MANAGEMENT OF COMPLICATIONS OF HYSTEROSCOPY BY DR SHASHWAT JANI

1. Dr. Shashwat Jani.
M. S. ( Obs – Gyn ), F.I.A.O.G.
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Introduction
 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% gynaecologists perform
operative hysteroscopic procedures.
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3. Incidence…
 2.7% to 3.8% of all hysteroscopies.
Propst AM, et al. Obstet Gynecol 2008
 A multicenter study in the Netherlands.
 0.13% - diagnostic hysteroscopy.
 0.96% - operative hysteroscopy.
Jansen FW, et al. Obstet Gynecol 2007
 Highest rate of complications seen with
hysteroscopic adhesiolysis (4.5%)
Hulka JF, et al. J Am Assoc Gynecol Laparosc 2005
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4. Incidence
McGurgan et al., 2015
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5. Perforation
Bleeding
Fluidoverload
Infection
Hematometra
Hysteroscopic Complications
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6. Incidence
 Complications have reduced significantly
over the years:
Improved equipment.
Better understanding of the risk factors.
Proper training and better experience of the
operating surgeons.
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7. Operative
Hysteroscopy
• Operative Hysteroscopy is not for the novice,
but should be an extension of basic skill learnt
at diagnostic hysteroscopy.
• It is recommended by one author that unless
you have done 500 diagnostic hysteroscopy,
you should not venture operative hysteroscopy.
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8. “ Ignoring contraindications to
hysteroscopic surgery increases
the risk of complications and is
the single greatest factor leading
to patient injury and physician
liability.“
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9. Contraindications
 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.
 Unfamiliarity with equipment, instruments or
technique
 Lack of appropriate equipment or staff familiar with
the equipment.
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10. Peri-operative Complications
 Patient Positioning.
 Vasovagal Attack (Pain)
 Anesthesia Complications
 Access To The Endometrial Cavity:
Cervical Trauma, False Passage.
Uterine Perforation.
 Intraoperative Bleeding.
 Thermal Injury, Air Or Gas Emboli
 Fluid Overload.
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11. Post-operative complications
EARLY
Infection.
Post-operative bleeding.
LATE – sequale
Persistent complain.
Intrauterine adhesions, hematometria.
Uterine rupture during pregnancy.
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12. Positioning The Patient
Incorrect positioning of the patient may
result in:
1. Nerve injuries
2. Back injuries
3. Damage to soft tissues
4. Deep venous thrombosis (DVT)
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13. 1. Nerve Injuries
 The degree of Trelendenberg tilt required for
hysteroscopic surgery is less than that for operative
laparoscopy.
 Brachial plexus injury may result from incorrectly
placed shoulder restraints or from leaving the
patient's arm abducted on an arm board.
 A non-slip mattress is preferable to restraints
that compress the patient's shoulders.
 Injury can result from 15 minutes in a faulty
position.
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14. Nerve injury
Sciatic nerve
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15. • Pressure on the peroneal nerve by lithotomy
stirrups may result in paraesthesia and foot
drop.
• If lithotomy poles are used, the legs are
adequately padded.
• Supports which hold the leg in a padded
gutter are preferable.
• If injury occur, the advice of a neurologist
should be sought immediately.
1. Nerve Injuries
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16. 2. Back Injuries
• The anaesthetized patient is defenseless
against traction injury to the lumbar spine.
• The legs should be lifted simultaneously and
kept together until they are at the appropriate
height when they should be abducted gently
and placed in the supports.
• They should never be over-abducted as this
can lead to damage to the sacro-iliac joints.
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17. 3. Damage To Soft Tissues.
• It is the responsibility of the surgeon to
ensure that there is no injury from moving
parts of the table to the patient's soft
tissues or hands.
• No part of the patient is in contact with
metal parts of the table because these can
act as return plates for electrical energy
and burns can occur at the point of
contact.12-Nov-18
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18. 4. Deep Venous Thrombosis.
• Can result from prolonged
compression of the calves by the leg
supports.
• The surgeon should ensure that the
type of support is appropriate and well
padded.
• If DVT is suspected the appropriate
anticoagulant therapy is instituted.12-Nov-18
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19.  Cervical laceration
 False passage
 Perforation
 Bleeding
Injury To Genital Tract
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20. 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
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21. Failed Entry /
False Passage
Causes:
 Stenotic cervix.
 Nulliparous cervix.
 Menopausal flushed cervix.
 Previous surgeries likecervical biopsy, cone
biopsy, cryosurgery
 Acute anteflexion or reteroflexion
 Prior useof GnRH agonist.
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22. Cervical Lacerations
Due to:
Excessive traction on cervix by tenaculum.
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.
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23. If cervical stenosis is encountered, &
misoprostol have not been used or were
ineffective:
 Deep intra cervical injection of dilute vasopressin at 4
and 8 o’clock on the cervix): reduces the force
required for cervical dilation.
 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.
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24. A False Passage…
 If muscle fibers are visible and the tubal ostea are
not, assume the passage is false.
 Slowly remove the hysteroscope and identify the true
cavity for confirmation.
 Discontinue the procedure—even if no perforation is
detected—to prevent distention fluid from being
absorbed into the circulation through the injury.
Adequate distention is not possible at this time.
 Delay repeat hysteroscopy for 2 to 3 months.
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26. To Avoid Creating A False Passage…
 Dilate the cervix with slow, steady pressure and stop as
soon as the internal os opens; do not attempt to push the
dilator to the uterine fundus.
 Often the external os opens, but the internal os cannot be
dilated the extra 1 to 2 mm necessary to accommodate the
27- French resectoscope.
Rather than exert more force and risk perforation or
laceration, simply turn on the resectoscope’s inflow with the
outflow shut off, and let the fluid pressure dilate the cervix.
 Always insert the hysteroscope or resectoscope under
direct vision rather than use an obturator.
 Keep the “dark circle” in the center of the field and slowly
advance the hysteroscope toward it until the cavity is
reached.
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27. Perforation…
 In the AAGL survey, the incidence of perforation
was 14 per 1,000.
 It was even higher during transection of lateral
and fundal adhesions: 2 to 3 per 100.
 Although perforation is more common with
thermal energy sources, it may occur mechanically
when scissors are used to transect a uterine
septum, synechiae, or polyps.
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28. 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%
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29. Uterine Perforation
 Predisposing factors:
• acute ante or retroversion of uterus
• cervical stenosis, uterine synechiae
• endometrial malignancy
• uterine malformation.
 Recognition of perforation:
• Loss of uterine distension.
• Rapid increasing in fluid deficit.
• Intestinal loops or omentum is seen.
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30.  Management:
1. Procedure should be stopped immediately.
2. If perforation is of small caliber and is not
caused by electric current : Expectant tt,
observed for signs of hge
3. Tachycardia and hypotension indicates
ongoing hge:
Uterine Perforation
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31.  Laparoscopy: stop bleeding by endocoag-
ulation or sutures.
 Laparotomy if adjacent organs injury
 Broad spectrum antibiotics
Hysteroscopy can be repeated after 6 weeks
Uterine Perforation
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32. 12-Nov-18
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33. 12-Nov-18
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34. Prevention:
Pelvic examination to determine uterine, size,
position.
Stop when Pink myometrium becomes visible.
 Septal Resection to be done till both
ostia seen simultaneously.
Laparoscopic guidance or USG guidance.
Uterine Perforation
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35.  Prevention
 Activate the foot pedal only
when the electrode is moving
toward the operator, not the
fundus.
 Never activate the device
during a forward movement.
 Use roller-ball based
device at the cornu.
Uterine Perforation
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36. Intra-op/Post-op bleeding
Most Common Complications:
Cervical laceration, Perforation.
Myoma or endometrial resection.
Depends on the form of energy used for
resection. With loop and roller ball or loop
alone the incidence is 2.57% and 3.53%
respectively whereas with laser or roller ball it
is 1.17% and 0.97% (Maresh 1996).
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37. Intra-op / Post-op bleeding
Management:
Clear the field by opening the outflow channel.
Increase the distension pressure above the
mean arterial pressure (100mmHg) which
compresses the uterine wall sufficiently to stop
the bleeding.
Then the bleeding vessels can be coagulated
with a 3mm ball electrode.
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38. 12-Nov-18
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39. To Achieve Hemostasis
1 ) Insert a Foley catheter with a 30-cc balloon into
the uterine cavity, inject 15 to 20 mL (or more for a
larger cavity) of fluid into the balloon, and observe
the patient.
2 ) Pack the uterus.
1/2-inch–gauge packing that has been soaked in a
dilute vasopressin solution.
(20 U [1 mL] in 60 mL Normal Saline).
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40. Benefits of Vasopressin:
Before balloon tamponade or Packing the uterus,
Inject very dilute vasopressin :
(4 U [0.2 mL] in 60 mL normal saline)
directly into the cervix 2 cm deep,
at the 4 and 8 o’clock positions.
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41. Complications
Of Distension
Media
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42. Gas
CO2
Liquid
Distension Media
LMW
Non electrolyte
• 1.5% Glycine
• 3% Sorbitol
• 5% Mannitol
• 5% Dextrose
HMW
32% Dextran
Electrolyte
• Normal saline
• Ringer lactate
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43. 1.5 % Glycine
Simple amino acid that is mixed in water &
supplied in 1/2, 1,3 liters bags:
Non electrolytic
Hypo-osmolar (200mOsm/L)
Non hemolytic
Non Immunogenic
Low Molecular Weight (LMW)
Fluids Low Viscosity
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44. Intravascular Absorption Syndrome
 Occurs with electrolytes free medium
(Glycine 1.5%).
 More In Reproductive Women
 Female sex steriods – inhibits Na-K+/
ATPase pump , thus water and sodium
not thrown out of cells.
 GnRH agonists inhibits such hormones
action – may prevent this complication to
occur.
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45. Mechanism and CP
Rapid intravascular absorption of glycine
through exposed venous sinuses:
 Dilutional hyponatremia
 Acute fluid overload
 High blood pressure, reflex bradycardia.
 Cerebral odema, pulmonary oedema.
 This is followed by Hypotension, nausea,
vomiting , headache, visual disturbance,
agitation, confusion and lethargy.
Intravascular Absorption Syndrome
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46. The severity depends on:
 Amount of fluid absorbed
 Number of vascular apertures,
 Duration of procedure
 Flow pressure
It can present intra or postoperatively.
Intravascular Absorption
Syndrome
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47. 0.9% normal
Serum
Na (mEq/L)
Associated signs and
symptoms
Treatment
Nil
135-142 Normal serum Na
130-135
Mild hyponatremia-
apprehension,disorientation,nausea,v
omiting,irritability,twitching,shortness
of breath
Oxygen
Frosemide 40-
60mg IV
125-130
Mild to moderate hyponatremia
Dilute urine ,moist mucous memb,
moist skin, pitting oedema ,polyuria ,
pulm.rales
saline
<120
Severe hyponatremia
Hyponatremic encephalopathy, CHF,
lethargy, confusion ,twitching, focal
weakness, convulsions, death.
Ventilator
support
Frusemide IV
1mg/kg 4-6hrly
<115
Possible brainstem herniation,
grandmal seizures, coma, resp.arrest,
mortality up to85%
3% hypertonic
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48. Preoperative Prevention
 GnRHa:
 Decreases volume of systemically absorbed
distension media.
 Dilute Vasopressin:
Immediate before cervical dilatation
 8 ml (0.1U/ml) injected deeply about 4 and
8 o’clock in the cervix.
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49. Before Using The Resectoscope
Baseline serum electrolyte levels should be
measured.
Women with cardiopulmonary disease should be
evaluated carefully for shifts in fluid volume.
 Operating at the lowest effective IU pressure (50–
80 mm Hg), always trying to keep this at less than
the mean arterial pressure
Intra - Operative Fluid
Media Management
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50.  Completing the procedure as quickly as
possible.
 Measurement of fluid inflow and outflow in a
closed system: precise calculation of the
absorbed volume.
 Bulk vaporizing electrodes: reduced systemic
absorption compared with the resection loops
{greater degree of electrocoagulation: collateral
vessel sealing}.
Intra - Operative Fluid
Media Management
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51.  Deficit should b calculated frequently:
 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, if :
Serum sodium decrease to < 125 mEq/L,
Deficit: 1500 to 2000 ml for glycine
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52. Normal saline (0.9% NaCl)
 Safest, widespread availability.
 Low operative cost
 Physiological disposal by peritoneal absorption.
 Excessive vascular absorption fluid overload
Pulmonary odema.
NOT SUITABLE FOR MONOPOLAR SYSTEM : good
conductor of electrons.
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53. Distention medium delivery system
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54. Air or Gas Embolism
 The risk of gas embolism is the primary
complication associated with the use of carbon
dioxide as the distention medium.
 Carbon dioxide is a soluble gas, so these
emboli generally resolve rapidly.
 In contrast, room air emboli are more likely
to be fatal.
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55. Gas Embolus
 Faulty methods
Use of laparoscopic insufflator to infuse CO2
in uterus.
Diagnosis:
Tachycardia , desaturation & Hypotension
Cog-wheel murmur (10% cases) –
disappearance once the hysteroscopy stops
Rapid fall in expired CO2.
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56. Precautions To Prevent Embolism
Avoid Trendelenburg positioning.
Remove last dilator just before inserting the
resectoscope. Minimize cervical trauma.
Limit repeated removal-reinsertion of the
resectoscope.
Maintaining intrauterine pressures below 100
mm Hg and flow rates below 100 mL/min .
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57.  Management
DURANT Maneuver – left lateral with
head low position with tredelenberg
position
100% oxygen
CVC insertion or direct needle in right atrium
to remove the air
May require CPR.
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58. Late onset complications
1. Infection
Avoid hysteroscopy in gross cervical infection,
uterine infection & salpingitis.
 Role of antibiotics controversial.
Supportive studies in cases with RHD, CHD.
Suspected chronic endometritis
Submucous myomas procedure
Imbedded IUDs.
ACOG guidelines do not recommend routine prophylactic
antibiotics for hysteroscopy.
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59. 2. Vaginal Discharge,
Vaginal discharge is common after any ablative
procedure and is usually self limiting.
3. Hematometria
If obstruction of the internal OS secondary to
adhesion due to hysteroscopic surgery.
Isthmus region and cervical canal
should be avoided during resection.
Late Onset Complications
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60. 4. Adhesion Formation
Intrauterine adhesions are common especially
after myomectomy when two fibroids are
situated on opposing uterine walls.
After lysis of IU adhesion, excessive endomet-
rial resection.
Prevention:
Cyclical hormone tablets to facilitate the
growth of the endometrium
Insertion of IUCD
Late onset complications
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61. Complications can never be avoided
completely & 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.
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