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Complications Associated withHysteroscopic Surgery
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329
efforts must be made to avoid pressure on the
femoral nerve.
It is not uncommon for the surgical assistant to
lean over the patient’s thigh with the risk of
stretching the sciatic nerve.
Finally, surgeons in training must be educated
to appreciate the importance of adequate patient
positioning. The risks of these avoidable
hysteroscopic complications could be minimised
by highlighting the links between poor leg positioning and the development of compartment
syndrome and nerve injuries.
5 Cervical Injury
Application of the vulsellum or tenaculum to stabilise the cervix during hysteroscopy can cause
bleeding from tenaculum bite and avulsion of the
cervix if the instrument detaches during traction.
Difculties with cervical dilatation may cause
cervical laceration and creation of false passages.
Risk factors for cervical trauma include cervical
stenosis, postmenopausal status, preoperative use
of GnRH agonist, nulliparity, previous cervical
surgery and acute uterine retroversion/anteversion. Anatomic variation and abnormalities of the
cervix and cervical canal may render dilatation
difcult and predispose to cervical injury.
Stenosis may be at the level of the external or
internal cervical os. Deviation of the course of
the cervical canal by broids or other local
lesions may render access difcult and lead to
cervical trauma and creation of false passages
during hysteroscopy.
5.1 Prevention
Routine use of the non-touch vaginoscopic technique will avoid tenaculum associated bleeding
and cervical injury. Early exposure of the trainee
surgeon to the non-touch vaginoscopic technique
will enhance patient’s experience especially during outpatient procedures and also minimise
local cervical trauma.
A good understanding of the principles of the
angle of the hysteroscopy is important in the
practice of the non-touch technique. The appropriate view of the cervical canal depends on the
angle of the view of the hysteroscopy lens. For
instance, a zero-degree lens would give a panoramic view of the cervical canal and can be
inserted directly. However, for a hysteroscope
with an angled lens, the insertion should be at an
angle such that cervical canal will be visible at 6
o’clock depending on the angle of the objective
lens of the hysteroscope. For very retroverted
uteri, it may be easier to rotate the hysteroscope
180° and keep the cervical canal at 12 o’clock
(Fig.1). Attempting to insert an angled hysteroscope with the cervical canal in a panoramic view
would normally be unsuccessful and may predispose to creation of false passage and local tissue
injuries.
Dilatation of the cervix is frequently not necessary during hysteroscopy, especially when a
small calibre hysteroscope is used. It is the
Authors’ practice not to routinely dilate the cervix unless necessary. However cervical dilatation
is usually required for most operative hysteroscopic procedures when hysteroscopes with
wider diameters are required. Even in such cases,
it is usually reasonable to initially attempt direct
insertion without routine cervical dilation. We
nd that initial aqua dilatation makes subsequent
mechanical dilatation easier. Furthermore, dilation will be easier and perforation less likely
since the course and direction of the cervical
canal would have been assessed using the hysteroscope and before dilatation.
A good vulsellum bite is required to minimise
cervical tear/laceration but a ‘good vulsellum
bite’ may also cause bleeding. The use of double
vulsella without ratching either to the end groove
would improve grip whilst minimising the risk of
bleeding. When difcult dilatation is anticipated
and in situations where the cervix is decient in
length, it is the Authors’ practice to use double
vulsellums. Whilst these may annoyingly get on
the way of the surgeon, it provides the necessary
cervical grip without increasing bleeding from
the bite sites.
Other measures that have been proposed to
facilitate cervical dilation and minimise risks of
cervical trauma include preoperative use of cer-
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With 0o hysteroscopes, the cervical
canal should be placed in the centre
during entry, irrespective of whether
anteverted or retroverted
With 30o hysteroscopes, and an
anteverted, axial or retroverted uterus,
the cervical canal should be placed at 6
o’clock at entry
If rotating 30o hysteroscopes 180o for
severe retroversion or retroflexion,
then place cervical canal at 12o’clock
E. Kalu et al.
Fig. 1 View of the cervical canal in relation to the angle of the lens of the hysteroscope
vical softening agents including oral or vaginal
6 Uterine Perforation
misoprostol (200–400 μg) usually 12–24 h
before the procedure. Hygroscopic seaweed
(laminaria tent) (commonly used in the USA but
not in Europe or the UK) inserted before the
procedure can be very effective. Hygroscopic
dilators come in 3 and 4 mm diameters and
swell to two to three times their original diameter. The seaweed versions act over 24h, whereas
the synthetic versions act over 4h [6]. Others
have also described deep intracervical injection
of 20mL of dilute vasopressin (4U of vasopressin in 80mL of normal saline at 0.05U/mL) at
4 and 8 o’clock on the cervix to facilitate cervical dilatation [7].
The incidence of uterine perforation during hysteroscopy ranges from 0.12% to 1.4% [3, 8].
Most perforations occur during dilatation.
Cervical dilatation to Hagar 8 or 10 is usually
required for operative hysteroscopy, and such
dilatation increases the risk of uterine perforation. Other risk factors for uterine perforation are
same as those discussed under cervical injury.
Uterine perforation can also occur during
insertion of the hysteroscope or during resectoscopic procedures involving the use of sharp
instruments like the scissors or by activated
electrode.
Level of Internal
Cervical Os
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331
The uterine fundus is the commonest site for
perforations that occur during cervical dilatation.
However, the uterine cornus with its thin myometrium is particularly susceptible to perforation
during resection procedures in this area.
Early signs of uterine perforation include
inability to distend the endometrial cavity or sudden loss of uterine distension, signicant and
sudden distension uid imbalance (as the uid
rushes freely into the peritoneal cavity), bleeding
and sometimes direct visualisation of pelvic/
abdominal visceral organs.
Recognition of uterine perforation is important since early intervention and appropriate
management would reduce morbidity.
Most perforations involving the use of dilators
or the uterine sound are not associated with other
injuries. However, when the uterus is perforated
by sharp hysteroscopic instruments like the scissors or by an activated electrode, there is signicant risk of injury to other pelvic structures
including blood vessels and bowel.
6.1 Prevention
Since most simple perforations occur following
cervical dilatation, measures described above
aimed at facilitating cervical dilatation would
help minimise risk of uterine perforation.
Insertion of the hysteroscope under direct
vision minimises risk of uterine perforation
caused by insertion of the hysteroscope.
To minimise uterine perforations caused by an
activated electrode during resection, it is important to ensure the loop is retracted and protected
within the hysteroscope when advancing the hysteroscope. Furthermore, the surgeon must avoid
forward movements of the hysteroscope whilst
activating the electrode as this increases the risk
of perforation. These important basic hysteroscopic principles should be adhered to at all times
to minimise risks associated with perforation
whilst using activated electrodes.
Another important hysteroscopic principle is
to always resect towards the surgeon and avoid
resecting forward (so-called backhanding).
Resecting towards the surgeon and into the
ceramic sheath of the resectoscope is a safe technique that minimises the risk of uterine perforation but also limits the resection footprint and
avoids collateral endometrial damage during
resection of submucous broids.
6.2 Identication
andManagement
Failure to recognise signicant uterine perforation may have serious consequences. Most simple fundal perforations caused by the dilator
may not require any further intervention if there
is no signicant bleeding. It is the Authors’
practice to give a course of prophylactic antibiotics and admitted such patients for overnight
observation.
Non-fundal uterine perforations may be
more problematic as these may involve other
pelvic structures including uterine vessels,
broad ligament injuries and bladder or bowel
injuries. We would normally consider pelvic
assessment by laparoscopy when non-fundal
perforation occurs.
Uterine perforations caused by activated
electrodes are usually more severe and warrant
immediate laparoscopy and sometimes laparotomy to assess for visceral damage. The assistance of general surgical colleagues should be
sought in such cases so that the bowel can be
thoroughly assessed for injuries as such injuries
may sometimes go unrecognised, with obvious
consequences.
7 Occult Visceral Thermal
Injuries
Occult thermal burns to pelvic/abdominal viscera
may occur following the use of surgical energy.
Dispersion of energy and stray current from
monopolar electrodes can cause tissue damage
beyond the view of the hysteroscope. For exam-
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E. Kalu et al.
ple, the use of monopolar energy during resection
around the uterine corn and where the myometrium is thin including along a previous caesarean
section scar can lead to increased risk of thermal
injury to structures outside the uterine cavity.
Bowel loops adherent to the serosal surface of the
uterus are particularly vulnerable to heat energy
generated inside the uterine cavity during resectoscopic procedures. Such thermal injuries might go
unrecognised at the time of the procedure, and the
patient may present much later with peritonitis,
sepsis and stula formation with fatal
consequences.
7.1 Prevention
Bipolar energy is much less likely to cause occult
thermal injuries as inadvertent energy spread is
much less than monopolar. However, the risk of
energy-related injuries is still very much possible
even with bipolar energy and more so if perforation occurs.
Utmost care must be exercised when resecting
over areas of thin myometrium, including uterine
cornus and over Caesarean section scars. During
rst-generation global endometrial resection/
ablation, it is good practice to use the rollerball to
ablate over areas of thin myometrium rather than
the loop. It is however still worth noting that rollerball ablation using monopolar energy has also
been known to cause occult thermal visceral
injuries.
Preoperative assessment of myometrial thickness using MRI or 3D ultrasound scan may aid
surgical planning, although this has not been
validated.
The safe technique of always withdrawing the
activated electrode towards the hysteroscope
minimises the risk of uterine perforation and also
reduces the risk of thermal transfer following
deep resection.
Procedures such as excision of uterine septa
where the activated electrode is usually moved
forward should only performed by surgeons with
the appropriate skills.
8 Complications Associated
withtheDistension Media
The various distension media used for hysteroscopy have been discussed elsewhere in this book.
Discussions here are limited to complications
that arise whilst utilising the various distension
media:
8.1 Gas Media
The use of gas (CO2) for distension is limited to
diagnostic procedures and no longer much used.
Cavity distension using CO2 has been shown to
cause more discomfort with reduced patient satisfaction. Carbon dioxide embolisation is not
uncommon. The incidence of subclinical CO2
embolisation has been reported to be in the region
of about 0.51%. Embolisation of small amounts
of CO2 is not dangerous. However, embolisation
of large amounts of CO2 (more likely to happen
when the wrong type of CO2 insufator is used)
has been associated with fatality. Laparoscopic
insufators should therefore never be used to
insufate the uterine cavity during hysteroscopy
as CO2 embolism is more likely to occur with
such high insufation pressures.
8.2 Fluid Distension Media
The high-viscosity solution Dextran 70 (32%
Dextran 70 in D10W) is no longer commonly
used. Although Dextran gives clearer views especially in patients with ongoing bleeding (Dextran
does not mix with blood), it requires signicant
pressures to infuse, and if high volumes are
infused, its hydrophilic properties can lead to signicant intravascular uid shifts with consequent
uid overload, electrolyte imbalance and cardiac
failure. Fluid overload can occur with much
smaller volumes of Dextran compared with lowviscosity uids.
Dextran has also been associated with signi-
cant anaphylaxis (1:10,000) and intravascular
Complications Associated withHysteroscopic Surgery
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coagulopathy. The use of low-viscosity media
where available is recommended and if Dextran
must be used, then we suggest the use of small
volumes, strict uid balance surveillance and
close monitoring of vital signs.
Commonly used low-viscosity media include
1.5% glycine, 3% sorbitol, 5% mannitol, normal
saline, Ringer’s lactate, amongst others.
Complications associated with the use of lowviscosity media are mainly due to excessive uid
absorption that could occur during usually prolonged operative hysteroscopic procedures that
involve transection and disruption of the numerous ne networks of blood vessels within the
endometrium/myometrium or on broids.
Excessive absorption of hypotonic lowviscosity uids (1.5% glycine and 3.3% sorbitol) can cause fatal hyponatraemia with
consequent neurological sequelae. Glycine is
metabolised in the liver and kidney into glycolic
acid and causes neurological symptoms. Also,
excessive absorption of glycine can cause transient loss of vision.
Although isotonic solutions (normal saline
and Ringer’s lactate) are safer to use, massive
absorption of large amounts of even these isotonic uids can cause uid overload with resultant pulmonary oedema and congestive cardiac
failure.
8.3 Prevention, Recognition
andManagement ofExcessive
Fluid Absorption
Risk factors for increased uid absorption include
high intrauterine uid delivery pressures, lengthy
operating time and resectoscopic procedures,
including resection of large broids (Pic. 1), division of uterine septum, endometrial ablation and
division of synechia.
The risk of excessive uid absorption during
hysteroscopic myomectomy correlates with the
duration of the procedure, the diameter of the
broid and the proportion of broid in the myometrium [9].
333
Pic. 1 Large vascular submucous broid. Risk factors for
increased uid absorption include resection of large
broids. (Courtesy of Mr. E.Kalu)
Also, constant interruption of the resection
procedure to clear the cavity of broid chippings
during myomectomy would extend operating
time and increase risk of uid absorption.
Although the entire surgical team must pay
due attention to uid balance, it is good practice
to assign a specic member of the team to keep a
close eye and audibly announce uid inputoutput balance at agreed regular intervals. This
would enable early recognition of excessive uid
absorption and allow for early intervention.
Risk reduction strategies include appropriate
choice of solution (isotonic solutions safer than
hypotonic solutions), the use of lowest pressures
required to achieve and maintain suitable uterine
distension and keeping procedure time as short as
necessary. Patients should be counselled that
some procedures may not be completed in one
setting and may require repeat procedures.
Removal of chippings to clear the uterine cavity should be kept to a minimum and performed
only when the operating eld is obscured by
accumulation of chippings.
Preoperative use of GnRH analogues for pituitary down-regulation and reduction of size of the
broid may minimise uid absorption by shortening length of procedure.
The team should maintain strict uid input
and output balance chart at all time, and the oper-
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E. Kalu et al.
by 1mmol/h. There is signicant risk of causing
central pontine myelinolysis if sodium levels are
corrected too rapidly.
Complications associated with uid distension media are largely preventable by understanding risk factors. Meticulous attention to
uid management and early recognition of the
complication will facilitate prompt intervention
and avert adverse outcomes.
9 Air Embolism
Pic. 2 A closed-circuit uid delivery and collection
systems
ating surgeon should be kept informed. The use
of a closed-circuit uid delivery and collection
systems will facilitate uid management by minimising uid loss to the oor and perineal drape
whilst enabling complete collection of uid
escaping from the uterine cavity and the resectoscope (Pic. 2).
It is advisable to discontinue the procedure at
a uid decit of 1.0 L when using hypotonic
solution and 2.0L when using isotonic solution.
Early signs of uid overload and hyponatraemia include headaches, severe nausea and vomiting as well as agitation, which may start shortly
after the patient recovers from anaesthesia, and
sometimes in the recovery room. Muscle cramps,
restlessness and lethargy are other symptoms that
patient develop especially when the fall in serum
sodium level is rapid and severe.
Treatment of hyponatraemia is usually supportive and aimed at reducing uid overload and
correcting serum sodium levels. Furosemide
20–40 mg should be given intravenously to
induce diuresis. An indwelling catheter should be
inserted to facilitate measurement of urine output. Patients with severe hyponatraemia (when
serum sodium levels go below 120 mmol/L)
should ideally be nursed in an intensive care unit.
Usually, normal saline is used to carefully and
slowly restore sodium levels, although hypertonic saline could be used in cases of severe
hyponatraemia who show neurologic and cardiac
symptoms. The aim is to raise the sodium level
Air embolism on the other hand is a potentially
more serious complication. Thankfully it is not
common, but when it occurs, it could be fatal. Air
can gain access into the uterine cavity during cervical dilatation and when air in the infusion tubing is not ushed out before hysteroscopy. Air
can also enter the cavity with repeated removal
and insertion of the hysteroscope during an operative procedure. Such room air that accumulates
into the uterine cavity is compressed into small
venous blood vessels in the resected endometrium, and the high intrauterine pressure can push
this air into venous channels and into the vena
cava and the right atrium and ventricle.
The risk of air embolism is increased when
patient is in the Trendelenburg position. In this
position, the uterus is located above the level of
the heart, and diastole creates a negative intravenous pressure that facilitates air advancement
into venous channels.
The patient manifests decline in cardiac output, hypotension, decrease in arterial saturation,
tachycardia, arrhythmia and a noticeable sudden
decrease in end-tidal CO
and a decrease in oxy-
2
gen saturation.
9.1 Prevention
The distension uid should be allowed to run
through and ush out any air column from the
insufation tubing before the hysteroscope is
inserted into the patient. This routine step would
minimise introduction of air pockets from the
tubing.
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For obvious reasons discussed above, the
Trendelenburg position should be avoided during
hysteroscopy.
Efforts should be made to minimise multiple
repeat insertion and removal of the hysteroscope
during a procedure. This will minimise risk of
introducing room air in the cavity. Also, shorter
operating time and the avoidance of excessive
infusion pressures are all measures that will
reduce risk of air embolism.
Finally, a drop in end-tidal CO2 is a warning
feature that should be recognised by the anaesthetist as a sign for air embolism.
10 Intraoperative andPost-
operative Bleeding
Bleeding during hysteroscopic surgery is not
uncommon with an incident of about 2.2–2.4%.
Haemorrhage complicating hysteroscopy can
occur during or after the procedure. Bleeding is
usually secondary to injury to myometrial vessels
especially during resection procedures. Bleeding
can also be the result of uterine perforation especially non-fundal perforations that can involve
vessels in the broad ligament, the uterine artery
or other pelvic vessels. Bleeding can also occur
following cervical trauma.
10.1 Prevention andManagement
Risk of intraoperative bleeding can be minimised
by preoperative administration of GnRH analogues.
Limiting the depth of resection in the isthmic region
will reduce the risk of lateral uterine perforation,
which could involve the pelvic vessels.
Raising the intrauterine distension pressures
can easily control small vessel bleed. Bleeding
from larger vessels is usually more of a problem
as hysteroscopy views become suboptimum, and
the procedure may become difcult to continue.
The use of coagulating current with a wire loop to
coagulate bleeding vessels is usually successful in
controlling bleeding from larger vessels [10, 11].
Other measures that may be helpful to control
ongoing intrauterine bleeding include bimanual
uterine massage, insertion of intrauterine balloon
for tamponade, injection of vasopressin and intravenous administration of tranexamic acid. These
measures are usually sufcient to bring bleeding
under control. Uterine embolisation could be useful for bleeding from major pelvic vessels, and
hysterectomy may be required in life-threatening
cases where bleeding is refractory.
Finally, when there is suspicion of intraperitoneal bleeding following uterine perforation, laparoscopy or laparotomy should be performed as
required.
11 Infection
Infection following hysteroscopy is uncommon.
Rate of infection has been reported to be as low
as 0.01–1.42% [2, 12]. Endometritis and even
more rarely parametritis can occur. Risk factors
for postoperative endometritis include inadequate
aseptic precautions, extensive tissue destruction,
prolonged operative procedures and pre-existing
pelvic infection. There have been case reports of
tubo-ovarian abscess following hysteroscopic
procedure on a patient with a history of pelvic
inammatory disease [13].
Postoperative endometritis can occur several
days after the procedure, and symptoms would
include pain, vaginal discharge, pyrexia and uterine tenderness.
The benets of routine use of antibiotics to
prevent infection during hysteroscopy in patients
with no risk factors have not been established.
12 Uterine Synechia Following
Hysteroscopic Surgery
Intrauterine adhesions are a potential long-term
complication of hysteroscopic surgery. They
could be primary, occurring after hysteroscopic
surgeries such as myomectomy or resection of
intrauterine septum, or secondary when reoccurring after an initial hysteroscopic adhesiolysis
has been performed [14]. These surgeries can
cause adhesions as a result of surgical trauma to
the endometrium.
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E. Kalu et al.
The rate of adhesions following hysteroscopic
uterine septa resection is about 6.7% which
appears to be higher in hysteroscopic myomectomy [15]. Acknowledging these risks is therefore
very important in the prevention of intrauterine
adhesions. These risks along with the benets of
the surgery should always be considered and
weighed against the risk of adhesions especially
in patients with cavity-related subfertility issues.
12.1 Prevention andManagement
It is common to use oestrogen therapy to prevent
adhesions. This can be used alone or as ancillary
treatment either with intrauterine device (IUCD) or
pediatric Foley’s catheter. Intrauterine application
of gel barrier such as hyaluronic acid for secondary
prevention of adhesions has been advocated.
A study comparing intrauterine balloon,
IUCD and hyaluronic acid gel demonstrated that
the balloon and IUCD were more effective than
hyaluronic acid [16].
13 Risk ofMorbidly Adherent
Placenta Following
Reproductive Hysteroscopic
Surgery
The risk of morbidly adherent placenta (such as
placenta accreta, increta and percreta) is increased
by hysteroscopic surgeries [17]. As such, it
should be considered a potential long-term complication in pregnancies following hysteroscopic
surgical interventions such as adhesiolysis,
metroplasty and myomectomy. Endometrial
trauma that may be sustained during such procedures may lead to defects in the decidua basalis
resulting in abnormal placentation when the
anchoring placental villi adheres to the surface of
the myometrium, beyond the endometrium [18].
14 Other Complications
Some other complications associated with hysteroscopic surgery include haematometria, which
can occur if cervical stenosis complicates resec-
toscopic procedures. Patients would normally
present with chronic pelvic pain.
Myometrial deciency caused by deep hysteroscopic resections of broids or uterine septum may be a risk factor for uterine rupture when
pregnancy occurs.
Pregnancy following global endometrial ablation can be associated with signicant complications involving the foetus and placentation.
Women requesting endometrial ablation should
be counselled about the need to avoid
pregnancy.
Haematometria and chronic pelvic pain have
been reported in women who had tubal occlusion and endometrial ablation and who continue
to have light bleeding with retrograde bleed into
the occluded proximal fallopian tubes. Patients
with this so-called post ablation tubal sterilisation syndrome may present up to a year after
endometrial ablation with cyclical, cramping
and lower abdominal pain which could be unilateral or bilateral. Laparoscopy is diagnostic,
and salpingectomy is therapeutic. Ligating the
fallopian tube as close as possible to the cornua
would minimise the risk of occurrence of
this uncommon complication of endometrial
ablation.
Other long-term sequelae of global endometrial ablation include difculties with the investigation and diagnosis of post ablation endometrial
cancer. These women usually have islands of
active endometrium left behind following ablation and may be unfortunate to develop endometrial adenocarcinoma. Radiological investigations
including TVS and MRI are of limited values in
assessing the endometrium in this situation, and
hysteroscopy and endometrial biopsy could be
difcult. The diagnosis of cancer can be delayed
in these cases.
Learning Points
• Although basic hysteroscopy is a safe proce-
dure, risk of complications increases with sur-
gical complexity.
• Optimal positioning of the patient will mini-
mise risk of nerve injury.
• A good understanding of the principles of the
angle of the hysteroscopy is important to facil-
itate access into the cavity.
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• It is important to ensure the loop is retracted
and protected within the hysteroscope when
advancing the hysteroscope. This will minimise uterine perforations caused by an activated electrode during resection.
• It is safe and good practice to resect towards
the surgeon and avoid resecting forward.
• Uterine perforations caused by activated electrodes are usually more severe and warrant
immediate laparoscopy and sometimes laparotomy to assess for visceral damage.
• Risk factors for increased uid absorption
include high intrauterine uid delivery pressures, lengthy operating time and resectoscopic
procedures, including resection of large
broids.
• Attention must be paid to uid balance to
enable early recognition of excessive uid
absorption and timely intervention. It is advisable to terminate when uid decit exceeds
1L with hypotonic solutions and 2.0L when
using isotonic solutions.
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