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.
This complication is less likely after hydrothermablation, since the free-flowing saline ablates the cornua completely. After more than 50 hydrothermablations performed in patients with prior tubal sterilizations, I have not seen any cases of post-ablation tubal ligation syndrome.
Treatment consists of bilateral salpingectomy or tubal fulguration at the cornual region and repeat ablation or resection of viable endometrial tissue. Another option is hysterectomy.
Post-ablation pregnancy can be very complicated
Pregnancy after endometrial ablation occurs at a rate of 0.2% to 1.6%. Counsel patients that this procedure does not prevent pregnancy and that contraception is vital. Uterine rupture after fibroid resection has been reported.
In a review of 37 post-ablation pregnancies, only 11 of 17 women who chose not to terminate carried the gestation beyond 28 weeks. In addition, there was a high incidence of intrauterine growth restriction, prematurity, and placenta accreta.22
Hysteroscopic tubal sterilization with the Essure system (Conceptus, San Carlos, Calif), or laparoscopic tubal fulguration performed at the time of ablation averts these complications.
Complications of global ablation
Global ablation technologies were developed to enable gynecologists with limited operative hysteroscopy skills to perform endometrial ablation and to make ablation safer for the patient. These technologies completely eliminate the risk of distention-media complications, but widespread use has resulted in other complications that have been reported in the literature to only a limited extent.
Most published articles on global endometrial ablation are from the original US Food and Drug Administration (FDA) trials, in which the complication rates were extraordinarily low. Widespread commercial use of these technologies since FDA approval, especially by practitioners with limited skills, has increased complications.
Do not override safety systems
Complications are more frequent when devices are misused or safety systems overridden. And, fear of litigation makes physicians unwilling to report complications.
In the FDA Manufacturer and User Facility Device Experience (MAUDE) database (www.fda.gov.cdrh/maude.html), complications include bowel burns after unrecognized perforation, and bowel burns associated with electrosurgical, microwave energy, or heat transferred through intact myometrium.23 Vaginal burns, uterine necrosis myometritis requiring hysterectomy, and death from unrecognized bowel burn also have been reported.
Most global procedures are performed blindly, and some doctors fail to perform diagnostic hysteroscopy before and after surgery, which I feel is mandatory with any endometrial ablation. Hydrothermablation is the only global technique that has the advantage of direct observation. In more than 150 procedures done in my office under local anesthesia, the only complications were 2 false passages. Both were promptly identified during diagnostic hysteroscopy, and the surgery was rescheduled 2 to 3 months later.
The author has served on the speakers’ bureau for Boston Scientific.
