical passage time increased across grades (medians 37, 101, 170 and 240 s; p < 0.001); operation time did not (p = 0.11). Perforation occurred in five patients (3.6%): one during vision-controlled passage and four during blind rescue dilatation after failed grade 4 attempts; all were managed conservatively. Conclusions: Vision-controlled passage achieved access without blind dilatation in every cervix not completely obliterated; complete obstruction remains its limit. The grading and techniques require prospective, multicentre and interobserver validation.