Hysteroscopy: Managing and minimizing operative complications
Techniques to assess the site, spot imminent perforation, and avoid or correct the 5 most common types of problems.
Inability to insert the hysteroscope
This may be caused by a stenotic, nulliparous cervix; menopause; GnRH agonists; previous cone biopsy, laceration, or cryosurgery; or an acutely retroflexed or anteflexed uterus.
Acute flexion problems can be corrected using a long-bladed, open-sided Graves speculum deep in the anterior or posterior fornix. The speculum pushes the fundus to the midposition and facilitates dilation. Once the hysteroscope is inserted, remove the speculum.
Placing a tenaculum on the posterior lip of the cervix of an acutely retroflexed uterus will straighten the cervical canal when traction is applied.
Inserting a laminaria tent the evening before surgery helps dilate the cervix easily and atraumatically.4 However, the laminaria can sometimes create a false passage, leading to perforation.
Cervical ripening agents such as intravaginal or oral misoprostol (200 μg inserted vaginally or 400 μg orally 8 to 12 hours preoperatively) also can facilitate dilation.
Intracervical injection of vasopressin solution (4 IU in 100 cc sodium chloride, injected at the 4 and 8 o’clock positions) can reduce the force needed to dilate the cervix.5 Half-size dilators may help; they also reduce the risk of cervical laceration.
Laceration of the cervix
Although this is a minor complication, substantial bleeding sometimes occurs when the cervix is lacerated by the tenaculum. In these cases, suture the cervix.
Occasionally, a touch of cautery from the rollerball electrode at low power (20 to 30 W) can control the bleeding.
Silver nitrate sticks or ferric subsulfate (Monsel’s) paste are also effective on superficial lacerations.
Bleeding from lower uterus or cervical canal can obscure view
In some cases, bleeding is delayed, necessitating additional surgery. Intravasation of distention fluid also can occur at these lacerations. Coagulation with the electrode may be necessary when bleeding is heavy.
Check for collateral injury when uterine perforation occurs
Perforation is a well-documented risk of operative hysteroscopy and should be discussed with the patient when obtaining informed consent. In the AAGL survey,1 the incidence of perforation was 14 per 1,000. It was even higher during transection of lateral and fundal adhesions: 2 to 3 per 100.6
Although perforation is more common with thermal energy sources, it may occur mechanically when scissors are used to transect a uterine septum, synechiae, or polyps.
When the cervix is stenotic or the uterus is acutely ante- or retroflexed, sounds and dilators can perforate the uterus.
Most perforations—even those involving large dilators—usually do not require treatment, although further assessment may be necessary to rule out bowel injury. Most perforations occur in the fundal region or posterior lower segment.
A false passage can be created when entering the uterus. Occasionally the surgeon may be fooled into thinking the hysteroscope is in the uterine cavity, since the false passage distends (FIGURE 1). If muscle fibers are visible and the tubal ostea are not, assume the passage is false. Slowly remove the hysteroscope and identify the true cavity for confirmation. Discontinue the procedure—even if no perforation is detected—to prevent distention fluid from being absorbed into the circulation through the injury. Adequate distention is not possible at this time.
Delay repeat hysteroscopy for 2 to 3 months.
To avoid creating a false passage, dilate the cervix with slow, steady pressure and stop as soon as the internal os opens; do not attempt to push the dilator to the uterine fundus.
Often the external os opens, but the internal os cannot be dilated the extra 1 to 2 mm necessary to accommodate the 27-French resectoscope. Rather than exert more force and risk perforation or laceration, simply turn on the resectoscope’s inflow with the outflow shut off, and let the fluid pressure dilate the cervix.
Always insert the hysteroscope or resectoscope under direct vision rather than use an obturator. Keep the “dark circle” in the center of the field and slowly advance the hysteroscope toward it until the cavity is reached.
Avulsion of the myometrium sometimes occurs during removal of incompletely resected myomas (FIGURE 2). Keep the myoma grasper away from the fundus when removing myoma segments, and avoid excessive traction on what may be a thin segment of myometrium. Injuries can occur when the grasper perforates the uterus and bowel is inadvertently grasped. Large injuries require laparoscopic repair.
Perforation is more likely in repeat procedures. In a report of 80 repeat endometrial ablations, Townsend and colleagues7 noted 8 perforations that prevented completion of the procedure. In a series of 75 repeat ablations compared with 800 primary ablations by the same surgeon, the rate of serious perioperative complications was significantly higher in the repeat ablation group (9.3% versus 2.0%).8
