Complications of hysteroscopy

1. Complications of Hysteroscopy
Aboubakr Elnashar
Benha university, EgyptAboubakrelnashar

2. Contents
1.Introduction
1.Incidence
2.Classification
2. Complications
1. Distention media
2. Mechanical
3. Electrocautery
4. Anesthesia complications
5. Late complications.
3. Conclusion
Aboubakrelnashar

3. Incidence
McGurgan et al, 2015
Aboubakrelnashar

4. Complications have reduced significantly over the
years
1. Improved equipment
2. Better understanding of the risk factors
3. Proper training and better experience of the
operating surgeons.
Aboubakrelnashar

5. RCOG classification of operative hysteroscopy
levels.
Level 1
Diagnostic hysteroscopy with target biopsy
Removal of simple polyps
Removal of intrauterine contraceptive device
Level 2
Proximal fallopian tube cannulation
Minor Asherman's syndrome
Removal of pedunculated fibroid (type 0) or large polyp
Level 3
Division/resection of uterine septum
Major Asherman's syndrome
Endometrial resection or ablation
Resection of submucous fibroid (type 1 or type 2)
Repeat endometrial ablation or resection
Aboubakrelnashar

6. Classification
1. Distention media related
2. Mechanical
3. Electrocautery.
4. Anesthesia.
5. Late.
Aboubakrelnashar

7. Aboubakrelnashar

8. Aboubakrelnashar

9. 1. Complications of Distending Media
Distending Media
Why?
Create a viewing space for visual diagnosis
Performance of surgical procedures.
Types:
Now:
Saline
1.5% glycine.
low-viscosity media
used when electrosurgery is to be
performed using monopolar instruments
{nonionic: donot disperse current}
Aboubakrelnashar

10. For diagnostic and simple procedures
Rare
Operative procedures:
Glycine or saline can gain access to the
systemic circulation if the integrity of the uterine
vasculature is breached.
In the extreme
Fluid overload: electrolyte disturbances
Aboubakrelnashar

11. Electrolyte disturbance:
Hypervolemia
severe hyponatremia
decreased osmolarity.
Hazards:
right heart failure
pulmonary and cerebral edema
death.
Rate:
0.2-2%
Aboubakrelnashar

12. Mechanism and CP
Rapid intravascular absorption of glycine
through exposed venous sinuses:
dilutional hyponatremia
acute fluid overload
high blood pressure
reflex bradycardia.
This is followed by
Hypotension
nausea, vomiting,
headache, visual disturbance, agitation,
confusion and lethargy.
It can present intra or postoperatively.
Aboubakrelnashar

13. Gylcine is metabolized into
1. Ammonia.
Higher concentration in the brain decreases
the visual acuity.
2. Glyoxylic acid
forms oxalate
Glycine is contraindicated in patients with renal
failure.
Aboubakrelnashar

14. The severity depends on:
Amount of fluid absorbed
number of vascular apertures,
duration of procedure
flow pressure
After about 85 min
Glycine moves to the interstitial space: hypo-
osmolar hyponatremia
The free water then moves to the interstitial
space and then to the intercellular space in
order to achieve a balance:
Pulmonary edema
Cerebral edema
life-threatening.
Aboubakrelnashar

15. Aboubakrelnashar

16. Preoperative Prevention
1. GnRHa:
Decrease volume of systemically absorbed
distention media
2. Dilute Vasopressin:
Immediately before cervical dilation
8 ml (0.1U/ml) injected deeply about 4 and 8
o’clock in the cervix.
Aboubakrelnashar

17. Intraoperative Fluid Media Management
1. Before using the resectoscope
 baseline serum electrolyte levels should be
measured.
 Women with cardiopulmonary disease should be
evaluated carefully for shifts in fluid volume.
{Absorbed volumes tolerated by healthy women may be
catastrophic in the context of compromised cardiac
function.}
2. Operating at the lowest effective IU pressure
(50–80 mm Hg), always trying to keep this at less than the mean
arterial pressure
Aboubakrelnashar

18. 3. Completing the procedure as quickly as
possible.
4. Detection of impending excess systemic
absorption
5. Measurement of fluid inflow and outflow in a
closed system: precise calculation of the absorbed
volume.
6. Bulk vaporizing electrodes: reduced systemic absorption compared
with the resection loops
{greater degree of electrocoagulation: collateral vessel sealing}.
Aboubakrelnashar

19. 7. If an automated system is not available:
volume should be measured
deficit calculated every 5 to 10 min.
If the deficit reaches a predetermined limit
(depending on the patient’s baseline status,
could be 750–1500 ml)
:serum electrolytes are measured
Furosemide: IV, 10-40 mg, depending on
renal function.
Termination of procedure:
serum sodium decrease to < 125 mEq/L,
Deficit: 1500 to 2000 m for glycine
For saline double
Aboubakrelnashar

20. Postoperative management of clinically significant
fluid and electrolyte disturbances
Critical care unit
{cerebral edema, pulmonary edema, and right
heart failure}
1. Ventilator support
2. Use of diuretics and
3. Inotropic agents
4. judicious administration of hypertonic saline
solutions.
Aboubakrelnashar

21. 2. Mechanical Complications
The most common
Cervical laceration
Perforation of the uterus
{premature termination of the procedure}
Occur in
Diagnostic hysteroscopy
Operative hysteroscopy.
Aboubakrelnashar

22. 1. Cervical Lacerations
Due to:
Excessive traction on cervix by tenaculum or
clamp
When cervix is forcefully dilated.
Predisposing factors:
Nulliparity
Menopause
Cervical hypoplasia
Diagnosis:
Dilatation itself can also cause bleeding from
the cervix.
Diagnosis is usually easy and immediate.
Aboubakrelnashar

23. TT:
Bleeding is less: expectant.
Sutures can be placed if necessary.
Prevention:
Stenosed cervix:
Preoperative preparation of cervix with
prostaglandin gel or vaginal misoprostol (200
microgms) kept 2 h prior to surgery
Postmenopause:
Misoprostol may be ineffective
addition of systemic estrogen for two weeks
before the procedure
Aboubakrelnashar

24. If cervical stenosis is encountered, and misoprostol
have not been used or were ineffective:
Deep intracervical injection of dilute vasopressin
(0.05 U/ml to 0.1U/ml, 4 ml at 4 and 8 o’clock
on the cervix): reduces the force required for
cervical dilation. Care must be taken to prevent systemic
injection as it can result in severe cardiorespiratory complications.
In cases of previous access failure, adhesions or
synechiae in the canal frequently exist:
Use of mechanical scissors passed through the
operating channel to divide the adhesions under
direct vision.
Aboubakrelnashar

25. 2. Endometrial Lesions and False Passage: Avulsion
of the endometrium
Occurs during:
Dilatation of the cervix, without actually perforating the uterus.
Predisposing factors:
Menopause
Stenosed cervix
Acute RVF
Diagnosis:
Use of a smaller diameter office hysteroscope
Warning signs:
Difficult dilatation and bleeding from the cervix
TT:
Usually of no consequence and can be left alone
Aboubakrelnashar

26. Aboubakrelnashar

27. Aboubakrelnashar

28. Dilator trauma to anterior wall endometrium
Aboubakrelnashar

29. 3. Uterine Perforation
Occur during
dilatation of cervix
inserting hysteroscope.
Predisposing factors:
acute ante or retroversion of uterus
cervical stenosis
uterine synechia
endometrial malignancy
uterine malformation.
Diagnosis:
Sudden loss of distension despite proper
distention medium pressure and flow
Intestinal loops or omentum is seen.
Aboubakrelnashar

30. TT:
1. Procedure should be stopped immediately.
2. If perforation is of small caliber and is not
caused by cutting or electric current :
Expectant tt, observed for signs of hge
3. Tachycardia and hypotension indicates ongoing
hge:
Laparoscopy: stop bleeding by
endocoagulation or sutures.
Broad spectrum antibiotics
Hysteroscopy can be repeated after 6 w
Aboubakrelnashar

31. Perforation hemostasis confirmed
Perforation coagulatedPerforation
Aboubakrelnashar

32. Aboubakrelnashar

33. 4. Bleeding
infrequent
Can be reduced by:
 Preoperative GnRHa
Intraoperative (just before cervical dilation)
injection of diluted vasopressin into the cervical
stroma
Aboubakrelnashar

34. TT:
Temporary increase of the intrauterine
pressure
±reduce the blood flow sufficiently: improve
visualization: allow using ball electrode for
coagulation.
Intractable bleeding:
injection of diluted vasopressin.
Postoperative bleeding:
 usually stops by itself.
Foley catheter
inserted into the uterine cavity and the
balloon inflated to 30–50 Ml
 removed after 6 h.
Aboubakrelnashar

35. 3. Electrocautery Complications
Sites:
1. Intraperitoneal structures, especially bowel
 if an activated electrode perforates the
myometrium and serosal surface
 without perforation if bowel was adherent to the
serosal surface and deep myometrial resection
is used specially in the region of uterine cornua.
2. At the site of placement of the patient plate
if it is improperly placed or dislodged
3. Rarely (with monopolar instrumentation)
current diversion:
injury to cervix, vagina, or vulva through the
speculum or the tenaculum.
Aboubakrelnashar

36. 4. Overzealous use of resectoscope and current:
irreversible damage to endometrium:
inadequate growth of the endometrium in
subsequent cycles
adhesion formation with fibrosis.
Secondary bleeding from the uterus
{excessive coagulation of the tissues}:
dead tissue getting infected and
sloughing off
Aboubakrelnashar

37. Prevention
1. Footswitch should not be placed in a location
which may result in accidental activation of the
current.
2. Operate using a bipolar resectoscope
{no opportunity for current diversion}.
3. The patient plate (monopolar resectoscopes only)
should be securely affixed to the patient.
4. It is safer to use low-voltage (cutting) current,
minimizing the use of high-voltage (coagulation)
current
{such waveforms facilitate these complications}.
Aboubakrelnashar

38. 5. One sign of current diversion:
absence or reduction of the electrosurgical effect.
Confirm that power to the ESU and connections
in the circuit are intact before temptation to
increase the generator output.
Ensure that potentially traumatic current
diversion is not taking place.
Avoid contact of any metallic object (vaginal
speculum or a cervical tenaculum), with the external
sheath
Aboubakrelnashar

39. 4. Anesthesia Complications
Local Anesthesia
1. Anxiety:
To alleviate anxiety
create a relaxed setting
good communication between surgeon and
patient.
2. Vasovagal reaction.
{Traction and dilatation of cervix}
Patient feels unwell, hypotension, bradycardia
Prevented by:
Atropine:
0.6 mg IM, 30 min before the procedure.
Aboubakrelnashar

40. 3. Pain
 Due to:
dilatation of cervix beyond Hegar 5 to 6
 over distention of uterine cavity.
Diminished by:
Preoperative administration of analgesic rectal
suppository
local anesthetic for paracervical block.
Local anesthetic agents rarely cause adverse drug
reactions. If there is a rapid absorption from the injection
site or accidental intravascular injection
has taken place, the cardiac effect is manifested as
bradycardia, cardiac arrest, shock or convulsions.
Treatment is IV atropine 0.5 mg and adrenaline with
cardiac resuscitation.
Aboubakrelnashar

41. General Anesthesia
It should always be administered with continuous
positive pressure respiration and endotracheal tube
or a laryngeal mask.
Aboubakrelnashar

42. 5. Late Complications
1. Infection
Rare
Risk factors:
history of PID.
Endometritis
pain, odorous discharge, fever, tenderness on
manual examination of the uterus.
TT:
oral antibiotic cover for 14 days
Aboubakrelnashar

43. 2. Hematometra
if there is obstruction of the internal os secondary to
intrauterine adhesions due to hysteroscopic surgery.
To prevent:
isthmus region and cervical canal should be
avoided during resection.
3. Intrauterine Adhesion
Due to excessive resection.
Prevention:
Cyclical hormonal tablets to facilitate the growth
of the endometrium.
Intrauterine devices
4. Uterine Rupture and Placenta Accreta
±in pregnancy postablation.
Aboubakrelnashar

44. 4. Complications Related to Patient Positioning
Acute Compartment Syndrome
Dorsal lithotomy position: postoperative compartment
syndrome in the lower legs
Mechanism:
pressure in the muscle of an osteofascial
compartment is increased to an extent that
compromises local vascular perfusion}: ischemia is
followed by
reperfusion
capillary leakage from the ischemic tissue
 increase in tissue edema in an ongoing cycle
Ultimately: neuromuscular compromise:
rhabdomyolysis
 permanent disability.
Aboubakrelnashar

45. Neurologic Injury
The principal motor nerves arising from the lumbosacral
plexus (T12 to S4)
Femoral
Obturator
Sciatic nerves.
risk increases with prolonged operative time.
Aboubakrelnashar

46. Femoral neuropathy
{one or a combination of excessive hip flexion,
abduction, and external hip rotation that contribute to
extreme angulation (>80) of the femoral nerve beneath the
inguinal ligament: nerve compression}.
Aboubakrelnashar

47. Sciatic and peroneal nerves
 are fixed at the sciatic notch and neck of the fibula
respectively, making them susceptible to stretch injury.
Two orientations create maximal stretch at these points:
flexion of the hip with a straight knee, which essentially
positions the entire leg vertically; and extreme external
rotation of the thighs at the hip. The sciatic nerve can also
be traumatized with excessive hip flexion.
Peroneal nerve is injured if there is excessive pressure
over the head of the fibula from, for example, a stirrup,
neural injury results in foot drop and lateral lower extremity
paresthesia.
Aboubakrelnashar

48. 5. Dissemination of T umor Cells
No evidence that hysteroscopic surgery displaces
fragments of endometrium into the peritoneal cavity:
Endometriosis
Metastasis of endometrial carcinoma cells.
However, hysteroscopy is contraindicated
in proven cases of cervical or endometrial malignancy
Aboubakrelnashar

49. Conclusion
Hysteroscopic surgery
Specific risks due to the distension media and
surgical technologies used.
Safe and effective
Most new technologies avoid the use of nonionic
distension media and hence many of the
complications of fluid overload.
To minimize the risk of complication.
1. Appropriate case selection
2. Recognition of the learning phase.
3. Patient and surgical team preparation.
4. knowledge of distension media used
5. Knowledge of hysteroscopic equipment used
Aboubakrelnashar

50. Aboubakr elnashar
You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura