Laparoscopic Articles from Laparoscopy Hospital

Dr MONA AL-AIRAN MBBS,ARBD ,SABD, DMAS
Associate consultant in obstetrics & gynaecology and laparoscopic surgeon

BACKGROUND

Complications due to hysteroscopy are relatively rare events. They occur more frequently with operative hysteroscopy than with diagnostic hysteroscopy. Exact complications rates are difficult to determine owing to the natural tendency to report successes but not complications. Recognition of these situations will lead to prevention; in fact, all the most serious complications of operative hysteroscopy can be avoided when proper precautions are taken and close communication is maintained among gynaecologic surgeon, the anaesthesiologist and nursing staff.

Abstract

Objective:

To evaluate the rate of uterine perforation during different operative hysteroscopic procedures, whether it can be predicted by specific patient characteristics or type of hysteroscopic procedure and risks of uterine rupture during subsequent pregnancies. Methods: A web search was performed to identify the relevant publications with no limitations of languages from Jan 1995 till august2008.

Conclusion:

The incidence of complications from hysteroscopy varies widely by institution and operative procedure. The risk of uterine perforation was higher during hysteroscopic adhesiolysis than during other procedures. Uterine perforation and/or the use of current monopolar section during operative hysteroscopy increase the risk of uterine rupture in subsequent pregnancy.

Keywords

complication in hysteroscopic procedures, uterine perforation subsequent pregnancy outcome , Metroplasty , Uterine rupture & Synechiae.

Introduction:

Hysteroscopy is the gold standard method for the abnormal uterine bleeding. Hysteroscopy is an important diagnostic and therapeutic tool for patients presenting with intrauterine diseases. During the past decade, the number of gynecologists doing operative hysteroscopy and the number of procedures done have increased. The incidence of complication from the hysteroscopy varies widely by institution and operative procedure. Appropriateness and safety of hysteroscopy depend on predicting complications (1)

Materials and Methods

A literature search was performed using Highwire press, Springerlink, Pubmed and the search engine Google. The following search terms were used: hysteroscopic surgeries (diagnostic procedure, polypectomy, myomectomy, endometrial ablation, uterine septum resection, lysis of adhesions, endometrial curettage), hysteroscopic complication (uterine perforation) risk factors for uterine perforation and for uterine rupture and uterine rupture with subsequent pregnancy. Three handerd citations used matching the above criteria, the institution where the study was done plus good patients number.

Discussion

Minimally invasive procedures have many benefits compared with traditional procedures, including lower costs, shorter hospital stays, and shorter recovery time. Complications during hysteroscopic surgery are rare (1) The incidence of complications from hysteroscopy varies widely by institution and operative procedure (1,9). Operative complications occurred in 2.7% hysteroscopies, excessive fluid absorption was the most frequent complication.(1)

Hysteroscopic myomectomy and resection of uterine septum were associated with greater odds of complications (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.3, 16.6 and OR 4.0, 95% CI 0.9, 19.6, respectively). Hysteroscopic polypectomy and endometrial ablation were associated with lower odds of complications (OR 0.1, 95% CI 0.0, 0.7 and OR 0.4, 95% CI 0.1, 3.3, respectively). Hysteroscopies done by reproductive endocrinologists and preoperative GnRH agonist therapy were associated with 4–7 times higher odds for operative complications(1) Excessive glycine absorption occurred only in more complex procedures, including myomectomy, uterine septum resection, and endometrial ablation, diagnostic hysteroscopy with or without D&C and polypectomy had low risks of complications,(1). American Association of Gynecologic Laparoscopists member survey reported 17,298 operative hysteroscopies with a complication rate of 3.8%, including perforation in 1%, hospital admission in 0.7%, hemorrhage in 0.2%, and unplanned laparotomy in 0.2% of women.(2) The most important complications were (1.7%) uterine perforations, (6.9%) intraoperative haemorrhages and (5%) excessive hypotonic fluid absorptions.(3)

Risk factors for uterine perforation

Belloni recorded 1.7% (2), similar to Agostini reported 1.6% uterine perforation (3, 11) Perforation risk was higher during hysteroscopic adhesiolysis than during other procedures [endometrial ablation RR 9.39 (3.46-25.52), p <0.0001; uterine septa section RR 6.78 (0.91-50.6), p = 0.026; polyp RR 8.52 (2.60-30.80), p <0.0001 or myoma resection RR 7 (2.83-17.62), p <0.0001](4),(9,11).Frank found the most frequent surgical complication was perforation of the uterine cavity (rate 0.76%)(5).Approximately half of the perforations were entry-related. , attentionhas to be paid to the method of entry with the hysteroscope (ie, no unnecessary dilation of cervix and introduction of the scope under direct vision(5), The other half of complications were related to surgeons’ experience and type of procedure. (Obstet Gynecol 2000; 96:266–70. © 2000 by The American College of Obstetricians and Gynecologists.)(5,9). The total complication rate was 3%, with 1% of uterine perforations, two-thirds of the complications were related to cervical dilation or uterine entry, and infertility was found to be a risk factor(6). Efforts therefore should be focused on identifying the patients at risk and finding novel techniques for cervical priming (6).In most German centers, hysteroscopy is just being established. Nevertheless, the rate of complications such as perforation of the uterus, fluid-overload syndrome, infection and preoperative bleeding is small. This may be due to the high proportion of documented procedures performed by the more experienced centers (7).

Prevention of uterine perforation

To avoid any problems concerning the application of hysteroscopic procedures, it is important to take the necessary precautions both preoperatively and intraoperatively. For example, the preoperative use of thinning agents of the endometrium and the reduction of the operating time, or the avoidance of cutting too deeply into the myometrium, are some of the parameters to be considered when hysteroscopy is in argument(8). Using monopolar cutting devices and saline-free distension media, hysteroscopic surgery bears specific risks. The knowledge of these risks is important to avoid typical complications of operative hysteroscopy (10).

Management of uterine perforation

Complications during hysteroscopic surgery include) excessive glycine absorption, uterine perforation, technical problems,bleeding and postoperative sepsis. Imbalances were identified quickly and treated. Among women with excessive glycine absorption, the lowest serum sodium recorded was 126 mEq/L, hysteroscopic surgery is to stop the procedure when the glycine deficit is 1 L or greater. Serum sodium levels decrease about 10 mEq/L for every 1 L of hypotonic fluid (1).

When perforations occurred during the dilation of the cervical channel. Since the distention of the uterine cavity could not be achieved, the procedures were stopped. In patients intraoperative bleeding could not be controlled with electrocautery. In these cases in the operating room a Foley catheter was inserted into the uterine cavity and the bulb inflated with 10 to 30 mL of liquid to tamponade the bleeding. The catheters were removed 12 to 24 hours later(2).

Risk factors for uterine rupture in subsequent pregnancy

Uterine ruptures secondary to operative hysteroscopy are rare but serious. They can occur before onset of labor, and compromise vital maternofetal outcome. Hysteroscopic metroplasty subjected patients to high risks of uterine rupture during subsequent pregnancies (12). Uterine perforation and/or the use of electrosurgery increase this risk but are not considered an independent risk factor (12). Uterine perforation and/or the use of current monopolar section during operative hysteroscopy increase this risk. Uncomplicated hysteroscopic resection of submucous myomas and endometrial polyps do not alter obstetrical outcome (13).

The late complications of operative hysteroscopy result from either persistent endometrium after ablation or myometrial damage during surgery. Residual endometrium can become neoplastic, cause pain, or support a pregnancy. Myometrial damage can produce catastrophic consequences during a later pregnancy (14). Surgical correction of the complete uterine septum with preservation of the cervical septum is associated with low morbidity and satisfactory postoperative obstetric outcome (15).

Prevention of uterine rupture

Apart from favourable use of scissors for hysteroscopic metroplasty, no accurate methods to prevent or detect impending ruptures in subsequent pregnancies were found (12). Physicians providing care for patients with previous hysteroscopic metroplasty or complicated operative hysteroscopy, should be aware of the potential risks for uterine rupture during pregnancy (12). Considering hysteroscopic metroplasty, the use of coaxial bipolar electrode should be preferred (13). The obstetrician’s vigilance in this context must be extreme searching for the least clinical sign in favor of a pre-rupture of the uterus. Furthermore, systematic caesarean is not justified (16).

Fluoroscopically Guided Hysteroscopic Division of Adhesions in Severe Asherman Syndrome

This technique provides an intraoperative fluoroscopic view of pockets of endometrium behind an otherwise blind-ending endocervical canal in women with severe Asherman syndrome, allowing guided division of adhesions and reducing the likelihood of perforation and formation of false passageways (17).

Conclusion

Complications during hysteroscopic surgery are rare. The incidence of complications from hysteroscopy varies widely by institution and operative procedure. Perforation risk was higher during hysteroscopic adhesiolysis than during other procedures. The preoperative use of thinning agents of the endometrium and the reduction of the operating time, or the avoidance of cutting too deeply into the myometrium, are some of the parameters to be considered when hysteroscopy is in argument. Uterine perforation and/or the use of current monopolar section during operative hysteroscopy increase this risk. Uncomplicated hysteroscopic resection of submucous myomas and endometrial polyps do not alter obstetrical outcome. Myometrial damage can produce catastrophic consequences during a later pregnancy. The obstetrician’s vigilance in this context must be extreme searching for the least clinical sign in favor of a pre-rupture of the uterus. Furthermore, systematic caesarean is not justified.

References

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•  Hulka JF, Peterson HB, Phillips JM, Surrey MW. Operative hysteroscopy. American Association of Gynecologic Laparoscopists 1991 membership survey. J Reprod Med 1993;38:572–3.

•  Belloni C,Pasini A, Intraoperative complications of 697 consecutive operative hysteroscopies Minerva Ginecol. 2001 Feb;53(1):13-20.

•  Agostini A, Cravello L, Bretelle F, Shojai R, Roger V, Blanc B Risk of uterine perforation during hysteroscopic surgery J Am Assoc Gynecol Laparosc. 2002 Aug;9(3):264-7

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•  Jonathan DBe, and thierry g. V, instruments & methods fluoroscopically guided hysteroscopic division of adhesions in severe asherman syndrome.