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Hysteroscopy: Managing and minimizing operative complications

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Techniques to assess the site, spot imminent perforation, and avoid or correct the 5 most common types of problems.


 

References

KEY POINTS
  • Perform endometrial sampling for abnormal uterine bleeding before scheduling operative hysteroscopy.
  • Most uterine perforations do not require treatment— even those involving large dilators—although further assessment may be necessary to rule out bowel injury.
  • Most complications of electrosurgery involve activating an electrode at the time of perforation, or diverting current to the outer sheath.
  • Scrupulously monitor fluid intake and output to prevent hyponatremic complications.

WHAT WENT WRONG?

A 44-year-old woman undergoing resection of a submucous myoma from the left cornual region has persistent bleeding at the resection site. The surgeon continues coagulation at the bleeding site, using a rollerball electrode in an attempt to achieve hemostasis, but perforates the uterus. Immediate laparoscopy to identify collateral injury reveals some thermal damage on the posterior leaf of the broad ligament, but no bowel injury. After 24 hours of observation, she is afebrile without leukocytosis. She is discharged with explicit instructions to return if she has symptoms suggesting bowel injury. She returns in 72 hours, with abdominal pain and low-grade fever. CT reveals extravasation of contrast from the left ureter in the pelvis. Immediate laparotomy finds perforation of the left ureter secondary to a thermal injury. She undergoes ureteroneocystotomy and recovers.

This case illustrates one of the most common complications of operative hysteroscopy: uterine perforation with collateral injury. Both could have been avoided if the Ob/Gyn had stopped the procedure when bleeding first occurred, removed the instruments, and allowed the uterus to contract spontaneously.

This is just one of the strategies that can reduce the risks of hysteroscopic surgery. Numerous reports confirm that operative hysteroscopy is safe and effective, but as more gynecologists perform an increasing number of procedures, we must be aware of potential complications and do our best to minimize risk to our patients.

Complications cannot be completely avoided, and may occur when a procedure is done correctly by experienced doctors. They are far more likely if techniques or equipment are used improperly. This article describes ways to minimize risk.

When the American Association of Gynecologic Laparoscopists (AAGL) surveyed its members in 1993, it found a complication rate of 2% for operative hysteroscopy.1 The rate of major complications—perforation, hemorrhage, fluid overload, and bowel or urinary tract injury—was less than 1%. A prospective multicenter trial2 of 13,600 procedures in the Netherlands found a higher complication rate for operative (0.95%) than for diagnostic hysteroscopy (0.13%).

Preoperative precautions

We can reduce the risk of complications if contraindications are not ignored, equipment is thoroughly inspected and understood, and the surgeon goes through a mental checklist and plans each procedure. A “time out”before the operation begins, when every member of the team is briefed, is also valuable in preventing errors.

A hands-on course necessary before undertaking advanced resectoscopic surgery, to become familiar with equipment and techniques, followed by proctoring by a surgeon credentialed for the procedure.

Contraindications

Ignoring contraindications to hysteroscopic surgery increases the risk of complications and is the single greatest factor leading to patient injury and physician liability.

Contraindications include:

  • Unfamiliarity with equipment, instruments, or technique
  • Lack of appropriate equipment or staff familiar with the equipment
  • Acute pelvic inflammatory disease
  • Pregnancy
  • Genital tract malignancies
  • Lack of informed consent
  • Inability to dilate the cervix
  • Inability to distend the uterus to obtain visualization
  • Poor surgical candidates who may not tolerate fluid overload because of renal disease, or radiofrequency current when a cardiac pacemaker is present
  • The patient desires and expects complete amenorrhea3

Mechanical or traumatic complications

These types of complications are among the most common. Other categories include preoperative complications (ie, improper patient selection and lack of informed consent), electrosurgical and gaseous, complications related to distention media, and postoperative complications (ie, infection and late sequelae).

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