Complications of hysteroscopy

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Complications of hysteroscopy
Dr .Ashraf Fouda Damietta General Hospital E.
mail ashraffoda_at_hotmail.com
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INTRODUCTION

• Complications may occur in diagnostic or
  operative hysteroscopy.
• The complication rate in diagnostic hysteroscopy
  is low and was estimated by Lindemann (1989) to
  be 0.012 .
• Complications from operative hysteroscopy are
  more common and potentially more serious.

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Complications may result from
(Taylor Gordon, 1994)

• Anesthesia
• Positioning the patient
• The distension media
• The surgery
• Uterine perforation
• Haemorrhage
• Delayed complications
• Infection
• Adhesion formation
• Failure of resolution of the presenting symptoms

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THE ANAESTHETIC

• The risks to the patient from the anesthetic are
  similar to those from any other operation.
• The complications which are specific to
  hysteroscopic surgery are those which may present
  as shock resulting from
• Uterine perforation or
• Injury to a major vessel or from
• Fluid overload.

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THE ANAESTHETIC

• The anesthetist may be the first to recognize
  the onset of danger and may recommend that
  the surgeon discontinue the procedure and to
  institute appropriate treatment.

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POSITIONING THE PATIENT

• Incorrect positioning of the patient may result
  in
• Nerve injuries
• Back injuries
• Damage to soft tissues
• Deep venous thrombosis (DVT)

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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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1. Nerve Injuries

• 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.

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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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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.

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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.

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THE DISTENSION MEDIA

• Complications produced by the distension media
  are specific to hysteroscopic surgery.
• It is essential that all the operating room staff
  should know the side effects of the distension
  media.

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THE DISTENSION MEDIA

• The nature of the complications depend on the
  type of medium in use.
• The medium may be carbon dioxide (CO2) in the
  case diagnostic hysteroscopy or fluid in both
  diagnostic and operative procedures.
• The fluid may be of high or low molecular weight.

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• If excessive amounts of distension
  media are absorbed the
  following complications may occur

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1. Carbon dioxide.

• Cardiac arrhythmia may occur with diagnostic
  hysteroscopy.
• The complication should be extremely rare if the
  correct insufflator is used.
• The hysteroflator delivers CO2 at a rate of not
  more than 100ml per minute whereas the
  laparoflator can deliver 1-6 litres in the same
  time.

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1. Carbon dioxide.

• A laparoflater should NEVER be used for
  hysteroscopy.
• It is rare for CÓ2 to produce any side effects if
  gas embolism of less than 400ml occurs.

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2. High molecular weight fluidsDextran

• Dextran is popular in some countries for both
  diagnostic and operative hysteroscopy when
  mechanical instruments are used.
• It may produce an
• Anaphylactic reaction,
• Adult onset respiratory distress syndrome (ARDS)
  or
• Pulmonary oedema.

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2. High molecular weight fluidsDextran

• Anaphylaxis should be treated by the
  administration of
• Oxygen,
• Antihistamines,
• Glucocorticoids and
• Intravenous fluids.

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2. High molecular weight fluidsDextran

• Adult onset RDS requires the administration of
• Glucocorticoids,
• Oxygen and, occasionally,
• Assisted respiration.

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3. Low molecular weight fluids.

• Saline may be used with the laser
• But only non-electrolytic fluids should be used
  with electrosurgery because of the risk of
  producing burns to other organs.
• All low molecular weight fluids may produce fluid
  overload.

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3. Low molecular weight fluids

• Accountancy of fluid input and output is
  mandatory in any hysteroscopic procedure.
• The severity and management of fluid overload
  depends on the nature of the medium in use.

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Saline overload

• Produces a
  simple hypervolaemic state which may be treated
  by
• Insertion of a central venous line,
• Administration of
  a diuretic, oxygen and, if necessary, cardiac
  stimulants.

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Saline overload

• A blood pressure cuff may be applied to each limb
  to occlude venous return which, in effect,
  performs a bloodless phlebotomy.

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Overload with sorbitol

• May produce hypoglycaemia in the diabetic
  patient, haemolysis or signs of hyper-volaemia.
• Hypoglycaemia should be treated with
  administration of glucose, measurement of blood
  sugar levels and restoration of euglycaemia.

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Overload with glycine

• May produce
• Nausea and vertigo,
• Hyponatraemia,
• Transient hypertension followed by hypotension
  associated with confusion and disorientation.
• Excessive overload may produce elevated blood
  ammonium levels leading to encephalopathy and,
  rarely, death.

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Overload with glycine

• Hyponatraemia should be treated with
  administration of diuretics and hypertonic saline
  solution combined with monitoring of serum
  electrolyte levels until normality has been
  restored.
• Encephalopathy requires haemodialysis to be
  performed.

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Fluid Overload

• Usually occur in the immediate post-operative
  period.
• The surgeon and/or anesthetist have the
  responsibility to begin resuscitative procedures
  and seek appropriate advice and help from their
  colleagues in internal medicine.
• If such complications should occur during the
  procedure, surgery must be abandoned.

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Prevention of Fluid Overload

• May be accomplished by
• Using appropriate distension media and delivery
  systems
• Keeping operating times to a minimum
• Avoiding entering the vascular channels
• Keeping fluid pressures below 80mmHg and gas
  pressures below 100mmHg.
• Meticulous accountancy of fluid balance.
• The procedure must be abandoned if the deficit
  rises to 2 litres or there is evidence of venous
  congestion..

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THE SURGERY

• Complications of surgery may arise during the
  operation or be delayed.
• Intra-operative complications include uterine
  perforation and haemorrhage.
• Delayed complications include infection,
  discharge and adhesion formation.

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1. Uterine Perforation

• The incidence of perforation is about 0.8 (Hill
  et al, 1992).
• In the British Mistletoe study perforation
  occurred in 0.64 and 0.65 of cases respectively
  with roller ball and laser but in 1.29 and 2.47
  of cases when roller ball and loop or loop alone
  were used (Maresh 1996).

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1. Uterine Perforation

• The uterus may be perforated by
• A dilator,
• The hysteroscope or
• A surgical instrument.

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1. Uterine Perforation

• The management will depend on the
• Size, method and site of the perforation,
• Whether there is risk of injury to another organ
  and
• Whether or not concomitant observation with a
  laparoscope was being performed.

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1. Uterine Perforation Simple
perforation

• Simple perforation may be made with a cervical
  dilator or with the hysteroscope.
• Perforation should be suspected if the dilator
  passes to a depth greater than the length of the
  uterine cavity.
• Perforation with the hysteroscope should be
  avoided by always introducing the telescope under
  direct visual control.

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1. Uterine Perforation Simple
perforation

• Simple perforation rarely causes any further
  damage and may be treated conservatively by
  observation and appropriate broad spectrum
  antibiotics.
• Laparoscopy may be considered to exclude
  bleeding.

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1. Uterine Perforation Complex perforation

• Complex perforation may be made with
• Mechanical,
• Electrical or
• Laser instruments

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1. Uterine Perforation Complex
perforation

• It is unusual for perforation with scissors to
  cause injury to other organs although this may
  occur when dividing adhesions in cases of
  extensive Asherman's syndrome.
• Hysteroscopy in these cases should always be
  accompanied by laparoscopy to recognize impending
  or occult perforation.

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1. Uterine Perforation Complex
perforation

• Complex perforation caused by electrosurgical
  instruments or laser may be associated with
  thermal injury to adjacent structures including
  bowel or large vessels.

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1. Uterine Perforation
Laser

• Laser may produce thermal injury at a
  distance from the site of the perforation
  because, once the myometrium has been breached,
  it will vaporize the next surface in
  its path.
• Displacement of bowel from the pelvis does not
  protect it from laser burns.

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1. Uterine Perforation
Laser

• If perforation is suspected
• The energy source should be switched off and
• The hysteroscope left in situ unless
• Laparoscopic monitoring has been in progress in
  which case the telescope can be withdrawn.

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1. Uterine Perforation

• If the perforation has been caused by an
  electrosurgical instrument and concomitant
  monitoring has been performed, laparoscopic
  examination to exclude bowel injury
  may be all that is necessary.

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1. Uterine Perforation

• In the majority of cases of electrical injury,
  and in all cases where laser has been used
• Laparotomy and
• Detailed examination of the bowel, pelvic blood
  vessels and aorta is mandatory.

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2. Haemorrhage

• The prevalence of haemorrhage depends on the form
  of energy used for ablation.
• 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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2. Haemorrhage

• Intrauterine bleeding occurring during the
  procedure should be immediately obvious and
  can usually be controlled by spot
  electrocoagulation.

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2. Haemorrhage

• If coagulation fails to control the bleeding, the
  procedure may have to be abandoned and tamponade
  performed by inserting a Foley catheter and
  distending the balloon.
• The catheter should be left in situ for a few
  hours after which the bleeding nearly always
  stops.

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2. Haemorrhage

• Occasionally these simple measures fail to
  control haemorrhage.
• This may occur if resection has been carried out
  too deep into the myometrium and a plexus of
  vessels opened.
• In this case
• Hysterectomy,
• Ligation or
• Ultrasound guided embolization of the anterior
  branches of the internal iliac arteries may be
  necessary.

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2. Haemorrhage

• Less significant bleeding may be caused by
  tearing of the cervix with the tenaculum or
  uterine perforation.
• Lateral tears of the cervix may produce
• Significant bleeding and may also
• Lead to excessive absorption of the distention
  medium.

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LATE ONSET COMPLICATIONS

• 1. Infection
• Acute pelvic inflammatory disease is rare
  following hysteroscopic surgery.
• This may be prevented by prophylactic
  antibiotics.
• The diagnosis is made by the presentation of the
  classic symptoms and signs and
• Treatment should be by appropriate antibiotics
  following culture of vaginal swabs and blood.

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LATE ONSET COMPLICATIONS

• 2. Vaginal Discharge
• Vaginal discharge is common after any ablative
  procedure and is usually self limiting.

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LATE ONSET COMPLICATIONS

• 3. Adhesion Formation
• Intrauterine adhesions are common especially
  after myomectomy when two fibroids are situated
  on opposing uterine walls.
• In this case the myomectomy is better performed
  in stages to prevent adhesion formation.

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LATE ONSET COMPLICATIONS

• 3. Adhesion Formation
• An intrauterine device and
• Administration of oestrogen and progestogen
  therapy
• may help to prevent adhesion formation following
  
• Resection,
• Adhesiolysis or
• Division of a septum.

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FAILURE OF RESOLUTION OF THE PRESENTING SYMPTOMS

• The procedure may fail to cure the presenting
  symptoms.
• This may be because of poor patient selection or
  failure of the surgery.

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FAILURE OF RESOLUTION OF THE PRESENTING SYMPTOMS

• Approximately 15 of patients have an early
  pregnancy loss following septum resection (Taylor
  Gordon, 1993).
• There is also greater risk of third stage
  complications.

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FAILURE OF RESOLUTION OF THE PRESENTING SYMPTOMS

• Myomectomy for menorrhagia or infertility gives
  disappointing results.
• About 20 have no immediate improvement and 80
  fail to conceive.

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FAILURE OF RESOLUTION OF THE PRESENTING SYMPTOMS

• Endometrial ablation produces amenorrhoea in
  about 30 of cases and satisfactory improvement
  in about another 50.
• 10 will require further surgery which may be a
  repeat ablation or hysterectomy.

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FAILURE OF RESOLUTION OF THE PRESENTING SYMPTOMS

• Adhesiolysis for Asherman's syndrome is only
  curative in about 30-40 of cases.

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Thank you