Hysteroscopy:<br/>Managing and minimizing operative complications

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February 2005 · Vol. 17, No. 2

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.

Fast Track

Ignoring contraindications is the single greatest factor leading to injury and liability

When obtaining informed consent, advise the patient of the risk of perforation. An AAGL survey found an incidence of 14 per 1,000

To prevent myometrial avulsion, keep the myoma grasper away from the fundus when removing myoma segments

Inform the patient of the potential for delayed perforation from thermal injury, which can occur as late as 2 weeks after surgery

Avoid perforating the uterus by applying current only when the electrode is moving toward the operator, not the fundus

To reduce risk of gas embolism:

Avoid Trendelenburg positioning
Remove last dilator just before inserting the resectoscope
Limit repeated removal-reinsertion of the resectoscope
Vaporizing myomas eliminates the need to remove fibroid chips
Intracervical injection of vasopressin may block gas from entering circulation

Continuously record inflow and outflow using electronic monitoring with the deficit alarm set to 500 mL

To prevent infection, give 1 g ceftizoxime intravenously 30 to 60 minutes before surgery

Forewarn patients that endometrial ablation does not cancel out all possibility of pregnancy—and that contraception is vital

Diagnostic hysteroscopy to assess the uterus before and after global ablation is mandatory

Mark H. Glasser, MD

Chief, Department of Obstetrics and Gynecology Kaiser Permanente Medical Center San Rafael, Calif

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.

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Hysteroscopy:Managing and minimizing operative complications

Hysteroscopy:
Managing and minimizing operative complications