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10. The High-Risk G

necolog

Patient: Assessment and Management 93

12. Talaat AS, Das N, Athavale R. Evaluation of P-POSSUM scorin

stem in patients

oin

naeco

ica

onco

sur

nt J G

naeco

Cancer. 2004;14(supp

)

7–

118

13. Gris

M, Trayner E, Dammann O, et a

. Symptom

imite

stair c

ing as a pre

tor o

post-operative car

iopu

monary comp

ications a

ter

ris

surgery. C

est.

2001;120

47–

14. Reilly DF, Mcneely MJ, Doerner D, et al. Self reported exercise tolerance and the risk

f serious

erio

erative com

lications.

rch Intern Med

1999;1

218

5–

2192.

15. Older P, Hall A, Hader R. Cardiopulmonar

exercise testin

as a screenin

test

for perioperative mana

ement of ma

or sur

in the elderl

hest. 1999;11

355

–

16. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative

morta

ocar

arction in

ris

patients un

oin

vascu

sur

. Dutc

ocar

rap

ic Car

iac Ris

Eva

uation App

Stress

ocar

iograp

y Stu

y Group.

Eng

J Me

1999;3

–

17. Devereaux PJ, Scott Beatie W, C

oi PTL, et a

. How strong is t

e evi

ence

e use o

erio

erative

-bl

ers in non-car

iac surgery? Systematic review an

eta-analysis of randomised controlled trials. Br Med

. 2005

;

331:313–321.

18. Stuhmeier KD, Mainzer B, Cier

ka J, et al. Small oral dose of clonidine reduces the

incidence of intraoperative m

ocardial ischaemia in patients havin

vascular

sur

naesthesiolog

. 1996;85:706–712.

19. S

oema

er WC, Appe

PL, Kram HB, et a

. Prospective tria

supranorma

ues

survivors as t

erapeutic

s in

-ris

sur

ica

patients.

est

1988;94:1176–

118

20. Wi

son J, Woo

s I, Fawcett J, et a

. Re

ucing t

e ris

major e

ective surgery:

ran

omise

contro

tria

preoperative optimisation o

oxygen

ivery. Br Me

1999;318

1099

–

1103

21. Alexander C, Liston W. Operating on the obese woman—a review.

Obste

Gynaecol. 200

;113:11

7–1172

22. Gan TJ, Horaek A, Maroof M, et al. Intraoperative volume expansion

uided b

esopha

eal doppler improved postoperative outcome and shortens hospital sta

Anesthesiolog

2002;97:820–826

23. No

ett SE, Snow

en CP, S

enton BK, et a

. Ran

omize

inica

tria

assessin

effect of doppler-optimised ﬂ

uid management on outcome after elective colorectal

resection.

r J

urg. 200

93:10

9–107

24. Moraca RJ, S

on DG, T

y RC. T

e ro

e o

epi

ura

anest

esia an

ana

gesia

in surgica

practise.

urg. 2003

;

238:

3–

25. Pearse R, Dawson D, Fawcett J, et al. Early goal directed therapy after major surgery

reduces complications and duration of hospital stay. A randomised controlled trial.

Crit Care. 2005

;

87–

93.

26. Cutillo G, Maneschi F, Franchi M, et al. Early feeding compared with nasogastric

ecompression after ma

or oncolo

naecolo

ic sur

: a randomised stud

Obstet G

naecol. 1999;93:41–45.

https://t.me/med1917

1. Complications in H

steroscopic

urger

: Prevention and

anagemen

Paul McGur

Peter

’Donova

ve years to learn when to operate and twenty years to learn when not

”

—Anon

mous

ere is

itt

t t

at minima

-access surgery (MAS) presents many a

van

ages over conventiona

surgery: sma

er scars, re

uce

postoperative pain,

orter

ospita

stay, an

spee

ier recovery.

any operation, t

ere may

e associate

comp

ications. T

ese may

divided into general risks, for example, anesthesia problems, and risks speciﬁ

o t

e way t

e operation is per

orme

. MAS is no exception;

ysteroscopic

roce

ures invo

ve intro

uction o

instruments into t

e uterus, an

istension

ia in a

ion not use

conventiona

y. As a resu

t, MAS

as a poten

y increase

ris

iatrogenic comp

ications, particu

uring t

earn

ng p

ase o

e surgeon. T

is review

ocuses on practica

tec

ogica

vances w

ere

y comp

ications may

ecrease

uring

ysteroscopic

The Sc

the Pr

erent proce

ures

ave

erent comp

ication rates; an overview o

owing

ata is presente

in Ta

e 11.1, w

gives t

e comp

ication an

mergency

ysterectomy rates reporte

or t

e MISTLETOE (Minima

y Inva-

ive Surgica

Tec

niques—Laser, En

erma

, or En

oresection) Stu

y [1]

omplications related to minimal-access procedures are relatively infre

uent. However, t

ere is

itt

e room

or comp

acency; rare comp

ications

n in

ivi

surgeon can sti

represent a major pro

em on an internationa

ormation o

nationa

supervisory

ies,

or examp

e, t

e Roya

ege o

stetricians an

Gynaeco

ogists (RCOG) Wor

ing Party [2] an

e American Association o

Gyneco

ogic Laparoscopists (AAGL),

as pro

e impetus

or structure

training an

accre

itation.

https://t.me/med1917

11. Complications in H

steroscopic Surger

eneral Principles of Safe Hysteroscopic Surger

enera

princip

es o

ysteroscopic surgery inc

e t

owing:

Appropriate case se

ection

Pat

ent preparat

Proper equipment, inc

ing optima

exposure an

now

gea

se o

ectrica

sources in e

ectrosurgery

Awareness o

earning p

ase

App

riate Case Selection

roper case selection is one of the most important factors in reducin

complication rates for hysteroscopic surgery.

irst, one must accept that not all cases are suitable for h

steroscopic

. There are uncertainties as to whether some patients are suitable for

MAS, e.

., h

steroscopic sur

for lar

e (

5 cm) type 2 submucous ﬁ

Table 11.2). While there ma

be claims b

a few specialists that it is feasible

o carry out these procedures hysteroscopically, it is important to appreciate

hat what ma

be achieved b

a small number of

ifted sur

eons ma

not be

eadil

achievable b

the avera

e practicin

eneral

necolo

ist

roper case selection is of particular importance in the “learning phase”;

s a rule, start with simple cases. For example, when performin

steroscopic

resection of ﬁ

broids, start with small type 0 or type 1 submucous ﬁ

broids.

nce

experience and conﬁ

dence have been gained, more difﬁ

cult cases may be

ndertaken. There is

ood evidence that complications are more likel

durin

steroscopic m

omectom

and septum resections [3]

le 11

Com

lications Associated with Endometrial Ablation or Resection

Technique Complication Rates (%) Emergenc

sterectom

Resection alone 10.9 13

1000

Rollerball alone 4.5 3

1000

Com

ine

resection

7.7 5

1000

Laser 5.5 2

1000

Source: Ref. 1

e 11.2. Classi

ication o

Submucous Leiomyoma

ype Locat

Pedunculate

0% intramura

https://t.me/med1917

6 P. McGur

an and P. O’Donovan

ent Preparat

App

riate

atient

aration wi

e t

e o

eration easier an

uce

ication rates

reoperat

ve Counsel

ng and Accurate Documentat

e most important

actor in

ecreasin

iti

ation is a

lly

orme

atient, particu

ere are

nown ris

actors,

or examp

e, a

esions, to

erformin

sur

. Patients ma

have unrealistic expectations about these

new procedures; a leaﬂ

et explaining the procedure is a useful adjunct to a full

iscussion. A

lan should be made for a “worst-case scenario,” for instance,

he need for a laparotom

or h

sterectom

in the event of a uterine perfora-

ion. When complications do occur, the

should be full

documented, and

emedial sur

instituted as soon as possible [4].

ndometr

al Preparat

n Hysteroscop

c Surger

he need for endometrial

aration

rior to endometrial ablation is well

eco

nized. However, there is no consensus on endometrial preparation for

other hysteroscopic surgery, such as removal of septae or submucous ﬁ

ds.

e met

preparation varies,

ein

eit

er mec

anica

(curetta

e), or

harmacolo

ical (

onadotropin-releasin

hormone [GnRH], GnRH analo

nd danazol). The Cochrane collaboration [5] found that GnRH analo

s are

ssociated with shorter duration of sur

reater ease of sur

, and hi

her

ate of postoperative amenorrhea at 12 months with h

steroscopic resection

or ablation. There also appears to be a beneﬁ

cial effect on dysmenorrhea. The

se of GnRH analo

s has no effect on intraoperative complication rates, and

atient satisfaction with this sur

is hi

h, irrespective of the use of an

reoperative en

ometria

innin

ent. T

er-term e

ects o

in-

ents are

ess certain,

ut w

ere reporte

, t

e e

ect o

ometria

thinning agents on beneﬁ

ts such as

osto

erative amenorrhea a

ears to

educe with time

[

]

roper Equ

pment

t is essential to be properl

equipped before embarkin

on h

steroscopic

. The minimum requirements should include a

ood-qualit

camera

ystem, light source, and image-recording facilities. However, it is more

mportant that both the surgeon and the theater staff be familiar with whatever

he available equipment is and how it operates

here are general precautions to follow to avoid complications arising

rom the use of electrical sources in hysteroscopic surgery [6]:

. Ensure good exposure. Activate the electric energy only when the tip

f the instrument is in contact with the target tissue and in the vie

f the hysteroscope, using the lowest possible power setting

https://t.me/med1917

11. Complications in H

steroscopic Surger

. Use

ar instruments w

enever

ossi

e; t

is met

oes not

nvo

ve use o

a return p

ate, an

a sma

amount o

tissue is

in t

e circuit, w

means t

ar instruments can

sua

y on

esiccate, an

capacitance cannot occur. Monopo

systems require a return plate, and the current ﬂ

ows through the

ore exitin

. A

monopo

ar instruments are

ore versati

e, capacitance an

irect coup

ing may occur i

precau-

ions are not ta

en [7]

3. Be aware o

e warnin

ns o

ectricit

, suc

as invo

untar

ontraction o

e patient’s musc

es, or “

tning” arti

acts on mon-

tors an

ectronic equipment. A re

uction in t

e expecte

ectro-

urgica

ect at a given power setting an

energy mo

e may in

icate

at some o

e e

ectrica

energy

issipate

away

rom t

e tip

e active e

ectro

e. Do not

eep increasing t

e power output.

nstea

, c

e app

ication o

e neutra

ate an

e insu

ation

e active e

ectro

e easiest way to avoi

irect coup

ing is to activate energy on

y w

e active part o

e instrument is visua

ize

, an

to ensure t

at part o

it is not in contact wit

any ot

er instrument. Direct coup

ing can a

so occur

ue to insu

ation

ure, w

may

e a

ect in t

e instrument’s insu

ation

invisible to the naked eye. This can be effectively conﬁ

rmed only by electrical

tests on t

e instrument, an

emp

asizes t

e nee

or regu

ar inspection

testers to ensure t

e instrument’s integrity

e t

e intro

uction o

contact-qua

ity monitoring o

e return e

ec-

tro

e (Va

, Bou

er, Co

o) e

ective

y e

iminate

ternate-site

urns, t

intro

uction o

“active s

ing” o

e e

ectrosurgica

evices in t

e 1990s

ectroscope, Bou

er, Co

o) means t

evices using t

is tec

ogy are

extreme

y sa

e. T

ese

evices can

etect

irect coup

ing an

insu

ation

ects,

capture capacitive

y coup

energy. By e

imination, t

eaves t

urgeon so

y responsi

or any a

verse e

ects.

ysteroscopic use o

ectrosurgery

as conventiona

to use a

nonionic

istension me

ium

or o

vious reasons. G

ycine 1.5% an

sor

ito

% are common

y use

or operative

ysteroscopy. Consi

era

e amounts o

ese non-iso-osmotic su

stances can

e a

sor

systemica

y, wit

resu

tant

mor

ity an

morta

ity (Ta

e 11.3). T

e use o

ipo

ar e

ectrosurgica

le 11

.3.

AAGL Guidelines

or the Management

or Iatrogenic H

steroscopic Fluid

ver

load

icit Mana

ement

0.75 L Plan for completion of the case, as impendin

excessiv

ntr

1.5 L none

ectro

yte so

ution Conc

e case, assess e

ectro

ytes, consi

iuretic

ministration, an

initiate interventions as in

icate

2.5 L e

ectro

yte so

ution Conc

e case, assess e

ectro

ytes, consi

iuretic

ministration, an

initiate interventions as in

icate

Source: Ref. 16.

https://t.me/med1917

8 P. McGur

an and P. O’Donovan

evice (Versa

oint, Et

icon, Jo

nson & Jo

nson, New Brunswic

, NJ), w

perates in an ionic sa

ine me

ium, represents a consi

era

eat o

ineer

a va

e new instrument

steroscopic sur

. T

e instrument’s

iameter means t

at operative proce

ures may

e per

orme

on con

ous pat

ents

n an outpat

ent sett

wareness of the Learn

ng Phas

t is well reco

nized that complication rates are hi

her for cases performed

sur

eons durin

their learnin

phase. The followin

recommendations ma

to reduce com

lication rates

. One should be competent and experienced in doin

the procedure

ia laparotom

prior to embarkin

on an endoscopic approach

. T

ere are

erent

eve

s o

comp

exit

steroscopic sur

[2].

ne s

in wit

simp

e proce

ures an

not un

erta

e comp

rocedures until enou

h experience has been acquired. The compli

ation rates of advanced h

sterscopic sur

are 7 times those of

simpler h

steroscopic procedures [3]

3. In some cases, h

steroscopic sur

be safer with concurrent

aparoscopic control, for example, resection of a t

pe 2 submucous

broid (especially if situated over the cornual region) and removal

uterine septum or

ense intrauterine a

esions (As

erman’s s

rome). An experience

assistant wit

a secon

camera an

source continuousl

monitors the amount of li

ht transmitted across

e uterine wa

eeps t

owe

awa

rom t

e uterus. T

mount o

t transmitte

e compare

wit

at via t

ornual re

ion—and should be no more than the latter. Combined

synchronous laparoscopic control should be considered in all difﬁ

ult h

steroscopic cases and durin

the learnin

curve of be

inners

. T

e RCOG

as out

ine

specia

s mo

es in con

unction wit

e Britis

Societ

or G

naeco

ica

oscop

. T

ese specia

skills modules are desi

ned for trainees who have completed their

asic trainin

or esta

consu

tants to conso

ate t

eir

s. G

neco

ists s

contact preceptors in t

eir re

ion to

iscuss un

erta

trainin

ompl

cat

ons Spec

c to H

steroscop

s with any surgical procedure, there are potential complications due to

he mode of access as well as the actual sur

ical procedure performed. In this

section we conﬁ

ne ourselves to the general principles of hysteroscopic surgery

ith emphasis on the accepted and newer methods of avoiding complications.

https://t.me/med1917

11. Complications in H

steroscopic Surger

Appropriate training in this new ﬁ

eld is vital, with staged levels of procedures,

pro

ressin

ter a

equate experience is

eve

ope

at eac

sta

e in

tra

e 3 intrinsic comp

ications to an

steroscopic proce

ure are

atin

e cervix, t

e use o

istension me

ia, an

e possi

uterine

erforation.

lat

on and Perforat

necolo

ists are tau

ht to dilate the cervix from their earliest sur

ical

trainin

. However, patients for operative h

steroscop

will often have received

GnRH analo

s. While these dru

s are an important part of preoperative

endometrial preparation, they can have a signiﬁ

ste

ect

cervix. In the past, mana

ement options included traditional methods o

cervical dilation such as laminaria stents (Lamicel, Cabot Medical, Lan

horne,

Pa) or the more commonl

administered pharmacolo

ical methods, for

example, prosta

landins such as P

E2 or P

. Increasin

, misoprostol

(Searle PLC, C

totec, Chica

o, Il) has been used as a method to prepare the

cervix prior to h

steroscopic sur

. A recent metaanal

sis has demonstrated

that the dru

is safe, and effective in reducin

cervical trauma and the need

for dilation

[

]

e mana

ement o

per

oration

epen

on t

e instrument

ein

used. If a perforation occurs durin

uterine soundin

, a conservative approach

can be followed, b

stoppin

the procedure, treatment with antibiotics, and

overni

t sta

. A

ter per

oration wit

ator or an operative

stero

cope, it is usua

lly

visa

e to per

orm a

aparoscop

to eva

uate t

e extent

of trauma. Occasionall

it ma

be necessar

to perform a laparotom

, particu-

larl

if a perforation b

a “hot” instrument has occurred, or even a h

sterec-

tom

if bleedin

is heav

. The incidence of perforation durin

operative

proce

ures is experience

epen

ent an

is estimate

at 1%–2% o

steroscopic cases [10]

stens

on Med

as or liquid distension media are needed as a prerequisite for h

stero-

copic sur

, in order to keep the uterine walls separated and obtain a clear

view. It is the use of these media that creates complications speciﬁ

steroscop

he use of

was ﬁ

rst described by Rubin in 1925. Its advantages are

that it is cheap, easily available in operating theaters, nonﬂ

ammable, and rela

tivel

soluble in blood. It has a similar refractive index to air and allows

ood-

qualit

ima

es to be obtained. The disadvanta

es of CO

causes

bubbling in the presence of excess ﬂ

uid or any bleeding; this effectively limits

https://t.me/med1917

00 P. McGur

an and P. O’Donovan

ts use to

nostic

steroscop

. I

intravasation occurs,

eat

ave

een

orte

ue to C

gas embolism. Therefore, ﬂ

ow rates o

ess t

an 100 mL

min are ﬁ

xed (a ﬂ

ow rate of 30–40 mL/min is usually satisfactory).

Liquid distension media include high-viscosity ﬂ

suc

uids such as 5% dextrose, 1.5% glycine, 3% sor-

ito

, an

0.9% sa

ine. Di

erent sur

eons

ave t

eir pre

erences: In t

e Unite

tates man

sur

eons pre

er H

ecause o

its immisci

wit

its

viscosit

, w

ecreases t

e ris

extravasation. However, t

high viscosity makes this medium difﬁ

rk wi

ecess

tates

mmediate washin

of instruments in contact with it. Althou

h extravasation

is uncommon, a volume of only 300 mL is sufﬁ

cient to cause pulmonary edema.

his is because dextran 70 is ver

drophilic and in the circulation it osmoti

all

shifts 6 times its own volume of water into the intravascular compart-

ent. The compound also has an effect on blood coa

ulation, rarel

causin

disseminated intravascular coa

ulation-t

pe consumptive coa

ulopath

nd has been linked to adult respirator

distress s

ndrome [11].

Low-viscosity ﬂ

uids are more commonly used in the United Kingdom;

lthou

h the

are miscible with blood, the

are not associated with an

coa

opat

ic or a

ic comp

ications. Dextrose 5% is rare

use

; it

as no a

van

e over saline and has the side effect of bein

po-osmolar. The solutions

ainl

used for operative h

steroscop

are 1.5%

cine and 3% sorbitol. Both

f these are nonionic and therefore suitable for electrosur

. Gl

cine, which

as used ori

inall

urolo

ists, is h

po-osmolar, and excess absorption

esults in a dilutional h

ponatemia, which can be further complicated b

ubsequent h

perammonemia, which results from

cine’s intrahepatic

etabolism, causin

the TURP s

ndrome. With all these compounds, vi

ance is man

ator

, an

eat

ave

een reporte

. Sor

ito

is simi

ar to

gly

cine,

ein

po-osmo

ar (approx. 170 mOsm); it a

as meta

ic com-

lications, causin

per

cemia due to its breakdown. Mannitol is a rela

ivel

new medium bein

used [12]. Its advanta

e is that it is iso-osmolar

rox. 285 mOsm), and it is a natural osmotic diuretic. Little ex

erience of

comp

ications

een

ocumente

in t

iterature to

ate;

owever,

annitol will cause a volume overload if lar

e intravasation occurs.

ntil recentl

, operative h

steroscopic sur

was limited to requirin

onionic me

ium, as e

ectrosur

in an ionic environment cou

not

orme

; t

e current wou

simp

isperse t

rou

out t

e me

ium.

owever, Versapoint can operate in an ionic saline medium (Fi

ures 11.1 and

1.2), w

represents a consi

era

eat o

ineerin

. T

e instrument

ecome a va

evice in

steroscopic sur

; t

e sma

iameter (5

rench) means that operative procedures ma

also be performed on conscious

atients in an outpatient settin

. Our experience [14] a

rees wit

e ver

positive initial reports. However, care must still be taken to avoid ﬂ

load, although the osmotically induced ﬂ

hif

acte

med

minimiz

ed.

t is essential that all operatin

theaters performin

steroscopic sur

have a system for monitoring ﬂ

uid deﬁ

cits during the procedure and a proto-

col for the management of excessive deﬁ

cits

(

Table 11.3

)

[15,16]. Prevention

s better than cure, and there are man

devices that attempt to calculate the

https://t.me/med1917

11. Complications in H

steroscopic Surger

101

ure 11.1. Versapoint (Ethicon, Johnson & Johnson, New Brunswick, NJ) “smart”

enera-

tor, which automaticall

controls power output to the tissue impedance

amount of ﬂ

uid absorbed during the procedure. These range in sophistication

from syringes, to calibrated ﬂ

uid bags hung at a certain height over the level

of the uterus (60–100 cm) with a collectin

bucket or pouch in the subperineal

drapes, to calibrated spring-weight gauges. If any of these simpler devices are

used, the ﬂ

uid balance must be checked every 5 minutes.

l m

used

assess

abso

bed

ﬂ

addition of a small

(

1%–2%

)

amount of ethanol to the distension media; this

measures the s

stemic ﬂ uid absorption b

anal

zin

the alcohol expired b

the patient. There is ver

little literature on this area, bein

mostl

small trials

[14], and the potential complications of s

stemic alcohol in a postoperative

atient are cause for concern

here are a wide variety of pump systems, ranging from simple pumps,

ere a constant rate o

ﬂ

ow o

ﬂ

is pro

uce

at a given pump rate, to

isticate

pressure-contro

pump systems. Our experience is wit

e pressure-

imite

rotary pump system (t

is avoi

s t

e catastrop

ic com-

ications

ue to t

e gas-

riven variety), t

e Hamou En

omat (Kar

Storz,

Tuttlingen, Germany). Our experience agrees with Hamou’s ﬁ

ndings [17]

https://t.me/med1917

02 P. McGur

an and P. O’Donovan

ecrease

ﬂ

sorption an

ecrease

mor

ity. At present t

ere is

o consensus on

steroscopic monitorin

;

owever, in France,

overnment

egis

ation

ysteroscopic surgery un

ess a pump system is

eing

leedin

e preva

ence o

emorr

age

epen

s on t

orm o

energy use

blation. With loop and rollerball or loop alone, the incidence of hemorrhage

s 2.57% an

3.53%, respective

y, w

ereas wit

aser or ro

it is 1.17%

nd 0.97%, respectively [1]. The new “second-generation” endometrial abla-

ion devices usually have no risk of causing uterine bleeding as a result of their

ndometrial destructive rather than resective designs

ntrauterine

ing occurring

uring t

e proce

ure s

e imme

y o

vious an

can usua

e contro

y spot e

ectrocoagu

ation. I

oagu

ation

s to contro

ing, t

e proce

ure may

ave to

e a

an-

one

tampona

e per

orme

y inserting a Fo

ey cat

eter an

isten

ing

oon. T

e cat

eter s

t in situ

or a

ours, a

ter w

ing near

y a

ways stops

alin

nmen

Vap

ket

Con

tro

lle

TheThe

rma

ect

Tis

sue

Cur

ren

Act

ive

ctr

ode

ure 11.2

Versa

oint (Ethicon, Johnson & Johnson, New Brunswick, NJ) bi

olar electro

urger

in an ionic environment.

https://t.me/med1917

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