hysteroscopy is a procedure with a very rare incidence of major side effects . a thorough knowledge of how to tackle them is must for anyone practicing hysteroscopy......

1. Dr Santosh Jaybhaye
MBBS;DGO;FCPS;PGDMLS
Dip. Gyn Endoscopy( Germany)
Director : Om Sai Hospital &
Advanced Gyn. Endoscopy Centre

2.  Americal Association Of Gynaecologic laparoscopy
 ( AAGL) Survey of its members in 1993 revealed a
complication rate of only 2 % for operative hysteroscopy.
 Risk is even much less in diagnostic hysteroscopy
 Large multicentric trial of 13600 procedures in netherlands
found a complication rate of 0.95% for operative
procedures as against 0.13% for diagnostic procedures
 Rate of major complications like perforation;haemorrhage;
fluid overload bowel /urogenital injuries is less than 1% of
total cases performed.
 Despite of these encouraging figures its a sad fact that only
less than 30% gynaecologiat perform operative
hysteroscopic procedures

3.  Complications can never be avoided completely and
are likely to occur even in the hands of experienced
surgeon but a proper use of correct technique and
appropriate technology helps in a long way to reduce
the incidence of complications.

4. Broadly complications can occur due to:
 Lack of informed consent
 Improper surgical technique or lack of skills
 Improper use of equipments or instrumrnts
 Improper patient selection
 Lack of trained support staff

5. Preoperative Precautions
 Proper informed consent.
 Adequate preoperative counselling
 Adequate training of surgeon and support staff
 Good quality equipments
 Proper case selection

6. Classification of complications
A) Entry Related Mechanical Problems
1) Entry Related Trauma/ Perforation .
2) Failed Entry/ false passage
B) Method Related Complications
1) Technique Related
Perforation
Haemorrhage
Vasovagal Shock
Gas Embolism
2) media related complication
3) electromechanical injurires
C) Delayed post operative complications:
Infections
Endometrial Cancer Upstaging
Itrogenic Adenomyosis
Hematometra
Post Endometrial Ablation Tubal Ligation Syndrome
Pregnancy Related Concerns

7. A) Entry Related Mechanical Problems
Entry Related Trauma/ Perforation :
Cervical laceration & bleeding
Entry related perforation:
Due to excessive force during dilatation
Force applied in wrong direction during dilatation.
Almost 50% of total hysteroscopy
perforations occurs during entry

8. Failed Entry/ false passage
Causes:
 Stenotic cervix.
 Nulliparous cervix.
 Menopausal flushed cervix.
 Previous surgeries like cervical biopsy, cone
biopsy, cryosurgery
 Acute anteflexion or reteroflexion
 Prior use of GnRH agonist.

9. Ways to tackle difficult entry
 Cervical Traction
 Laminaria Tents
 Misoprostol 200 mcg vaginally 8 hrs before surgery
 Vasopressin 4 IU in 100 ml NS intracervical injection
at 4 & 8 o’ clock position.
 Ed’s solution:
5 IU of vasopressin with 30 ml of 1% lignocaine
Inject about 6 to 10 ml at 4 & 8 o’ clock position.
 USG guidence:
 Laparoscopic guidence:

10. Troubleshooting in difficult dilatation

11. False passage
 Usually occurs in cervical cannal when scope enters in
wrong direction or in uterine cavity during
adhesiolysis when dissection is done in wrong plane &
intramyometrial space is created

12. Always suspect false passage if you encounter criss cross
muscle fibre with no evidence of ostia

13.  Abandon surgery and repost after 2 to 3 months (as
false passage can lead to absorption of significant
amount of glycine from vascular channels in false
passage)
 Use of Ed’s solution/misoprostol can reduce the force
required for cervical dilatation and hence the
likelihood of false passage.

14. Method related complications
B) Method Related Complications
1) Technique Related
Perforation
Haemorrhage
Vasovagal Shock
Air Embolism
2) Media related complication
3) electromechanical injurires

15. Perforation
 Incidence:
Approximately overall incidence is 14/1000 cases
according to AAGL survey.
 More likely to occur when adhesiolysis or any other
surgical intervention is carried out on lateral uterine
wall or uterine fundus.( 20 to 30/1000 cases)
Type of perforation:
A) Cold perforation: Occurs due to dilators,
hysteroscope, hysteroscopic scissors
B) Thermal perforation: As a result of electrosurgical
current

16. Procedure related risk of
perforation
PROCEDURE PERCENTAGE RISK OF
PERFORATION
ADHESIOLYSIS 4.48%
TRANSCERVICAL RESECTION OF
ENDOMETRIUM
0.8%
MYOMECTOMY 0.75%
POLYPECTOMY 0.38%
REPEAT ADHESIOLYSIS 9.3%

17. Risk Factors Associated
With Perforation
 Postmenopausal uterus.
 Nulliparous status.
 Immediate postpartum status.
 Previous surgery like LSCS , Myomectomy, cone biopsy.
 Small size uterus due to chronic anovulation , pretreatment
with GnRH agonist , previous uterine artery embolisation.
 Previous koch’s
 Ca Endometrium
 Acute anteversion/ reteroversion
 Operator related: Undue force , Lack of adequate training

18. Management of perforation during hysteroscopy

19. Intraoperative haemorrhage
 Second most common complication
 About 0.5 to 1.9% cases need intervention to stop
bleeding
 Common in myomectomy & TCRE

20. Management strategies
A)Balloon Tamponade:
foley’s catheter no 12 / 14 with 10 to 20 ml of NS
(according to uterine size). Removed after 8 to 10 hours
depending on bleeding.
Volume of NS to be reduced from 20 to 10 ml after 1 hour to
avoid pressure necrosis of endometrium .
B) Uterine Packing:
c)Electrocautery : 60 to 80 watts coagulation current.
with electrocautery caution needs to be exercised while
coagulating near cornual area

21. Vaso vagal shock
Causes:
 inadequate anaesthesia
 Cervical dilatation during office hysteroscopy ( rare)
symptoms
Usually accompanied by nausea, dizziness , pallor &
sweating
Treatment:
 Stop the procedure
 Leg raising / Trendlenberg’s position.
 Fluid administration.
 Atropine ( in case of severe reaction)

22. Air Embolism
 Potentially serious & occassionally lethal complicatioN
 Signs & Symptoms:
sudden decrease in ETCO2
Bradycardia
Hypoxia
Precordial mill wheel murmur (classic sign of air in
heart).

23. Measures To Prevent Air Embolism
 Avoid doing hysteroscopy in head low position.
 Avoid forceful dilatation of cervix
 Minimise exposure of cervix & vagina to room air
 Do not introduce & take out scope more frequently
 keep the last dilator in place in cervical canal till
resectoscope is fully ready to go in.
 Intracervical injection of vasopressin helps to block
gas from entering into systemic circulation

24. Management Protocol
 Stop procedure
 Call for help
 Durant’s position ( left lateral decubitus position)
 Hemodynamic support like NS bolus; Dobutamine;
Nor Epinephrine.
 Hyperbaric Oxygen.
 Central venous catheterisation.
 Aspiration of air from right atriun may be attempted in
expert hands.
 CPR Protocols

25. Media Related Complications
 Overall incidence of dilutional hyponatremia is 0.2%
according to AAGL survey in 1993.
 One of the major cause of concern while using
monopolar resectoscope & glycine as distension media.
 Incidence much less when bipolar resectoscope is used
with NS as a distension media.( upto 2 ltr of fluid deficit
can be tolerated with NS safely).

26. Who Is At Risk
 Premenopausal young female with good intrensic estrogenic
load are maximum risk of glycine related complications.
 Estrogen inhibit Na-K ATPase pump in brain.
 Action of this pump is very important to prevent cerebral
edema.
 If glycine related hyponatremia sets in brain swells & tries to
become iso-osmotic with vascular system.
 This can lead to serious brain damage, permenant
neurological injury or even death
 Less common in males & postmenopausal females

27. Measures To Prevent Media Realted Complications
 High degree of vigilence from entire surgical tram is
required.
A ) Inflow outflow tracking:
 Meticulous monitoring of fluid inflow and outflow is
the single most important step.
 No scope for ‘’Asuming’’ losses of fluid by wet drapes &
spill on floor.

28. OPTIONS AVAILABLE
 Electronic Inflow Outflow Monitoring System.
 Collection of outflow fluid in a Measuring container/
suction bottle/ commercially available plastic pouch
like drapes

29. Tips To Prevent / Minimise Absorption Of Glycine During
Operative Hysteroscopy
 Operate at intrauterine pressure below MAP.
 Use of diluted vasopressin( Ed’s solution).
 Seal all the bleeders at the time they appear using
coagulation current .
 Operate under local or regional anaesthesia, so that
patient’s sensorium can be judged continuously
 Always do preoperative S.electrolytes.

30.  During surgery
 500 ml deficit: first alarm
 750 ml deficit: second alarm
20-40 mg Lasix at deficit of 750 ml
Re evaluate S. Na level.
 1.2 Ltr deficit: stop surgery preferably.
 1.5 Ltr deficit: never proceed beyond this point
 While using bipolar device fluid deficit permissible is upto
2 liters beyond which overload related problems may
occuer

32. Late postoperative complications
 Infections
 Upstaging of endometrial cancer
 Iatrogenic endometriosis
 Hematometra
 Pregnancy related concerns