Hysteroscopy: Managing and Minimizing Operative Complications

Mark H. Glasser, MD Chief, Department of Obstetrics and Gynecology Kaiser Permanente Medical Center OBGMANAGEMENT San Rafael, Calif

The surgeon may be fooled into thinking the hysteroscope is in the uterine cavity, since a false passage distends. If muscle fibers are visible and the tubal ostea are not, assume the passage is false. FAST TRACK Hysteroscopy: Ignoring contraindications Managing and minimizing is the single operative complications greatest factor leading to injury Techniques to assess the site, spot imminent perforation, and liability and avoid or correct the 5 most common types of problems.

ATTORNEY-OB/GYN ROUNDTABLE WHAT WENT WRONG? no bowel injury. After 24 hours of obser- ❙ Avoiding A 44-year-old woman undergoing resec- vation, she is afebrile without leukocyto- legal pitfalls tion of a submucous myoma from the sis. She is discharged with explicit Page 58 left cornual region has persistent bleed- instructions to return if she has symp- ing at the resection site. The surgeon toms suggesting bowel injury. She

continues coagulation at the bleeding returns in 72 hours, with abdominal pain IMAGE: KIMBERLY MARTENS site, using a rollerball electrode in an and low-grade fever. CT reveals extrava- attempt to achieve hemostasis, but per- sation of contrast from the left ureter in forates the uterus. Immediate the pelvis. Immediate laparotomy finds laparoscopy to identify collateral injury perforation of the left ureter secondary reveals some thermal damage on the to a thermal injury. She undergoes posterior leaf of the broad ligament, but ureteroneocystotomy and recovers.

42 OBG MANAGEMENT • February 2005 his case illustrates one of the most Contraindications common complications of operative Ignoring contraindications to hysteroscop- T hysteroscopy: uterine perforation ic surgery increases the risk of complica- with collateral injury. Both could have been tions and is the single greatest factor lead- avoided if the Ob/Gyn had stopped the ing to patient injury and physician liability. procedure when bleeding first occurred, Contraindications include: removed the instruments, and allowed the • Unfamiliarity with equipment, instru- uterus to contract spontaneously. ments, or technique This is just one of the strategies that • Lack of appropriate equipment or staff can reduce the risks of hysteroscopic sur- familiar with the equipment gery. Numerous reports confirm that oper- • Acute pelvic inflammatory disease ative hysteroscopy is safe and effective, but • Pregnancy as more gynecologists perform an increas- • Genital tract malignancies ing number of procedures, we must be • Lack of informed consent aware of potential complications and do • Inability to dilate the cervix our best to minimize risk to our patients. • Inability to distend the uterus to obtain Complications cannot be completely visualization avoided, and may occur when a procedure • Poor surgical candidates who may not is done correctly by experienced doctors. tolerate fluid overload because of renal They are far more likely if techniques or disease, or radiofrequency current equipment are used improperly. This arti- when a cardiac pacemaker is present cle describes ways to minimize risk. • The patient desires and expects com- When the American Association of plete amenorrhea3 Gynecologic Laparoscopists (AAGL) sur- veyed its members in 1993, it found a complication rate of 2% for operative hys- ❚ Mechanical or traumatic teroscopy.1 The rate of major complications—perforation, hemorrhage, fluid complications overload, and bowel or urinary tract These types of complications are among injury—was less than 1%. A prospective the most common. Other categories multicenter trial2 of 13,600 procedures in include preoperative complications (ie, the Netherlands found a higher complica- improper patient selection and lack of tion rate for operative (0.95%) than for informed consent), electrosurgical and diagnostic hysteroscopy (0.13%).

KEY POINTS ❚ ❚ Preoperative precautions Perform endometrial sampling for abnormal uterine bleeding before scheduling operative hysteroscopy. We can reduce the risk of complications if contraindications are not ignored, equip- ❚ Most uterine perforations do not require treatment— ment is thoroughly inspected and under- even those involving large dilators—although further stood, and the surgeon goes through a mental checklist and plans each procedure. assessment may be necessary to rule out bowel injury. A “time out”before the operation begins, ❚ when every member of the team is briefed, Most complications of electrosurgery involve activating is also valuable in preventing errors. an electrode at the time of perforation, or diverting current A hands-on course necessary before to the outer sheath. undertaking advanced resectoscopic surgery, to become familiar with equipment ❚ Scrupulously monitor fluid intake and output to prevent and techniques, followed by proctoring by hyponatremic complications. a surgeon credentialed for the procedure.

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FIGURE 1 injected at the 4 and 8 o’clock positions) Signs of a false passage can reduce the force needed to dilate the cervix.5 Half-size dilators may help; they also reduce the risk of cervical laceration.

Laceration of the cervix Although this is a minor complication, substantial bleeding sometimes occurs when the cervix is lacerated by the tenaculum. In these cases, suture the cervix. Occasionally, a touch of cautery from the rollerball electrode at low power (20 to 30 W) can control the bleeding. Silver nitrate sticks or ferric subsulfate Myometrial fibers signal that a false passage has (Monsel’s) paste are also effective on been created. Stop the procedure even if no perfo- superficial lacerations. ration is detected, to prevent distention fluid from being absorbed into the circulation through the injury. Bleeding from lower uterus or cervical canal can obscure view gaseous, complications related to disten- In some cases, bleeding is delayed, necessi- tion media, and postoperative complica- tating additional surgery. Intravasation of tions (ie, infection and late sequelae). distention fluid also can occur at these lacerations. Coagulation with the electrode Inability to insert the hysteroscope may be necessary when bleeding is heavy. This may be caused by a stenotic, nulli- parous cervix; menopause; GnRH ago- Check for collateral injury nists; previous cone biopsy, laceration, or when uterine perforation occurs cryosurgery; or an acutely retroflexed or Perforation is a well-documented risk of FAST TRACK anteflexed uterus. operative hysteroscopy and should be dis- When obtaining Acute flexion problems can be corrected cussed with the patient when obtaining using a long-bladed, open-sided Graves informed consent. In the AAGL survey,1 the informed consent, speculum deep in the anterior or posterior incidence of perforation was 14 per 1,000. advise the patient fornix. The speculum pushes the fundus to It was even higher during transection of lat- of the risk the midposition and facilitates dilation. eral and fundal adhesions: 2 to 3 per 100.6 Once the hysteroscope is inserted, remove Although perforation is more common of perforation. the speculum. with thermal energy sources, it may occur An AAGL survey Placing a tenaculum on the posterior mechanically when scissors are used to tran- found an incidence lip of the cervix of an acutely retroflexed sect a uterine septum, synechiae, or polyps. of 14 per 1,000 uterus will straighten the cervical canal When the cervix is stenotic or the uterus when traction is applied. is acutely ante- or retroflexed, sounds and Inserting a laminaria tent the evening dilators can perforate the uterus. before surgery helps dilate the cervix easily Most perforations—even those involv- and atraumatically.4 However, the laminar- ing large dilators—usually do not require ia can sometimes create a false passage, treatment, although further assessment leading to perforation. may be necessary to rule out bowel injury. Cervical ripening agents such as intravagi- Most perforations occur in the fundal nal or oral misoprostol (200 µg inserted region or posterior lower segment. vaginally or 400 µg orally 8 to 12 hours A false passage can be created when enter- preoperatively) also can facilitate dilation. ing the uterus. Occasionally the surgeon Intracervical injection of vasopressin solu- may be fooled into thinking the hystero- tion (4 IU in 100 cc sodium chloride, scope is in the uterine cavity, since the false

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passage distends (FIGURE 1). If muscle FIGURE 2 fibers are visible and the tubal ostea are Risk of myomectomy: not, assume the passage is false. Slowly Myometrial avulsion 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. 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 uter- Small bowel visible within the uterine cavity after ine fundus. avulsion of uterine wall at the time of myomectomy Often the external os opens, but the FIGURE 3 internal os cannot be dilated the extra 1 to 2 mm necessary to accommodate the 27- Use the hysteroscope French resectoscope. Rather than exert to assess perforation site 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 cir- cle” in the center of the field and slowly FAST TRACK advance the hysteroscope toward it until To prevent the cavity is reached. Avulsion of the myometrium sometimes myometrial occurs during removal of incompletely avulsion, keep resected myomas (FIGURE 2). Keep the Hysteroscopic view of perforation at the fundus. The the myoma grasper myoma grasper away from the fundus small bowel is visible beyond the perforation at left. when removing myoma segments, and away from avoid excessive traction on what may be a When perforation occurs during the use of the fundus thin segment of myometrium. Injuries can thermal energy, laparoscopy is necessary to when removing occur when the grasper perforates the assess the organs overlying the site.9 myoma segments uterus and bowel is inadvertently grasped. During setup for laparoscopy, bring the Large injuries require laparoscopic repair. hysteroscope near the area of perforation Perforation is more likely in repeat proce- to inspect the bowel beyond the uterus. dures. In a report of 80 repeat endometri- Since the pelvis fills quickly with distention al ablations, Townsend and colleagues7 fluid, the hysteroscope can even be placed noted 8 perforations that prevented com- through the perforation to yield an excel- pletion of the procedure. In a series of 75 lent view of the undersurfaces of the bowel repeat ablations compared with 800 pri- immediately adjacent to the injured area mary ablations by the same surgeon, the (FIGURE 3). (Disconnect the electrosurgical rate of serious perioperative complications cord before doing this!) was significantly higher in the repeat abla- Thorough laparoscopic inspection of tion group (9.3% versus 2.0%).8 the bowel in the pelvis often reveals ther-

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When perforation is imminent, the “serosal sign” appears

As the procedure progresses, the uterine serosa becomes visible from within the cavity, appearing as a smooth, bluish structure that can be moved with only slight pressure. As the ablation continues, the uterus perforates, necessitating laparoscopic inspection of the organs overlying the site.

Although the patient recovers, her menorrhagia eventually returns, and she opts for laparoscopically assisted vaginal hysterectomy 1 year later.

Uterine perforation is more likely during repeat procedures Prior to perforation, uterine serosa is visible through the This case illustrates one of the most common risks myometrium just above and behind the rollerball of operative hysteroscopy: uterine perforation, 42-year-old woman who underwent endometrial which occurs more frequenly in repeat procedures. Aablation 2 years earlier presents with persistent menorrhagia and a 12-week–size fibroid uterus and The case also highlights an important indicator of expresses a desire for repeat ablation. At the second perforation: the serosal sign, which I first described surgery, the uterine cavity appears scarred, with mul- in 1996.24 When the smooth, bluish structure tiple synechiae. appears, cease ablation in the region immediately.

mal injury, which appears as a whitish tion of fibroids. Bleeding sufficient to patch on the bowel serosa. To repair bowel require intervention occurs at a rate of FAST TRACK injuries, bring the injured segment out 0.5% to 1.9% in several reported series. Inform the patient through a minilaparotomy and excise the To achieve hemostasis via balloon tampon- damage with a 2- to 3-cm border. A gener- ade, insert a Foley catheter with a 30-cc of the potential for al surgeon should be called in to consult. balloon into the uterine cavity, inject 15 to delayed perforation If no injury is apparent, discharge the 20 mL (or more for a larger cavity) of fluid from thermal injury, patient but follow her closely, including into the balloon, and observe the patient.10 daily white blood cell counts for 4 to 5 If there is no bleeding in 1 hour, remove which can occur days. Instruct her to take her temperature half the fluid. Remove the remainder of the as late as 2 weeks twice daily and return to the hospital fluid and the catheter over the next hour if after surgery immediately if any signs of bowel perfora- no further bleeding occurs. tion develop. Delayed perforation from Alternative method: Pack the uterus. I pre- thermal injury can occur as late as 2 weeks fer 1/2-inch–gauge packing that has been following surgery, and the patient should soaked in a dilute vasopressin solution (20 be apprised of this possibility. U [1 mL] in 60 mL normal saline).11 The benefits of vasopressin. Before balloon Intraoperative bleeding is rare tamponade or packing the uterus, I inject Bleeding is unlikely unless vessels are lacer- very dilute vasopressin (4 U [0.2 mL] in 60 ated or injured in the cervical canal or mL normal saline) directly into the cervix lower uterine segment during dilation or 2 cm deep, at the 4 and 8 o’clock positions. deep ablation or vaporization. Bleeding is Phillips12 demonstrated a marked decrease more common when endomyometrial in blood loss during resectoscopic surgery resection is performed with the wire loop using this approach. I also do this routine- electrode or during ablation or vaporiza- ly prior to operative hysteroscopy, since

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the vasopressin-induced vasoconstriction Perforation with an active electrode reduces intravasation of distention media. This usually occurs when current is applied A vaporizing electrode may prevent signif- as the electrode is extended or the resecto- icant blood loss during myoma resection scope is moved toward the fundus. It can by sealing blood vessels as the tissue is be avoided if the electrode is activated only vaporized.13 All major manufacturers of when moving it toward the operator. hysteroscopic equipment produce these Perforations with intraabdominal electrodes. burns also have occurred during attempts In my series of 44 endometrial abla- to coagulate bleeders—especially in the tions and hysteroscopic myomectomies cornual regions. performed with the vaporizing electrode, blood loss was “minimal” or less than 50 Diversion of current mL in 29 cases. The maximum blood loss can be destructive was 300 mL in a patient with a 4-cm sub- Genital tract injuries have occurred as a mucous myoma who was managed emer- result of current diversion. Vilos and col- gently for hemorrhage.14 In another case, leagues16 reported 13 electrical burns dur- during resection of a 5-cm submucous ing endometrial ablation, and mention myoma, I encountered significant bleeding many more anecdotal reports. The usual from large vessels at the base of the cause: electrode insulation failure, which myoma, which required intrauterine tam- allows current to jump to the outer sheath ponade with a vasopressin-soaked pack. of the resectoscope. Preoperative measures may decrease vas- To avoid this, inspect all electrodes cularity. In their analysis of 16 randomized thoroughly before surgery and use them and nonrandomized controlled trials pub- only once. lished in the English literature between 1990 and 1996, Parazzini and colleagues15 Capacitative coupling found that preoperative danazol or GnRH also diverts current agonists decreased the thickness and vas- Since the sheath-within-a-sheath design of FAST TRACK cularity of the endometrium and shrank the resectoscope resembles a capacitor, Avoid perforating myomata, resulting in shorter operating high-voltage current can jump to the outer times, less blood loss, and less intravasa- sheath without direct contact from the the uterus tion of distending fluid. electrode. When Munro17 bench-tested by applying current electrosurgical generators and electrodes only when with and without insulation defects, he ❚ Electrosurgical found that capacitative coupling with the electrode intact electrodes occurred more frequently is moving toward and gaseous complications with high-voltage coagulation current than the operator, Most electrosurgical complications involve with lower-voltage cutting current. not the fundus activation of an electrode at the time of One way to avoid these injuries is to perforation, or current diversion to the activate the electrode intermittently, with outer sheath. short bursts, rather than rolling back and Thermal injuries also can be caused by forth over an area with continuous cur- overheating of the return pad or use of a rent. Another strategy is placing a damp weighted speculum that has not fully sponge in the posterior vagina extending cooled after removal from the autoclave. out the introitus; this protects the mucosa The latter can be avoided by immersing the and perineal skin—especially in obese entire speculum in cool saline for at least 1 patients. to 2 minutes prior to inserting it into the vagina. The blade cools much faster than How to avoid return-pad injuries the weighted ball, so be sure to check both Keep the patient’s thigh completely dry; to prevent a perineal or buttock burn. ensure that the pad is flat against the skin

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at application, with no bubbles or creases; Intracervical injection of dilute vasopressin and use only return electrode monitor prior to dilatation of the cervix creates vas- (REM) dispersive pads. cular spasm and may help prevent gas Especially when using vaporization from entering the circulation. electrodes, avoid prolonged activation of the electrode at high power. To minimize risk of vaporization, use a second disper- ❚ Complications sive pad connected to the first via a “y” connector to further disperse current and from distention media heat at the return pad. Excess absorption of distention media is Also, limit the use of coagulation cur- one of the most frequent complications. rent and use a maximum generator setting Most surgeons use low-viscosity, sodium- of 60 to 80 W in the coagulation mode. free fluids for operative hysteroscopy, since fluids that contain electrolytes are incom- Take steps to avert gas embolism, patible with monopolar electrosurgical but watch closely for signs instruments. The use of 3% sorbitol, 1.5% Initial reports of this potentially fatal com- glycine, or sorbitol-mannitol solutions can plication came mostly from laser ablation lead to dilutional hyponatremia and procedures, but gas embolism can occur hypoosmolality.18 Although the vast major- during all diagnostic and operative hys- ity of women quickly recover from these teroscopic procedures, especially the latter. conditions, some cases of permanent mor- Sources of gas embolism: room air, carbon bidity and even death have been reported.19 dioxide, carbon monoxide, and other The overall incidence of dilutional hypona- gaseous products of vaporization or tissue tremia was 0.2% in 1993, according to the combustion. The anesthesiologist is usual- AAGL member survey.1 ly the first to identify the signs. Signs of gas embolism. The surgeon Hyponatremia and hypoosmolality should ask to be immediately alerted to more likely in premenopausal women FAST TRACK any sudden fall in oxygen saturation, as These conditions may have catastrophic To reduce risk well as to hypotension, hypercarbia, consequences if they are not recognized arrhythmias, tachypnea, or a “mill wheel” and corrected promptly. The brain swells of gas embolism: murmur. If any of these signs are detected as it attempts to become isoosmotic with ❙ Avoid Trendelenburg and a gas embolism is suspected, stop the the vascular system. If swelling exceeds positioning procedure and ventilate the patient with 5%, the risk of severe neurological damage ❙ Remove last dilator 100% oxygen. dramatically increases. just before inserting Carbon dioxide is a soluble gas, so This is an important problem in pre- these emboli generally resolve rapidly. In menopausal women, since estrogen and the resectoscope contrast, room air emboli are more likely progesterone inhibit sodium-potassium ❙ Limit repeated to be fatal. adenosine triphosphatase (ATPase) activity removal-reinsertion Reduce the risk of air embolism by avoid- in the brain. This sodium pump protects of the resectoscope ing the Trendelenburg position and leaving the brain against cerebral edema, which the last dilator in the cervix until just can cause herniation of the brain stem and ❙ Vaporizing myomas before inserting the resectoscope. death. Although men and postmenopausal eliminates the need Also limit repetitive removal and rein- women develop dilutional hyponatremia, to remove fibroid chips sertion of the resectoscope, as often occurs they are less likely to suffer brain damage during myoma resection. By vaporizing because the sodium pump is intact. ❙ Intracervical injection rather than resecting myomas, it is possible Taskin et al20 conducted a randomized of vasopressin to eliminate the need to continually trial showing an increase in the sodium- may block gas from remove fibroid chips. Preoperative GnRH potassium ATPase pump activity and entering circulation agonists narrow venous sinuses and help decreased volume deficit during hystero- prevent this complication. scopic surgery in patients pretreated with a

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GnRH agonist, compared with a control patients without fibroids a single injec- group. This increased pump activity in the tion 4 to 6 weeks prior to the procedure. brain and endometrium may decrease • Place a fluid-collection drape or a larg- women’s susceptibility to hyponatremic er, plastic Mayo stand cover with the complications and brain damage. bottom cut off under the patient’s but- Vigilant monitoring of fluid intake/output tocks so that fluid drains into a “kick” during hysteroscopic surgery is necessary bucket. Also adjust the resectoscope’s to prevent hyponatremic complications. outflow tubing to drain into the collec- Avoid the pitfall of erroneously attributing tion bag, which should be kept on con- deficits to fluid “in the drapes” by using stant suction to the flow-stat electronic drapes with a fluid-collection pouch. fluid monitor. The standard of care is use of electron- • Continuously record inflow and out- ic inflow-outflow measuring systems. flow using the electronic monitor with Manufacturers of hysteroscopic equipment the deficit alarm set to 500 mL. offer highly accurate electronic fluid mon- • Keep distention fluid at room tempera- itoring systems that measure the weight of ture and monitor the patient’s core the distending fluid infused and collected temperature continuously. Significant rather than relying on manual estimation fluid intravasation will lower the of deficit. The latter method may be inac- patient’s temperature, and this may be curate since the volume of the supply bag the first sign of fluid overload. can vary by as much as 10%. • Perform operative hysteroscopy under Adjust intrauterine pressure to reduce the spinal or epidural anesthesia so the likelihood of intravasation. High intrauter- anesthesiologist can continually assess ine pressure may be desirable for visualiza- the patient’s sensorium. Confusion and tion, but it greatly increases the risk of irritability are early signs of dilutional intravasation. hyponatremia. I adjust pressure and flow rates by • If the fluid deficit reaches 750 mL, opening or closing the inflow and outflow immediately give 20 to 40 mg of intra- valves of the resectoscope until slight venous furosemide and draw a serum FAST TRACK amounts of bleeding from resected tissue sodium. Do not wait for the result of Continuously can be visualized. Since intrauterine pres- the sodium level before treatment, sure is extremely difficult to monitor accu- since a 5- to 20-minute delay can be record inflow rately during operative hysteroscopy, this catastrophic. and outflow practice ensures that it remains below the • Interrupt the procedure for 5 to 10 using electronic patient’s mean arterial pressure, thus mini- minutes to allow the uterus to contract mizing the risk of intravasation. and to seal off small blood vessels. monitoring with Use a dilute vasopressin injection to con- • Discontinue the procedure if the fluid the deficit alarm strict blood vessels and decrease the chance deficit reaches 1,500 mL or if the serum set to 500 mL of intravasation. sodium level is below 125 mEq/L. Vaporizing electrodes for myoma resection I do not limit the duration of resecto- and ablation seal blood vessels and reduce scopic procedures as long as fluid deficits fluid absorption. are below 750 mL, as measured by electronic fluid monitor. I also ensure that the Guidelines for distention media operating room staff is well educated in the To reduce the likelihood of these complica- use of the monitor and able to trouble- tions, I recommend that surgeons: shoot intraoperatively. • Draw preoperative serum electrolytes If the machine fails during the proce- for a baseline in all patients. dure, reset it with the alarm limit lowered • Give all patients with myomas 2 month- to reflect the deficit recorded before failure. ly injections of depot leuprolide acetate Monitor the color of the outflow fluid. (3.75 mg intramuscularly). Give Excessive blood loss counted as part of the

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outflow can occasionally mask a distention discharged on doxycycline (100 mg twice fluid deficit. daily for 7 days).

Choosing a distention medium Be alert for endometrial cancer There is no ideal distention medium for This malignancy has been diagnosed at the monopolar operative hysteroscopy. Several time of endometrial ablation and reported authors have suggested that 5% mannitol is in patients who have undergone prior advantageous since it is isosmolar and acts endometrial ablations or fibroid resec- as an osmotic diuretic. However, it does not tions. Thus, endometrial sampling should prevent hyponatremia. The main disadvan- be part of the workup of abnormal uterine tage of 5% mannitol is its high cost and lim- bleeding before the patient is scheduled for ited availability in 3-L bags or 4-L bottles. operative hysteroscopy. In women at high The use of bipolar devices in normal risk for endometrial cancer, perform office saline prevents dilutional hyponatremia, diagnostic hysteroscopy, with directed but fluid deficits must still be monitored biopsy of any suspicious areas. electronically so they do not exceed 2,000 When viable endometrial glands are mL. The false sense of security that may “buried” during ablation, or synechiae occur when normal saline is used for dis- develop, preventing the egress of blood, tention may lead to inaction when a large there is a chance that diagnosis of deficit occurs. This can lead to pulmonary endometrial cancer will be delayed. edema and death. However, this theoretical fear has not been proven clinically. Patients whose abnormal bleeding ❚ Postoperative recurs after ablation should undergo sampling and office hysteroscopy, just as if and late complications they had not undergone a previous abla- These include infection, endometrial can- tion. Theoretically, women who undergo cer, iatrogenic adenomyosis, hematome- endomyometrial resection or vaporization FAST TRACK tria, post-ablation tubal ligation syn- should have a lower incidence of endome- To prevent drome, and pregnancy. trial cancer, since the tissue most suscepti- ble to malignancy is removed. This has not infection, give Infection rate is 0.3% to 2% yet been proven scientifically. 1 g ceftizoxime Infection is relatively rare following In their comprehensive review of late intravenously endometrial ablation, with a rate of complications of operative hysteroscopy, 0.3% to 0.5% reported in most series. Cooper and Brady21 suggest that patients 30 to 60 minutes Endometritis, parametritis, and pyometra at high risk for endometrial cancer who before surgery are more common following resection of present with abnormal uterine bleeding submucous myomas, with rates as high as not controlled by hormones might be bet- 2% reported. ter served by hysterectomy. Unfortunately, Infection is more likely after pro- these patients tend to be high-risk surgical longed procedures, especially when the candidates. hysteroscope is repeatedly inserted and If atypia is present, do not perform removed. It also is more likely if the endometrial ablation or resection. I do per- patient has a history of pelvic inflammato- form ablation and resection in patients ry disease. I generally administer prophy- with complex hyperplasia without atypia if lactic antibiotics (1 dose of intravenous it has been reversed with progestin and ceftizoxime, 1 g, approximately 30 to 60 does not recur for at least 6 months with- minutes prior to surgery). out progestin therapy. These patients I also insert a laminaria tent the undergo office hysteroscopy and sampling evening prior to surgery. Patients with a of the endometrium before operative hys- history of pelvic inflammatory disease are teroscopy is scheduled.

CONTINUED

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Iatrogenic adenomyosis endometrium to collapse around the Two theories suggest this is a late complica- rollerball. A short burst of current is then tion of operative hysteroscopy. According applied to ablate the tissue. to the first, when the endometrium is This complication is less likely after incompletely resected, scarring over this tis- hydrothermablation, since the free-flowing sue causes the viable glands to grow into saline ablates the cornua completely. After the myometrium. The other theory suggests more than 50 hydrothermablations per- that viable endometrial debris is transport- formed in patients with prior tubal steril- ed into the myometrium by vessels opened izations, I have not seen any cases of post- at resection. ablation tubal ligation syndrome. I have found that using the vaporiza- Treatment consists of bilateral salpingecto- tion electrode followed by application of my or tubal fulguration at the cornual a rollerball over the surface of the cavity region and repeat ablation or resection of most effectively reaches maximal tissue viable endometrial tissue. Another option depth and, theoretically, prevents adeno- is hysterectomy. myosis. Since most adenomyosis occurs on the posterior wall, I take a strip from Post-ablation pregnancy this area for pathologic analysis to deter- can be very complicated mine whether adenomyosis preceded the Pregnancy after endometrial ablation ablation or developed subsequent to it. occurs at a rate of 0.2% to 1.6%. Counsel patients that this procedure does not pre- Hematometria vent pregnancy and that contraception is This can occur following operative hys- vital. Uterine rupture after fibroid resec- teroscopy if viable glands are left in the fun- tion has been reported. dal or cornual region and synechiae devel- In a review of 37 post-ablation pregnan- op in the lower segment, preventing egress cies, only 11 of 17 women who chose not to of blood. It also can occur if the upper terminate carried the gestation beyond 28 endocervix is ablated and subsequently weeks. In addition, there was a high inci- FAST TRACK scars, causing stenosis. To avoid this, ablate dence of intrauterine growth restriction, pre- Forewarn patients only to the level of the internal os. maturity, and placenta accreta.22 Diagnosis and treatment. Hematometria Hysteroscopic tubal sterilization with the that endometrial can be diagnosed easily by ultrasound and Essure system (Conceptus, San Carlos, ablation does not treated with office hysteroscopy using a Calif), or laparoscopic tubal fulguration cancel out narrow-diameter, rigid, continuous-flow performed at the time of ablation averts hysteroscope with an operating channel to these complications. all possibility pass small instruments. of pregnancy—and that contraception Post-ablation tubal ligation syndrome ❚ Complications is vital This is cornual hematometria that devel- ops when viable endometrial cells are left of global ablation in the cornua when the cavity also contains Global ablation technologies were devel- synechiae, causing cyclic bleeding. Since oped to enable gynecologists with limited there is no egress from the cervix or tubes, operative hysteroscopy skills to perform blood gradually builds up, leading to endometrial ablation and to make ablation hematosalpinx and pain. One way to safer for the patient. These technologies avoid this is to ensure complete ablation of completely eliminate the risk of distention- the cornual endometrium. media complications, but widespread use Prevention. Some experts recommend that has resulted in other complications that the small rollerball electrode be placed have been reported in the literature to only in the cornua, with slightly reduced a limited extent. intrauterine pressure, to allow the cornual Most published articles on global

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endometrial ablation are from the original 5. Phillips DA, Nathanson HG, Millim SJ, et al. The effect of dilute vasopressin solution on the force needed for US Food and Drug Administration (FDA) cervical dilatation: a randomized controlled trial. trials, in which the complication rates were Obstet Gynecol. 1997;89:507–511. extraordinarily low. Widespread commer- 6. Valle RF, Sciarra JJ. Intrauterine adhesions; hysteroscopic diagnosis, classification, treatment, and repro- cial use of these technologies since FDA ductive outcome. Am J Obstet Gynecol. approval, especially by practitioners with 1988;158:1459–1470. 7. Townsend DE, Quinlan DJ, Johnson GH. Repeat limited skills, has increased complications. endometrial ablation. Presented at the World Congress of Hysteroscopy, Miami, Florida, 1996. Do not override safety systems 8. MacLean-Fraser E, Penava D, Vilos GA. Perioperative complication rates of primary and repeat hysteroscop- Complications are more frequent when ic endometrial ablations. J Am Assoc Gynecol devices are misused or safety systems over- Laparosc. 2002; 9:175–177. 9. Loffer FD. Complications of hysteroscopy—their ridden. And, fear of litigation makes physi- cause, prevention, and correction.J Am Assoc Gynecol cians unwilling to report complications. Laparosc; 1995;3:11–26. 10. Goldrath MH. Uterine tamponade for the control of In the FDA Manufacturer and User acute uterine bleeding. Am J Obstet Gynecol. Facility Device Experience (MAUDE) 1983;147:869–872. database (www.fda.gov.cdrh/maude.html), 11. Townsend DE. Vasopressin pack for treatment of bleeding after myoma resection. Am J Obstet Gynecol. complications include bowel burns after 1991;165:1405–1407. unrecognized perforation, and bowel 12. Phillips DR, Nathanson HG, Milim SJ, et al. 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