Complications of hysteroscopy

Complications of hysteroscopy, their treatment and prevention

Undoubtedly, a greater number of complications arise with operative hysteroscopy, complex and prolonged endoscopic operations. Serious complications are rare, nevertheless they must be remembered and be able to prevent and eliminate them in time.

The described complications can be divided into the following groups:

1. Surgical complications.
2. Anesthesia complications.
3. Complications associated with the expansion of the uterine cavity.
4. Air embolism.
5. Complications caused by prolonged forced position of the patient.

Surgical complications

Surgical complications with hysteroscopy are possible both during the operation and in the postoperative period.

Intraoperative complications

1. Perforation of the uterus is the most frequent complication in both diagnostic and operating hysteroscopy. Perforation can occur with the expansion of the cervical canal or any surgical manipulation in the uterine cavity.

Predisposing factors

• Severe retroversion of the uterus.
• The introduction of a hysteroscope without good visibility.
• A common carcinoma of the endometrium.
• The elderly patient's age, causing age-related tissue changes (cervical atrophy, loss of tissue elasticity).

Endoscopists should immediately identify the perforation of the uterus. Signs of perforation:

• The expander enters a depth exceeding the expected length of the uterine cavity.
• There is no outflow of injected fluid or it is not possible to maintain pressure in the uterine cavity.
• Loops of the intestine or peritoneum of the small pelvis can be seen.
• If the hysteroscope is in the parameter (non-penetrating perforation of the leaves of the wide uterine ligaments), the endoscopist sees a very interesting picture: thin threads, similar to a gentle veil.
• With non-perforating perforation of the uterine wall, the visible picture is difficult to interpret correctly.

When perforating the uterus (or suspected perforation), the operation is immediately stopped. The tactics of the patient's management in the perforation of the uterus depends on the size of the perforation, its location, the mechanism of perforation, the probability of damage to the abdominal cavity.

Conservative treatment is indicated for small dimensions of the perforation and confidence in the absence of damage to the abdominal cavity organs, absence of signs of intra-abdominal bleeding or bruising in the parameter. Assign a cold to the bottom of the abdomen, reduce the uterus drugs, antibiotics. Carry out a dynamic observation.

Perforation of the lateral wall of the uterus is rare, but it can lead to the formation of a hematoma in a wide bundle. With an increase in the hematoma, a laparotomy is indicated.

Serious perforations occur when working with a resector, resectoscope and laser. Endoscopic scissors inserted through the operating channel of the hysteroscope can rarely damage neighboring organs, more often this occurs when working with resectoscope or laser. The risk of perforation of the uterus is maximal with the dissection of intrauterine synechia of III degree and more. With such pathology, it is difficult to recognize anatomical landmarks, so it is recommended to carry out a control laparoscopy. The frequency of perforation of the uterus when dissecting intrauterine synechia, even with laparoscopic control, is 2-3 per 100 operations.

Perforation during operative hysteroscopy is easy to recognize, since intrauterine pressure drops sharply due to fluid flow into the abdominal cavity, visibility deteriorates sharply. If at that time the electrode was not activated, the operation is immediately stopped and, in the absence of signs of intra-abdominal bleeding, a conservative treatment is prescribed. If the surgeon is not sure whether the electrode was activated at the time of perforation, and there is a possibility of damage to the abdominal organs, laparoscopy is shown with suturing the perforation and revision of the abdominal cavity organs, and if necessary, laparotomy.

Prevention of uterine perforation

• Careful expansion of the cervix, possible use of laminaria.
• The introduction of a hysteroscope into the uterus under visual control.
• Correct technical performance of the operation.
• Accounting for the possible thickness of the uterine wall in different parts of it.
• Laparoscopic control in complex operations with a risk of perforation of the uterine wall.

2. Bleeding during diagnostic and operating hysteroscopy may be caused by cervical injury by bullet forceps, dilator, hemorrhage during perforation of the uterus.

If bleeding occurs immediately after the end of the operation, you need to examine the cervix. Such bleeding is rarely abundant, requires compression of the injury zone or suturing of the cervix.

Bleeding during operative hysteroscopy occurs in 0.2-1% of cases, most often with resection of the endometrium and laser ablation of the endometrium by a contact technique.

Bleeding due to uterine perforation is treated depending on the nature of bleeding and perforation, perhaps conservative treatment, sometimes laparotomy is needed.

Bleeding due to deep damage to the myometrium and trauma to large vessels is the most common complication that does not occur against the background of the uterine perforation. First, you should try to coagulate the bleeding vessels with a ball electrode or laser coagulation. If this does not help, you can enter into the uterus of the catheter Foley No. 8 and inflate it. It is permissible to leave it in the uterine cavity for 12 hours (no longer). In addition, haemostatic therapy is performed. If this procedure does not help (very rarely), you have to perform a hysterectomy.

The main measures for the prevention of surgical bleeding: it is necessary to avoid deep damage to the myometrium, special care should be taken when manipulating the side walls of the uterus and in the area of the internal pharynx where large vascular bundles are located.

Postoperative complications. In the postoperative period, the most common complications are:

• Postoperative bleeding.
• Infectious complications.
• Formation of intrauterine synechia.
• Hematometer.
• Thermal damage to internal organs.

1. Postoperative bleeding is observed in approximately 2.2% of cases (Loffler, 1994). It can occur on the 7th-10th day after endometrial ablation or resection of the myomatous node with a large interstitial component.

Usually, with such bleeding, normal hemostatic therapy is sufficient.

2. Infectious complications occur more often on the 3-4th day after the operation, but may develop the next day. Their frequency is 0.2%. Most often there is an exacerbation of chronic inflammation of the uterine appendages, especially in the presence of saktosalpinks. In infectious complications, antibiotics with a wide spectrum of action with metronidazole are administered parenterally for 5 days.

Prevention. Women at risk at the occurrence of purulent-septic complications (frequent inflammatory processes of the uterine appendages, pyometra, remains of the fetal egg, etc.) should be prior to surgery and in the postoperative period to appoint cephalosporins short course: iv 1 g 30 minutes before surgery , then iv in 1 g 2 times with an interval of 12 h after the operation.

Preventive prescription of antibiotics after hysteroscopic operations to all patients is impractical.

3. Intrauterine synechiae can form after complex hysteroscopic operations leading to the formation of a large wound surface. Most often, synechiae are formed after laser ablation of the endometrium.

The formation of intrauterine synechia can lead to secondary infertility. In addition, endometrial cancer, developed on an endometrial site hidden by synechiae, is very difficult to diagnose hysteroscopically.

Prevention of the formation of intrauterine synechia after hysteroscopic operations:

• If resection of two myomatous nodes is planned, the operation is performed in two stages at intervals of 2-3 months in order to avoid the creation of a large wound surface.
• After electrosurgical ablation of the endometrium, intrauterine synechiae form less frequently than after the laser.
• After dissection of intrauterine synechia, it is advisable to administer IUD and the appointment of cyclic hormone therapy.
• After complicated hysteroscopic operations, it is recommended to perform a control hysteroscopy after 6-8 weeks to exclude intrauterine synechias or to destroy them. By this time delicate synechia is formed, it is easy to destroy them.

4. Hematometry - a rare pathology, accompanied by cyclical pains in the lower abdomen and false amenorrhea. It occurs as a result of endo-cervix injury and development of its stenosis. The diagnosis is made with ultrasound. Drainage can be performed under the control of hysteroscopy or ultrasound. After sensing it is advisable to expand the cervical canal.

5. Thermal damage to the internal organs (gut, bladder) often occurs when the uterus is perforated by a resectoscope loop or Nd-YAG laser light guide. However, cases have been described where the uterine wall was intact, and coagulative bowel necrosis resulted from the transfer of heat energy through the uterine wall, both in resectoscopy (Kivinecks, 1992) and using an Nd-YAG laser (Perry, 1990).

Anesthesia complications

Anesthesia complications most often develop due to allergic reactions to injected anesthetics (up to the development of anaphylactic shock). Therefore, before the operation, a complete examination of the patient, careful collection of anamnesis, especially with regard to intolerance to medicines, is necessary. During surgery, other anesthesia complications are possible, so the operating room should be equipped with anesthesia equipment; The operation is performed with constant monitoring of heart rate and blood pressure.

Complications associated with enlargement of the uterine cavity

To expand the uterine cavity, use of CO ₂ and liquid media.

Complications arising from the use of CO ₂

1. Cardiac arrhythmia due to metabolic acidosis.
2. Gas embolism, sometimes leading to death.

Signs of gas embolism: a sharp drop in blood pressure, cyanosis, auscultation is determined by "mill wheel noise", intermittent breathing.

These complications are treated by an anesthesiologist. The success of treatment depends on the time of diagnosis and the early onset of treatment of complications, therefore the operating room should be equipped with everything necessary for carrying out resuscitation.

Prevention

1. Compliance with the recommended parameters of the gas flow rate (50-60 ml / min) and pressure in the uterine cavity (40-50 mm Hg).
2. To feed gas into the uterine cavity, only devices suitable for hysteroscopy (hysterophore) can be used.

Complications arising from the use of liquid media

Complications and their symptoms depend on the type and amount of absorbed liquid.

• 1.5% glycine can cause the following complications:
  • Nausea and dizziness.
  • Hyponatremia.
  • Liquid overload of the vascular bed.
  • Transient hypertension following hypotension, accompanied by confused consciousness and disorientation.
  • The decomposition of glycine to ammonia (toxic product) leads to encephalopathy, coma, sometimes to death.
• 3-5% sorbitol can cause the following complications:
  • Hypoglycemia in diabetic patients.
  • Hemolysis.
  • Liquid overload of the vascular bed with pulmonary edema and heart failure. Simple physiological solutions can also lead to fluid overload of the vascular bed, but in a more mild form.
• Distilled water. When using distilled water to expand the uterine cavity, severe hemolysis can occur, so it is best not to use it.
• High molecular weight media can cause the following conditions:
  • Anaphylactic shock.
  • Respiratory distress syndrome.
  • Pulmonary edema.
  • Coagulopathy.

Pulmonary complications in the use of high molecular weight dextrans are due to an increase in the volume of plasma dextran, which entered the vascular bed (Lukacsko, 1985; Schinagl, 1990). To avoid this complication, high molecular weight liquid media is recommended for use in small amounts (not more than 500 ml) and for non-prolonged operations.

Treatment

1. Hypoglycemia in women with diabetes. Enter the / in glucose under the control of glucose in the blood.
2. Hemolysis. Infusion therapy is shown under careful control of kidney and liver function.
3. Liquid overload of the vascular bed. Introduce diuretics and cardiac drugs, conduct oxygen inhalation.
4. Hyponatremia. Enter in / in diuretics and hypertonic solution, it is mandatory to control the content of electrolytes in the blood.
5. Encephalopathy and coma caused by the formation of ammonia. Conduct hemodialysis.
6. Anaphylactic shock. Enter adrenaline, antihistamines, glucocorticoids, administer infusion therapy and inhalation of oxygen.
7. Respiratory distress syndrome is treated by the administration of glucocorticoids, by inhalation of oxygen, sometimes a transfer to mechanical ventilation is necessary.

Prevention of complications includes the following rules:

1. Use the extensible environments that correspond to the planned operation.
2. Use equipment that allows you to determine the pressure in the uterine cavity, apply fluid at a certain rate and at the same time suck it off.
3. Maintain intrauterine pressure when using fluid to widen the uterine cavity at a low enough level to provide a good view (average 75-80 mmHg).
4. Constantly fix the amount of injected and withdrawn fluid, prevent fluid deficiency more than 1500 ml when using low molecular weight solutions and 2000 ml with the application of physiological solution.
5. Avoid deep damage to the myometrium.
6. Try to perform the operation as quickly as possible.
7. Many authors recommend using during the operation drugs that reduce the myometrium, introducing them into the cervix

Air embolism

Air embolism is a rare complication of hysteroscopy (possible with liquid hysteroscopy). Air embolism can occur if during the procedure the uterus is located above the level of the location of the heart (when the patient is in the Trendelenburg position) and when air enters the endomat tube system. The risk of this complication increases if the patient is on spontaneous breathing. At the same time, air pressure can be higher than venous pressure, which leads to air entering the vascular bed with embolism and possible fatal outcome.

To prevent this formidable complication, care should be taken to ensure that air does not enter the system of fluid supply tubes and do not perform surgery in the patient's position with the head lowered, especially if the patient is on spontaneous breathing.

Complications caused by prolonged forced position of the patient

Prolonged forced position of the patient can lead to the following complications: damage to the brachial plexus and back, soft tissue damage, deep vein thrombosis of the shin.

The long uncomfortable position of the shoulder and the extended position of the hand can lead to an injury to the brachial plexus (sometimes it takes 15 minutes). To prevent injury, the anesthetist must ensure that the patient's shoulder and arm are comfortably fixed. A prolonged position with raised lower limbs in the chair with an incorrect position of the support holders can also lead to paresthesia in the legs. If such complications occur, the neuropathologist must consult.

Patients in anesthesia are not sufficiently protected against traction damage to the spine. An awkward pulling of the patient by the legs to create the necessary position on the operating table or the raising of the legs can lead to damage (overstretch) of the ligaments of the spine with the appearance of chronic pain in the back. Therefore, during the operation, the legs are diluted at the same time by two assistants, they are hindered in the desired position and physiologically fixed.

The damage of soft tissues by metal moving parts of the operating table is described. Most often, these injuries occur when the patient is removed from the table. In case of safety violations, soft tissue burns may occur during electrosurgery. Therefore, you must carefully monitor the connection of electrical wires, their integrity, the proper location of the neutral electrode.

Long-term local pressure on the calf on the gynecological chair can lead to thrombosis of the deep veins of the lower legs. If there is a suspicion of such a thrombosis, you need to beware of possible pulmonary artery thromboembolism. When the diagnosis is confirmed, anticoagulants, antibiotics and consultation of the vascular surgeon should be immediately prescribed.

Ineffectiveness of treatment

Criteria for the effectiveness of treatment depend on many factors, including the expectations of the patient. Before the operation, a woman should be informed of all possible outcomes and consequences of treatment. The effectiveness of treatment is determined by the following factors:

• Correct selection of patients.
• Careful approach to the details of the operation.
• Talk with the patient about the nature of the proposed operation and its possible consequences.

1. Before the excision of the septum in the uterine cavity, the woman should be told that about 15% of the patients after this operation subsequently have a miscarriage in the first trimester of pregnancy.
2. After ablation (resection) of the endometrium, not all have amenorrhea, hypomanorea develops more often. Approximately 15-20% of patients have an ineffective operation. If the patient wishes, you can re-operate it.
3. In patients who underwent hysteroscopic myomectomy, menorrhagia persists in 20% of cases. Removal of the submucosal node does not guarantee the onset of pregnancy in a patient with infertility.
4. After dissection of intrauterine synechiae (especially common) in 60-80% of patients, pregnancy does not occur. In case of pregnancy, it is possible to increase the placenta.

[1], [2], [3], [4], [5], [6]