Complications of hysteroscopy

Complications of hysteroscopy, their treatment and prevention

Of course, a greater number of complications arise during surgical hysteroscopy, complex and lengthy endoscopic operations. Serious complications are rare, but they must be remembered and they must be prevented and eliminated in time.

The described complications can be divided into the following groups:

1. Surgical complications.
2. Anesthetic complications.
3. Complications associated with the expansion of the uterine cavity.
4. Air embolism.
5. Complications caused by the patient being in a forced position for a long time.

Surgical complications

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

Intraoperative complications

1. Uterine perforation is the most common complication of both diagnostic and surgical hysteroscopy. Perforation may occur during dilation of the cervical canal or during any surgical manipulations in the uterine cavity.

Predisposing factors

• Marked retroversion of the uterus.
• Insertion of a hysteroscope without good visibility.
• Disseminated endometrial carcinoma.
• The elderly age of the patient, which causes age-related changes in tissues (atrophy of the cervix, loss of tissue elasticity).

The endoscopist must immediately identify the perforation of the uterus. Signs of perforation:

• The dilator is inserted to a depth exceeding the expected length of the uterine cavity.
• There is no outflow of the injected fluid or it is not possible to maintain pressure in the uterine cavity.
• Bowel loops or pelvic peritoneum may be visible.
• If the hysteroscope is in the parametrium (non-penetrating perforation of the broad ligaments), the endoscopist sees a very interesting picture: thin threads, similar to a delicate veil.
• In case of non-penetrating perforation of the uterine wall, the visible picture is difficult to correctly interpret.

In case of uterine perforation (or suspected perforation), the operation is stopped immediately. The tactics of patient management in case of uterine perforation depend on the size of the perforation hole, its location, the mechanism of perforation, and the probability of damage to the abdominal organs.

Conservative treatment is indicated for small perforation openings and confidence in the absence of damage to the abdominal organs, absence of signs of intra-abdominal bleeding or hematomas in the parametrium. Cold is prescribed to the lower abdomen, uterine contraction drugs, antibiotics. Dynamic observation is carried out.

Perforation of the lateral wall of the uterus is rare, but may result in the formation of a hematoma in the broad ligament. If the hematoma increases, laparotomy is indicated.

Serious perforations occur when working with a resector, resectoscope, and laser. Endoscopic scissors inserted through the surgical channel of a hysteroscope can rarely damage adjacent organs; this occurs more often when working with a resectoscope or laser. The risk of uterine perforation is highest when dissecting intrauterine adhesions of grade III or higher. With such pathology, it is difficult to recognize anatomical landmarks, so it is recommended to perform control laparoscopy. The frequency of uterine perforation during dissection of intrauterine adhesions, even with laparoscopic control, is 2-3 per 100 operations.

Perforation during surgical hysteroscopy is easy to recognize, since the intrauterine pressure drops sharply due to the fluid flowing into the abdominal cavity, and visibility deteriorates sharply. If the electrode has not been activated at this point, the operation is stopped immediately and, in the absence of signs of intra-abdominal bleeding, 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 with suturing of the perforation hole and revision of the abdominal organs is indicated, and, if necessary, laparotomy.

Prevention of uterine perforation

• Gentle dilation of the cervix, possible use of laminaria.
• Insertion of a hysteroscope into the uterine cavity under visual control.
• Correct technical execution of the operation.
• Taking into account the probable thickness of the uterine wall in different areas.
• Laparoscopic control in complex operations with the risk of perforation of the uterine wall.

2. Bleeding during diagnostic and surgical hysteroscopy may be caused by trauma to the cervix with bullet forceps, a dilator, or hemorrhage due to perforation of the uterus.

If bleeding occurs immediately after the end of the operation, the cervix should be examined. Such bleeding is rarely profuse and requires compression of the damaged area or suturing of the cervix.

Bleeding during surgical hysteroscopy occurs in 0.2-1% of cases, most often during endometrial resection and laser ablation of the endometrium using the contact method.

Bleeding resulting from uterine perforation is treated depending on the nature of the bleeding and perforation; conservative treatment is possible, but sometimes laparotomy is necessary.

Bleeding caused by deep damage to the myometrium and trauma to large vessels is the most common complication that does not occur against the background of uterine perforation. First, it is necessary to try to coagulate the bleeding vessels with a ball electrode or perform laser coagulation. If this does not help, a Foley catheter No. 8 can be inserted into the uterine cavity and inflated. It is permissible to leave it in the uterine cavity for 12 hours (no longer). In addition, hemostatic therapy is performed. If this procedure does not help (very rare), a hysterectomy must be performed.

The main measures for preventing surgical bleeding are: it is necessary to avoid deep damage to the myometrium, and to exercise special caution when manipulating the lateral walls of the uterus and in the area of the internal os, where large vascular bundles are located.

Postoperative complications. The following complications are most common in the postoperative period:

• Postoperative bleeding.
• Infectious complications.
• Formation of intrauterine adhesions.
• Hematometra.
• Thermal damage to internal organs.

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

Usually, for such bleeding, conventional hemostatic therapy is sufficient.

2. Infectious complications most often occur on the 3rd-4th day after surgery, but can also develop the next day. Their frequency is 0.2%. More often, there is an exacerbation of chronic inflammation of the uterine appendages, especially in the presence of sactosalpinx. In case of infectious complications, broad-spectrum antibiotics with metronidazole are prescribed parenterally for 5 days.

Prevention. Women at risk for purulent-septic complications (frequent inflammatory processes of the uterine appendages, pyometra, remnants of the fertilized egg, etc.) should be prescribed a short course of cephalosporins before surgery and in the postoperative period: 1 g intravenously 30 minutes before surgery, then 1 g intravenously 2 times with an interval of 12 hours after surgery.

Preventive administration of antibiotics after hysteroscopic surgery to all patients is not advisable.

3. Intrauterine adhesions may form after complex hysteroscopic surgeries that result in the formation of a large wound surface. Most often, adhesions form after laser ablation of the endometrium.

The formation of intrauterine adhesions can lead to secondary infertility. In addition, endometrial cancer that develops in the area of the endometrium hidden by adhesions is very difficult to diagnose hysteroscopically.

Prevention of the formation of intrauterine adhesions after hysteroscopic operations:

• If resection of two myomatous nodes is planned, the operation is performed in two stages with an interval of 2-3 months to avoid creating a large wound surface.
• After electrosurgical ablation of the endometrium, intrauterine adhesions form less frequently than after laser.
• After dissection of intrauterine adhesions, it is advisable to insert an IUD and prescribe cyclic hormonal therapy.
• After complex hysteroscopic operations, it is recommended to perform a control hysteroscopy after 6-8 weeks to exclude intrauterine adhesions or their destruction. By this time, delicate adhesions are formed, they are easy to destroy.

4. Hematometra is a rare pathology accompanied by cyclic pain in the lower abdomen and false amenorrhea. It occurs as a result of trauma to the endocervix and the development of its stenosis. The diagnosis is made by ultrasound. Drainage can be performed under hysteroscopy or ultrasound control. After probing, it is advisable to expand the cervical canal.

5. Thermal damage to internal organs (intestines, urinary bladder) most often occurs when the uterus is perforated by a resectoscope loop or an Nd-YAG laser light guide. However, there are cases where the uterine wall was intact, and coagulation necrosis of the intestine occurred as a result of the passage of thermal energy through the uterine wall both during resectoscopy (Kivinecks, 1992) and when using an Nd-YAG laser (Perry, 1990).

Anesthetic complications

Anesthetic complications most often develop as a result of allergic reactions to administered anesthetics (up to the development of anaphylactic shock). Therefore, before the operation, a complete examination of the patient, a thorough collection of anamnesis, especially with regard to drug intolerance, are necessary. During the operation, other anesthetic complications are also possible, therefore the operating room must be equipped with anesthetic equipment; the operation is performed with constant monitoring of heart rate and blood pressure.

Complications associated with uterine dilation

_CO2 and liquid media are used to expand the uterine cavity.

Complications arising from the use of _CO2

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

Signs of gas embolism: a sharp drop in blood pressure, cyanosis, auscultation reveals a “mill wheel noise”, intermittent breathing.

These complications are treated by an anesthesiologist. The success of treatment depends on the time of diagnosis and early treatment of the complication, so the operating room must be equipped with everything necessary to carry out resuscitation measures.

Prevention

1. Compliance with the recommended parameters of gas supply rate (50-60 ml/min) and pressure in the uterine cavity (40-50 mm Hg).
2. To supply gas into the uterine cavity, it is permissible to use only devices adapted for hysteroscopy (hysteroflator).

Complications arising from the use of liquid media

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

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

Pulmonary complications with the use of high-molecular dextrans are caused by an increase in plasma volume by dextran entering the vascular bed (Lukacsko, 1985; Schinagl, 1990). To avoid this complication, high-molecular liquid media are recommended to be used in small quantities (no more than 500 ml) and for short-term operations.

Treatment

1. Hypoglycemia in women with diabetes. Glucose is administered intravenously under control of blood glucose levels.
2. Hemolysis. Infusion therapy is indicated under careful monitoring of renal and hepatic function.
3. Fluid overload of the vascular bed. Diuretics and cardiac drugs are administered, oxygen is inhaled.
4. Hyponatremia. Diuretics and hypertonic solution are administered intravenously; monitoring of blood electrolyte levels is mandatory.
5. Encephalopathy and coma caused by ammonia formation. Hemodialysis is performed.
6. Anaphylactic shock. Adrenaline, antihistamines, glucocorticoids are administered, infusion therapy and oxygen inhalation are performed.
7. Respiratory distress syndrome is treated with glucocorticoids, oxygen inhalation, and sometimes mechanical ventilation is necessary.

Prevention of complications includes following the following rules:

1. Use expansion environments appropriate to the planned operation.
2. Use equipment that allows you to determine the pressure in the uterine cavity, supply fluid at a certain speed and simultaneously suck it out.
3. Maintain intrauterine pressure when using fluid to expand the uterine cavity at the lowest possible level to ensure good visibility (on average 75-80 mmHg).
4. Constantly record the amount of fluid introduced and removed, do not allow a fluid deficit of more than 1500 ml when using low-molecular solutions and 2000 ml when using saline solution.
5. Avoid deep damage to the myometrium.
6. Try to complete the operation as quickly as possible.
7. Many authors recommend using drugs that shrink the myometrium during surgery by introducing them into the cervix.

Air embolism

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

To prevent this serious complication, it is necessary to carefully ensure that air does not enter the system of tubes for supplying fluid, and not to perform the operation with the patient in a position with the head end down, especially if the patient is spontaneously breathing.

Complications caused by prolonged forced position of the patient

A prolonged forced position of the patient can lead to the following complications: damage to the brachial plexus and back, damage to soft tissues, thrombosis of the deep veins of the leg.

A prolonged awkward position of the shoulder and an extended arm can lead to injury of the brachial plexus (sometimes 15 minutes is enough). To prevent injury, the anesthesiologist should ensure that the patient's shoulder and arm are comfortably fixed. A prolonged position with the lower limbs raised in the chair with the leg holders in an incorrect position can also lead to paresthesia in the legs. If such complications occur, a consultation with a neurologist is necessary.

Patients under anesthesia are not sufficiently protected from traction injuries of the spine. Awkwardly pulling the patient by the legs to create the necessary position on the operating table or spreading the legs can lead to damage (overstretching) of the spinal ligaments with the appearance of chronic back pain. Therefore, during the operation, two assistants simultaneously spread the legs, put them in the desired position and physiologically fix them.

Soft tissue damage caused by metal moving parts of the operating table is described. Most often, these damages occur when the patient is removed from the table. If safety precautions are violated, soft tissue burns may also occur during electrosurgery. Therefore, it is necessary to carefully monitor the connection of electrical wires, their integrity, and the correct positioning of the neutral electrode.

Long-term local pressure on the calves on the gynecological chair can lead to thrombosis of the deep veins of the shins. If there is a suspicion of such thrombosis, one should be wary of possible pulmonary embolism. If the diagnosis is confirmed, it is necessary to immediately prescribe anticoagulants, antibiotics and consult a vascular surgeon.

Ineffectiveness of treatment

The criteria for the effectiveness of treatment depend on many factors, including the patient's expectations. Before the operation, the woman must be informed of all possible results and consequences of the treatment. The effectiveness of the treatment is determined by the following factors:

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

1. Before excision of the uterine septum, the woman should be told that approximately 15% of patients after such an operation subsequently have a miscarriage in the first trimester of pregnancy.
2. After ablation (resection) of the endometrium, not all women experience amenorrhea; hypomenorrhea develops more often. In approximately 15-20% of patients, the operation is ineffective. If the patient wishes, she can be operated on again.
3. In patients who have undergone hysteroscopic myomectomy, menorrhagia persists in 20% of cases. Removal of a submucous node does not guarantee pregnancy in a patient with infertility.
4. After dissection of intrauterine adhesions (especially common ones), pregnancy does not occur in 60-80% of patients. If pregnancy occurs, placenta accreta is possible.

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