News for Your Practice

Hysteroscopy: Managing and minimizing operative complications

OBG Manag. 2005 February;17(2):42-57

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

References

1. Hulka JF, Peterson HA, Philips JM, Surrey MW. Operative hysteroscopy: American Association of Gynecologic Laparoscopists’ 1993 Member Survey. J Am Assoc Gynecol Laparos. 1995;2:131-132.

2. Jansen FW, Vredevoogd CB, Van Ulzen K, et al. Complications of hysteroscopy: a prospective multicenter study. Obstet Gynecol. 2000;96:266-270.

3. Vilos GA. Hysteroscopic surgery: indications, contraindications, and complications. In: Pasic and Levine’s A Practical Manual of Hysteroscopy and Endometrial Ablation Techniques. London and New York: Taylor and Francis; 2004;237-258.

4. Ostrzenski A. Resectoscopic cervical trauma minimized by inserting Laminaria digitata preoperatively. Int J Fertil. 1994;39:111-113

5. Phillips DA, Nathanson HG, Millim SJ, et al. The effect of dilute vasopressin solution on the force needed for cervical dilatation: a randomized controlled trial. Obstet Gynecol. 1997;89:507-511

6. Valle RF, Sciarra JJ. Intrauterine adhesions; hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol. 1988;158:1459-1470

7. Townsend DE, Quinlan DJ, Johnson GH. Repeat endometrial ablation. Presented at the World Congress of Hysteroscopy, Miami, Florida, 1996.

8. MacLean-Fraser E, Penava D, Vilos GA. Perioperative complication rates of primary and repeat hysteroscopic endometrial ablations. J Am Assoc Gynecol Laparosc. 2002;9:175-177.

9. Loffer FD. Complications of hysteroscopy—their cause, prevention, and correction. J Am Assoc Gynecol Laparosc; 1995;3:11-26

10. Goldrath MH. Uterine tamponade for the control of acute uterine bleeding. Am J Obstet Gynecol. 1983;147:869-872

11. Townsend DE. Vasopressin pack for treatment of bleeding after myoma resection. Am J Obstet Gynecol. 1991;165:1405-1407

12. Phillips DR, Nathanson HG, Milim SJ, et al. The effect of dilute vasopressin solution on intraoperative blood loss during operative hysteroscopy: a randomized controlled trial. Obstet Gynecol. 1996;88:761-766

13. Brooks PG. Resectoscopic myoma vaporizer. J Reprod Med. 1995;40:791-795

14. Glasser MH. Endometrial ablation and hysteroscopic myomectomy by electrosurgical vaporization. J Am Assoc Gynecol Laparosc. 1997;4:369-374

15. Parazzini F, Vercellini P, Di Giorgio O, et al. Efficacy of preoperative medical treatment in facilitating endometrial resection, myomectomy and metroplasty: literature review. Hum Reprod. 1998;13:2592-2597

16. Vilos GA, Brown S, Graham G, et al. Genital tract electrical burns during hysteroscopic endometrial ablation: report of 13 cases in the United States and Canada. J Am Assoc Gynecol Laparosc. 2000;7:141-147

17. Munro MG. Factors affecting capacitative current diversion with a uterine resectoscope: an in vitro study. J Am Assoc Gynecol Laparosc. 2003;10:450-460

18. Istre O, Shajaa K, Schjoensky AP, et al. Changes in serum electrolytes after transcervical resection of endometrium and submucous fibroids with the use of 1.5% glycine for irrigation. Obstet Gynecol. 1992;80:218-222

19. Arieff AI, Azus JC. Hyponatremic encephalopathy after endometrial ablation. JAMA. 1994;271:345.-

20. Taskin O, Buhur A, Birincioglu M, et al. Endometrial Na+, K+–ATPase pump function and vasopressin levels during hysteroscopic surgery in patients pretreated with GnRH agonist. J Am Assoc Gynecol Laparosc. 1998;5:119-124

21. Cooper JM, Brady RM. Late complications of operative hysteroscopy. Obstet Gynecol Clin North Am. 2000;27:367-374

22. Rogerson L, Gannon, O’Donovan P. Outcome of pregnancy following endometrial ablation. J Gynecol Surg. 1997;13:155-160

23. Gurtcheff SE, Sharp MT. Complications associated with global endometrial ablation: the utility of the MAUDE database. Obstet Gynecol. 2003;102:1278-1282

24. Glasser MH. The serosal sign: the hysteroscopic appearance of the uterine cavity just prior to perforation. Presented at the World Congress of Hysteroscopy, Miami, Florida, 1996.

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

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).