COMPLICATIONS/ DIFFICULTIES

IN HYSTEROSCOPY

Dr Santosh JaybhayeMBBS;DGO;FCPS;PGDMLS

Dip. Gyn Endoscopy( Germany)Director : Om Sai Hospital &

Advanced Gyn. Endoscopy Centre

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

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.

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 selectionLack of trained support staff

Preoperative PrecautionsProper informed consent.Adequate preoperative counsellingAdequate training of surgeon and support

staffGood quality equipmentsProper case selection

Classification of complicationsA) Entry Related Mechanical Problems1) Entry Related Trauma/ Perforation .2) Failed Entry/ false passageB) Method Related Complications 1) Technique Related Perforation Haemorrhage Vasovagal Shock Gas Embolism 2) media related complication 3) electromechanical injuriresC) Delayed post operative complications: Infections Endometrial Cancer Upstaging Itrogenic Adenomyosis Hematometra Post Endometrial Ablation Tubal Ligation Syndrome Pregnancy Related Concerns

A) Entry Related Mechanical Problems

Entry Related Trauma/ Perforation :Cervical laceration & bleedingEntry related perforation: Due to excessive force during dilatation Force applied in wrong direction during dilatation.

Almost 50% of total hysteroscopy perforations occurs during entry

Failed Entry/ false passage Causes: Stenotic cervix.Nulliparous cervix.Menopausal flushed cervix.Previous surgeries like cervical

biopsy, cone biopsy, cryosurgeryAcute anteflexion or reteroflexionPrior use of GnRH agonist.

Ways to tackle difficult entryCervical TractionLaminaria TentsMisoprostol 200 mcg vaginally 8 hrs before

surgeryVasopressin 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:

Troubleshooting in difficult dilatation

False passageUsually 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

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

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.

Method related complicationsB) Method Related Complications 1) Technique Related Perforation Haemorrhage Vasovagal Shock Air Embolism 2) Media related complication 3) electromechanical injurires

PerforationIncidence: 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

Procedure related risk of perforationPROCEDURE PERCENTAGE RISK OF

PERFORATION

ADHESIOLYSIS 4.48%

TRANSCERVICAL RESECTION OF ENDOMETRIUM

0.8%

MYOMECTOMY 0.75%

POLYPECTOMY 0.38%

REPEAT ADHESIOLYSIS 9.3%

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’sCa EndometriumAcute anteversion/ reteroversionOperator related: Undue force , Lack of adequate

training

Management of perforation during hysteroscopy

Intraoperative haemorrhage

Second most common complication

About 0.5 to 1.9% cases need intervention to

stop bleeding

Common in myomectomy & TCRE

Management strategiesA)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

Vaso vagal shock

Causes: inadequate anaesthesiaCervical dilatation during office hysteroscopy

( rare)symptoms

Usually accompanied by nausea, dizziness , pallor & sweating

Treatment:Stop the procedureLeg raising / Trendlenberg’s position.Fluid administration.Atropine ( in case of severe reaction)

Air EmbolismPotentially serious & occassionally lethal

complicatioNSigns & Symptoms: sudden decrease in ETCO2 Bradycardia Hypoxia Precordial mill wheel murmur (classic sign

of air in heart).

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

Management ProtocolStop procedureCall for helpDurant’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

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).

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

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.

OPTIONS AVAILABLEElectronic Inflow Outflow Monitoring System.Collection of outflow fluid in a Measuring

container/ suction bottle/ commercially available plastic pouch like drapes

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.

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

Late postoperative complicationsInfections

Upstaging of endometrial cancer

Iatrogenic endometriosis

Hematometra

Pregnancy related concerns