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ESGE classication of submucosal broids
Table 1
Type 0 Pedunculated submucosal broids without
Type I When the submucosal broid is sessile and
Type II When the submucosal broid is sessile and
Fig. 1 Submucosal broid classication (FIGO)
signicant intramural extension
the intramural part is less than 50% of the
myoma volume
the intramural portion is equal to or more
than 50% of the myoma volume
3 Patient Selection
andIndications
forHysteroscopic
Myomectomy
Patient selection is a key factor in considering
hysteroscopic myomectomy in order to assess the
feasibility of surgery and prevent complications.
Myoma size of ≤3cm, Type 0 or I myoma, and
projected surgery time of less than 20min serve
as a guide in choosing patients that will likely
have a favourable surgery outcome [3]. Factors to
consider before embarking on hysteroscopic
myomectomy are desire for future fertility, size,
number and location of the submucosal broids,
serosal-myoma distance (for type II myoma) [9].
Other important considerations include the presence of other coexisting pelvic pathologies,
expertise and bias of the surgeon. These all could
inuence the route of myomectomy.
S. O. Onuh et al.
3.1 Indications forHysteroscopic
Myomectomy
The major indications for hysteroscopic myomectomy are abnormal uterine bleeding (AUB),
infertility and recurrent pregnancy losses [3].
Infertility was shown to be the commonest indication for hysteroscopic myomectomy in Nigeria,
followed by heavy menstrual bleeding [10].
• Abnormal uterine bleeding: This manifests in
most cases as heavy menstrual bleeding
(HMB) due mainly to the increase in endome-
trial surface area. In cases where fertility is no
longer desirous, concomitant endometrial
ablation produces a better outcome than hys-
teroscopic myomectomy alone [11, 12].
• Infertility: Submucosal broids lower fertility
rate, and the removal of such broids has been
found to improve fertility outcome [11].
• Recurrent pregnancy loss: The relationship
between submucosal broids and recurrent
pregnancy loss (particularly rst trimester)
remains unclear; however, some studies
have shown clear benets of removing such
myomas in preventing recurrent miscar-
riages [11].
In other situations, hysteroscopic myomectomy could be indicated where a patient with
submucosal broid has symptoms which appear
unrelated to the myoma but other management
modalities have failed. These conditions include:
• Dysmenorrhoea
• Cervical ectopic pregnancy
• Leucorrhoea
• Necrotic leiomyoma (from uterine artery
embolization)
• Histologic evaluation of intracavitary lesions
with unsure features on radiological studies
• History of preterm birth
• Postpartum haemorrhage
• Post menopause bleeding
• Puerperal infection arising in or aggravated by
submucosal myoma
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3.2 Contraindications
Contraindications to hysteroscopic myomectomy
are under general contraindications to hysteroscopy, which are majorly:
• Intrauterine pregnancy
• Pelvic infection
• Cervical carcinoma
• Endometrial carcinoma
4 Consenting andPreoperative
Evaluation
Informed consent is mandatory. The patient
should know the details of the procedure and possible complications that could arise from the procedure and possibility of a recurrence. It should
be explained to the patient the possibility of a
second-stage procedure and possibility of conversion to laparotomy if the need arises (particularly for anticipated difcult cases). Counselling
on interventional radiological procedures and
their medical management are vital.
Preoperative evaluation involves detailed history, examination and relevant investigations to
determine myoma-related symptoms and signs to
conrm diagnosis and rule out contraindications
and inoperability of the patient. General preoperative investigations are applicable to rule out
any medical condition that could affect the outcome of surgery.
Specic investigations to assess the uterus for
location of the myoma usually are mainly radiological [hysterosalpingography (HSG), saline
infusion sonography (SIS), trans-vaginal ultrasound scan (TVUS), trans-abdominal ultrasound
scan (TAUS) and magnetic resonance imaging
(MRI)] and diagnostic hysteroscopy.
SIS appears to be a good choice among the
imaging techniques as it is cheap, easier to use
and able to study both the characteristics of the
submucosal myoma and the depth of penetration
into the myometrium [13].
TVUS shows the depth of the myometrial
penetration, size and other broid locations.
MRI is very specic inlocation and relation
and differentiation of the myoma; however, it is
rather too expensive for use as a routine investigation tool in our environment.
HSG and CT scan are of limited value in
revealing the depth of myometrial involvement.
Diagnostic hysteroscopy (which could be an
ofce procedure) is of great value in the preoperative assessment of the endometrial cavity. It
reveals the extent of the submucosal myoma protrusion into the endometrial cavity.
The prior knowledge of the myoma features
helps to select patients, prevent and prepare for
blood loss, minimize uid overload and help with
necessary instrument selection for the procedure
[14].
5 Operating Tools
andDistension Media
The procedure for hysteroscopic myomectomy
could be achieved via the following instruments/
methods:
• Operative hysteroscope sheath with scissors
or grasper via channels
• Resectoscopes which could be (depending on
the applied current) monopolar loop or bipolar
loop
• Morcellators (e.g. Truclear and Myosure)
• Vaporization tools
Distension media used during hysteroscopy
depend on the instrument used and the nature of
current applied. Distention media/uid is instilled
into the uterine cavity to distend the cavity enabling
visualization. Continuous ow sheath system is
preferable to always clear the blood mixed media
for enhanced visualization. Fluid delivery could be
done under gravity, the use of pressure bags or by
automated systems. The automated pressure system is preferable, delivering uid at a pressure of
90–132cm of water [15], maintaining intrauterine
pressure at 70–80mmHg [16].
The goal for uid management includes preventing excess absorption, recognition of excess
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absorption in its early phase and choosing appropriate distension uid which will likely cause the
least complication should there be excess absorption [9].
The principal uids used are:
Hypo-osmolar/hypotonic (electrolyte-free)
uid such as 1.5% glycine, 3% sorbitol, 5% mannitol and hyskon (32% dextran 70 in dextrose)
are only used with monopolar electro-surgical
current.
Iso-osmolar/isotonic (electrolyte containing)
uid such as normal saline and Ringers lactate
should be used with bipolar electro-surgical current and mechanical devices.
Fluid management during surgery is very
vital. There should be a monitoring system in
place to observe uid decit. Fluid decit has
been observed to increase signicantly with the
degree of resection penetration. Lasmar in 2011
[17] observed an average uid decit of 450mL,
957mL and 1682mL with type 0, I and II myoma
resection, respectively. The maximum allowable
uid decit recommended is 1000 mL when
using hypotonic uids (except hyskon which is
500mL) and 2000–2500mL when using isotonic
uid [3] while operating on a normal adult. Once
the maximum decit level is reached, it is advisable to abort the procedure.
6 Preoperative Preparation
Medications
Some medications have been used either long
before surgery or at surgery to enhance good
outcome.
• Gonadotropin-releasing hormones (GnRH)
analogues: The use of GnRH analogue (depot
preparation) 2–3 months before surgery has
been proven to be benecial in the treatment
of anaemia by creating amenorrhoea to aid
restoration of haemoglobin and iron stores
[18]. GnRH analogue also reduces volume of
myoma, especially the intra-myometrial com-
ponent. This allows for complete resection
particularly in the type II submucosal broid.
GnRH analogue pre-treatment could improve
visualization during surgery and reduce the
absorption rate of distension media. However,
the general role of GnRH analogue in reduction of surgery time, reduction of systemic
distension medium absorption and improving
complete resection of myoma remains controversial [9].
• Prostagladins (misoprostol): Cervical dilata-
tion prior to insertion of the hysteroscope
could be a source of various forms of trauma.
The use of misoprostol for cervical priming
has been proven to reduce traumatic complication in pre-menopausal women [19, 20].
Misoprostol is used at doses of 200–400 μg
orally or vaginally 12–24h before surgery.
• Vasoconstrictor agents: Intracervical injection
of vasopressin has been found to reduce haemorrhage during the procedure, thereby increasing visualization and also reducing systemic
absorption of distension uid [14, 21]. Also,
intracervical injection of prostaglandin (carboprost) is effective in the reduction of systemic absorption of distension media [22].
7 The Procedure
Hysteroscopic myomectomy could be achieved
using the following devices:
• Cold scissors or grasping forceps via a channel in the operating sheet
• Cutting with energy as applicable with the
resectoscope and vaporization techniques
• Tissue extraction devices referred to as morcellators (intrauterine morcellator, Truclear
and Myosure)
The most popular technique used is the wire
loop resectoscopic technique (cutting with
energy) [13].
Anaesthesia used could be general or regional
and in some cases total intravenous anaesthesia.
The patient is placed in the lithotomy posi-
tion, cleaned and draped. It is important to avoid
the Trendelenburg position (as this position is
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Fig. 2 Type 0 submucosal broid. (Courtesy of
Gynescope Specialist Hospital)
associated with air embolism) [3]. The urinary
bladder should be emptied with a non-retaining
catheter. A bimanual examination is performed
to assess the pelvis. Sims speculum is introduced to expose the cervix. The anterior lip of
the cervix is grasped with a tenaculum. Cervical
dilation is performed. Some authors inject intracervical vasopressin or carboprost to induce
vasoconstriction reducing haemorrhage and also
absorption of distension media [15, 22]. The
uid delivery and collection systems are set up.
Likewise, set up the energy system. For monopolar electrodes, set the cutting current at
between 60 and 100W and the coagulating current at 60 W. For the bipolar system, use the
default setting on the machine.
The resectoscope is advanced under direct
vision as the uterine cavity is distended with
uid. Within the uterine cavity, a thorough
inspection is carried out noting the tubal ostia,
the broid base, the number, location and size(s)
of the broid(s) as in Fig.2.
Inspection also reveals the presence of concomitant pathologies like adhesions. After
inspection, start resecting the myoma by advancing the loop electrode beyond the area to be
resected. Activate the generator, and start shaving
towards the end of the hysteroscope. Always
ensure that the loop is visible before activating
321
the generator. Repeat the shaving process in the
same manner until you get to the base of the
broid. Do not keep the loop stationary for too
long while applying current, thereby avoiding
thermal injury to nearby endometrial tissues and
even adjoining bowels and bladder. It is important to allow for uterine contraction by deating
the cavity a while during surgery. This action
allows further protrusion of the myoma into the
cavity. Some agents like prostaglandins have
been used to aid uterine contractility [23, 24],
while uterine massage by bimanual palpation has
been described by some authors [25, 26]. It is
advisable to bluntly dissect the intramural component of the myoma from its pseudo-capsular
bed before applying energy to shave it. It is also
important to avoid excision of the myometrial tissue as this could cause myometrial scarring,
increase risk of haemorrhage, uid absorption
and uterine perforation. In an attempt to reduce
some of these complications, some authors have
advocated the cold loop hysteroscopic myomectomy [27]. This method is applicable to types I
and II submucosal broids. The intra-cavitary
component of the broid is removed by slicing
(shaving) with energy, while the cold loop is used
mechanically to remove the intramural
component.
It is very important to know when to abort the
procedure, particularly when dealing with a large
broid or type II myomas. Generally, the use of
ultrasound scan guidance may be of benet in
achieving complete resection [28].
Tissue/specimen removal: The tissue obtained
from resection of the myoma can be removed via:
• Use of the loop without applying current
• Use of polyp forceps or grasper
• Use of ovum forceps blindly
• Suction curettage
• Slow removal of the hysteroscopy allowing
the fragments to be washed out
Rate of complete resection using the resectoscope: The rate of complete resection largely
depends on the type and size of the submucosal
broid with the type II being more at risk of
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incomplete resection particularly when it is
larger than 3cm. Some series reported rate of
complete resection for types 0, I and II as
96–97%, 86–90% and 61–83%, respectively
[7, 29].
8 Further Consideration
andPost-operative Care
The use of prophylactic antibiotics may be necessary, even though infection rates are generally
very low. Where large broids are resected,
development of Asherman’s syndrome as a late
complication becomes a factor to consider, hence
the need to institute prophylactic measures to
prevent adhesion formation. Intrauterine cook
balloon or size 8–10 French gauge paediatric
Foley catheter can be inserted and inated with
about 3mL of saline or sterile water and left in
situ for 5–10 days. In hypoestrogenic women,
oestrogen therapy may help in expediting endometrial regeneration.
9 Newer Techniques:
Morcellation
andVaporization
ofSubmucosal Fibroids
These are newer techniques employed in the
management of submucosal broid.
9.1 Morcellation
• It makes resection easier; this in effect short-
ens the duration of surgery [29, 30].
• It greatly reduces the number of times the hys-
teroscope is removed and reinserted during
the procedure (this effect reduces the risk of
cervical stenosis).
• It produces less tissue fragments.
Disadvantages
• Most available morcellators (with the excep-
tion of the Symphion device) cannot cauterize
bleeding vessels.
• They are of limited use in the management of
type II submucosal broids.
9.2 Vaporization Techniques
This technique utilizes vaporization electrodes
at very high power density (120–220 W).
Tissues are vaporized. Bipolar current is usually utilized, but monopolar current could be
applicable. Vaporization techniques share similar advantages with the morcellation technique. The major disadvantage is that there is
usually no tissue obtained for histopathological examination. This disadvantage could be
overcome by replacing the vaporization process with loop electrode for completion of the
procedure (thereby obtaining tissue for histology). The other disadvantage of the vaporization technique is bubble formation in the
distension uid affecting visibility.
This method employs the use of a morcellator.
Examples of intrauterine morcellators include the
Truclear and Myosure. Most morcellators available today use rotatory blade for resection of the
submucosal myomas, and resulting fragments of
tissues are removed by suctioning. The symphonic system of morcellation, however, utilizes
a bladeless device for resection with radio frequency energy. It has a self-contained uid management and pressure system.
Advantages of the morcellation techniques
over the loop electrode cutting technique are:
10 Second-Stage Procedure
A second-stage hysteroscopic myomectomy is
sometimes necessary for some cases [31]. These
include myomas that are large, broad based or
penetrate very deep within the myometrium. So
also is the case when there are multiple myomas.
In cases of second-stage procedure, the commonest reason for aborting the initial procedure
is due to attainment of maximum distension uid
absorption level [29]. The patient must be reevaluated before a second-stage procedure.
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11 Advantages ofHysteroscopic
Myomectomy Over
Laparotomy
forMyomectomy inCases
ofSubmucosal Fibroid
• No need for hospital admission
• No abdominal scar
• Early recourse to feeding
• No risk of intra-abdominal adhesions
• Minimal or no myometrial scarring
• Early return to work
12 Complications
ofHysteroscopic
Myomectomy
Generally the incidence of complications following
hysteroscopic myomectomy is low. However, there
are only few reports of large series regarding complications specic to hysteroscopic myomectomy.
Complication rates of between 0.8% and 2.6% have
been documented in some series [32, 33]. Some
other series have shown that complication rates are
lower for single broid resection (1.4%) compared
with multiple broid resections (6.7%) [32].
Traumatic complications: This includes cervical laceration, uterine perforation, bladder or gut
injury. Cervical trauma could result from a traumatic grasping instrument, the process of dilation
or from the hysteroscopic or resectoscopic tools.
Traumatic injuries could either be mechanical or
thermal. Thermal injuries have the most consequences. Generally, traumatic complications are
not frequent [3, 34]. Where uterine perforation is
from mechanical factors, conservative management could be employed, but if it is thermal, then
laparoscopy or laparotomy would be indicated to
inspect and manage any resulting consequence.
Haemorrhage: Excessive bleeding as a complication of hysteroscopic myomectomy is
uncommon. Usually estimated blood loss following the surgery is about 5–100 mL [3]. Where
excessive bleeding occurs, it is mostly due to preoperative factors (history of heavy bleeding or
operating on a big broid mass). Heavy bleeding
could also occur from entering major myometrial
vessels particularly when operating on deep
broid on the lateral walls. The incidence of
excessive bleeding has been reported to be 1.7%
in a series [32]. In some cases, perioperative blood
transfusion is required. To prevent excessive
bleeding, intracervical injection of carboprost
(prostaglandin F2 alpha analogue) or vasopressin
has been used [22, 24]. Treatment of persistent
heavy bleeding could be achieved by intracavitary
insertion of Foley catheter/balloon inated with
saline to maintain pressure for some hours [34].
Packing of the uterine cavity with gauze soaked
with vasopressin has been advocated [35].
However the risk of systemic absorption has made
this approach unpopular. Uterine artery embolization has also been utilized to stop haemorrhage.
Complications related to distension medium:
These complications result from excessive
absorption of the distension medium. Even though
less frequent, it could be life-threatening when it
occurs. Specic complication is related to the
type of distension uid used. With isotonic solution, volume overload with resultant pulmonary
and cerebral oedema and congestive cardiac failure is the major fear. With the use of hypotonic
solution, in addition to volume overload, there
exists another major risk of electrolyte imbalance.
Hyperglycaemia characterizes the use of sorbitol,
hyperammonemia, hyponatraemia and transient
blindness with glycine. Hyskon is associated with
coagulopathy and anaphylaxis [3].
Other early complications are:
• Infection
• Thermal damages (particularly with monopo-
lar electrode)
• Vasovagal attack
• Anaesthetic-related complications
Late Complications
• Incomplete resection
• Recurrent broid
• Cervical stenosis with haematometria
• Intrauterine adhesions/Asherman’s syndrome
• Cervical incompetence
• Uterine rupture in subsequent pregnancy from
previous uterine perforation at surgery
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Learning Points
• Not all submucosal broids are resectable
hysteroscopically.
• Know when to abort a procedure with respect
to excessive absorption of distension medium
and the presence of other complications.
• When dealing with lateral broids (particularly type II), beware of large vessels.
• Take cognisance of the serosal-myoma distance for type II myoma to avoid uterine
perforation.
• Recognition of pseudo-capsular margin is key
to avoid myometrial scarring from cutting of
the myometrium.
• Do not remain stationary while applying
current.
• Always shave towards the hysterscopy lens
(i.e. towards the operator) never away.
• Avoid the use of Trendelenburg position (as
the risk of air embolism is high in that
position).
• When using vasopressin, be conscious of the
cardiovascular situation of the patient and
always work with the anaesthesiologist.
• Avoid multiple removal and reinsertion of the
hysteroscope (to prevent cervical stenosis).
• The use of a cervical priming agent reduces
traumatic complications.
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Complications Associated
https://t.me/med1917
withHysteroscopic Surgery
EmmanuelKalu, EmilyNzeribe,
andCharlesNzurumike
1 Introduction
An increasing number of gynaecologists are now
performing hysteroscopy for diagnostic and therapeutic purposes. The experience of surgeons
utilising this rapidly expanding technology varies. As the number of surgeons who take up intermediate and advanced hysteroscopic surgeries
increases, there is always the risk of increased
complications. It is therefore important that surgeons are familiar with complications that can
arise from hysteroscopic surgery, since early recognition and appropriate intervention may minimise adverse outcomes.
E. Kalu (*)
Assisted Conception Unit, Kingston Hospital NHS
Foundation Trust, Kingston upon Thames,
Surrey, UK
e-mail: e.kalu@nhs.net
E. Nzeribe
Obstetrics and Gynaecology Department, Federal
Medical Centre Owerri, Owerri, Imo State, Nigeria
C. Nzurumike
Obstetrics and Gynaecology Department, Federal
Medical Centre Lokoja, Lokoja, Kogi State, Nigeria
2 Prevalence
Basic hysteroscopy is generally a safe procedure
with low complication rates. The risk of complications is inuenced by various factors including
experience of the surgeon, case mix and complexity of the procedures. Quoted incidence of
complications that can occur during and following hysteroscopic surgery could be as low as
0.24% in Germany, 0.28% in Holland [1, 2] and
as high as 4.4% in the UK MISTLETOE study
[3] which was published over 20years ago and
where most complications were associated with
rst-generation endometrial ablation techniques.
Development of more advanced second- and
third-generation endometrial ablation techniques
has now rendered the procedure much safer with
much lower complication rates. Although diagnostic hysteroscopy is extremely low risk, more
complicated procedures including broid resection, excision of uterine septum and intrauterine
adhesiolysis of severe synechiae have been associated with complication rates as high as 10%
[4]. In their series of hysteroscopic procedures in
a private unit in Nigeria, Okohue etal. quoted an
overall complication rate of 1.2% [5].
Complications associated with hysteroscopic
surgery include anaesthetic complications (local
and general anaesthesia), neurological sequelae
following suboptimum positioning of the patient
during the procedure, trauma to the vagina, cervix
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
J. E. Okohue et al. (eds.), Gynaecological Endoscopic Surgery,
https://doi.org/10.1007/978-3-030-86768-3_31
327
328
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E. Kalu et al.
and uterus including lacerations and perforations,
bleeding, visceral injury from electrosurgical
and thermal damage, complications specic to
various distension media, infection and other
long-term sequelae of the procedure including
post ablation pregnancy complications, uterine
ruptures and chronic pelvic pain secondary to
the uncommon post ablation tubal sterilisation
syndrome.
3 Anaesthetic Complications
A detailed discussion on the risks of anaesthesia
during hysteroscopy has been covered elsewhere
in this book.
Availability of small calibre hysteroscopes
with high-quality optics means that most simple
procedures can now be performed in an outpatient
(ofce) setting, with no requirement for anaesthesia. However, sometimes local anaesthetics may
be required during outpatient procedures.
Complications associated with local anaesthetics
are uncommon but may be profound. Allergies,
anaphylaxis and unintentional intravascular injection of local anaesthetic agents can have major
implications. High doses can cause adverse cardiovascular and respiratory complications.
3.1 Prevention
To minimise this risk, care must be taken when
administering injectable local anaesthetic agents
to the cervix. Injecting at 4 and 8 o’clock on the
cervix would avoid the vessels. Routinely aspirating before injecting is a good basic injection
principle to avoid inadvertent intravascular injection. It is important to adhere to appropriate dosages and to avoid exceeding recommended doses
of local anaesthetics. Careful patient selection
would avoid the need to administer repeated
doses of local anaesthetics for patients with poor
tolerance to the procedure. Rather than risk overdosing with local anaesthetic agents, painful outpatient procedures can always be abandoned and
rescheduled to be performed in theatres with
appropriate anaesthetics.
4 Neurological Complications
Associated with
Suboptimum Patient
Positioning
Hysteroscopy is performed with patients in
lithotomy or modied lithotomy position. Leg
perfusion has been shown to be reduced in lithotomy position especially in obese patients. During
prolonged procedures, pressures in the muscle of
an osteofascial compartment further compromise
local vascular perfusion causing tissue ischaemia
and oedema that can result in neuromuscular
complications.
The common peroneal and femoral nerves are
vulnerable to injury in lithotomy. The femoral
nerve courses into the leg under the inguinal ligament and is susceptible to compression during
hyperexion, abduction and external rotation of
the hip which can lead to extreme angulation of
the femoral nerve. The patient may present with
weakness in the quadriceps muscles and numbness over the media and lateral thigh. Although
this femoral neuropathy tends to resolve with
time, it may cause signicant psychological and physical morbidity and may require
physiotherapy.
The common peroneal nerve is also susceptible to injury with patients in the lithotomy position. This nerve runs around the head of the bula
and is easily compressed with legs in lithotomy.
The patient presents with foot drop and inability
to dorsiex the foot.
4.1 Prevention
Ergonomically designed operating beds are wellpadded to support the patient’s legs safely in
lithotomy or other positions without pressure on
tissues or nerves. Where older beds with stirrups
are still used, appropriate positioning would generally minimise the risk of nerve injury. Optimum
lithotomy position requires only moderate exion at the knee and hip with limited abduction
and external rotation. This will minimise stretch
or compression on the femoral and sciatic nerves.
If stirrups are used to support the legs, conscious
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