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11. Complications in H

steroscopic Surger

ccasiona

lly

ese simp

e measures

to contro

emorr

e. T

is ma

occur i

resection

een carrie

out too

eep into t

e m

ometrium an

exus o

vesse

s opene

. In t

is case

sterectom

ation, or u

trasoun

gui

ization o

e anterior

ranc

es o

e interna

iac arteries may

e necessar

Less signiﬁ

cant bleeding may be caused by tearing the cervix with the

tenacu

um. T

is can usua

e manage

irect pressure (a sponge-

ing

orceps is use

), or occasiona

y a suture wi

e require

. Latera

tears o

the cervix may produce signiﬁ

cant bleeding and may also lead to excessive

sorption o

istension me

ium

hesi

n F

ntrauterine a

esions are particu

y common a

ter myomectomies

when 2 ﬁ

broids are situated on opposing uterine walls. In these cases the

myomectomy is

est per

orme

in stages to prevent a

esion

ormation. T

insertion o

a copper intrauterine

evice an

ministration o

estrogen mini

mize a

esion

ormation

owing resection, a

esio

ysis, or

ivision o

um.

onclus

his cha

ter is an evaluation of the different methods used to decrease the

risk of complications in h

steroscopic sur

. We have focused on the pre-

vention of those complications that are related to the basic principles of h

teroscopic surgery, rather than providing a discourse on speciﬁ

c o

erative

com

lications

espite the tremendous advances in this area of

necolo

ical sur

, and

the appropriate emphasis on trainin

, accreditation, and critical appraisal of

new techniques, there is a surprisin

lack of consensus on even the most basic

techniques. Due to lack of qualit

research to determine the safest approaches,

we have been unable to

ive an

didactic opinions; instead, we offer a critical

account of current practices, and look forward to the time when we can

ive

more deﬁ

nitive answers. Minimal access surgery has now proved its superior-

over conventional open sur

in a ran

e of operations; it is now time to

rmly establish the acceptable and safest methods for performing these opera-

tions, particularly in the ﬁ

e have attempted to

ive as comprehensive an overview of the equip-

ment currentl

available as possible. There have been excitin

developments

in this area, notabl

in improvin

the safet

aspects of these potentiall

dan

gerous devices. Good-quality trials to conﬁ

rm clinically the theoretical advan-

tages t

ese instruments possess are awaite

https://t.me/med1917

04 P. McGur

an and P. O’Donovan

ey Po

nts for Cl

cal Pract

Gener

Appropriate case se

ection is vita

ysica

psyc

ogica

patient preparation are equa

mportant.

Conﬁ

dence in surgery depends on appropriate training and the use

qua

ity equipment wit

e surgeon an

eater sta

are

ami

iar

steroscop

c Surger

Beware the difﬁ

cult cervical dilation; in our experience, the degree

f force re

uired is

ortional to the com

lication rate

Visualizin

the endometrial cavit

before and after “blind” endome

trial ablation techni

ues is recommended

Select the distension media to suit the

rocedure and the

atient;

always monitor ﬂ

ow rates and ﬂ

uid balance.

If the uterine cavit

collapses, this is uterine perforation until proven

otherwise. Have a low threshold for investi

atin

iatro

enic trauma

if this occurs in o

erative

rocedures.

erences

1. Overton C, Har

reaves J, Maresh M. A national surve

of the complications of

endometrial destruction techniques for menstrual disorders: the MISTLETOE stud

Minima

lly

Invasive Sur

ica

Tec

niques—Laser, En

erma

or En

oresection.

r J O

stet G

naeco

–

2. Roya

ege o

stetricians an

Gynaeco

ogists.

eport o

e RCOG Wor

art

on Training in G

naeco

ogica

oscopic Surger

. Lon

on: Roya

ege o

bstetricians and Gynaecologists Press; 1994.

3. Propst AM, Liberman RF, Harlow BL, Ginsburg ES. Complications of hysteroscopic

surgery: predicting patients at risk.

bstet Gynecol. 2000

;

:517–520

4. Ro

al Colle

e of Obstetricians and G

naecolo

ists.

ort o

the Audit Committee’s

Working Group on Communication Standards Gynaecology: Surgical Procedures.

London: Ro

al Colle

e of Obstetricians and G

naecolo

ists Press; 1995.

5. Pre-operative en

ometria

innin

ents

ore en

ometria

estruction

eav

enstrua

. Coc

rane Data

ase S

st Rev.

2002

;

6. Asc

R, Stu

J. Progress in repro

uctive me

icine. In: Nez

at et a

., e

s. New Yor

ant

eon Pu

ing; 1998:57–85

https://t.me/med1917

11. Complications in H

steroscopic Surger

7. Loffer FD. Preliminar

experience with the VersaPoint bipolar resectoscope usin

a vaporizin

ectro

e in a sa

ine

isten

ium. J Am Assoc G

neco

Laparosc.

2000

;7:4

–5

8. Xia E, Feng L, Duan H. Com

ination o

ysteroscopy an

aparoscopy in gyneco-

ogic operation: an ana

ysis o

65 case

in Me

1998;111

1001

–

1003

9. Crane JM, Hea

ey S. Use o

misoprosto

ore

ysteroscopy: a systematic review.

J Obstet Gynaecol Can. 200

28:373–379

10. Hulka J, Peterson H, Phillips J, Surrey M. Operative hysteroscopy. AAGL 1993 mem-

bership surve

1995;2:133–13

11. Mana

er D, Gerson JI, Wallweiner D, et al. Pulmonar

oedema and coa

ulopath

ue to H

skon. Anesth Anal

989;68:686–687

12. Kim AH, Keltz MD, et al. Dilutional h

ponatraemia durin

steroscopic m

omec-

wit

sor

ito

-mannito

istension me

ia. J Am Assoc G

neco

Laparosc

7–

13. O’Connor H. How to avoi

comp

ications at

ysteroscopic surgery. In: Bonnar J, e

Recent A

vances in O

stetrics an

naeco

. Lon

on: C

urc

Living

stone

;

199

4–

45.

14. Allweiner D, et al. Addition of ethanol to the distension medium in surgical hyster-

oscopy as a screening test to prevent “ﬂ

oad.

”

eburtshilfe Frauenheilkd.

1996;56:462–469.

15. Hamou J, Fr

man R, McLucas B, Garr

R. A uterine distension s

stem to prevent

ﬂ

uid intravasation during hysteroscopic surgery.

neco

osc

1996;5:131–136

moni-

oring gui

ines. T

e a

oc committee on

ysteroscopic training gui

ines o

American Association o

Gyneco

ogic Laparoscopists.

Am Assoc G

neco

Laparosc.

000

;

7:1

7–1

https://t.me/med1917

2. Minimizin

the Risk o

teriliz

n F

vidence-Based Approach

esh Varm

anesh K. Gupt

emale sterilization is one of the commonest procedures performed world

e. In 1999 aroun

50,000

ema

e steri

izations were per

orme

in Eng

n the National Health Service (NHS) and charitable sectors [1]. The procedure

s performed on mainly healthy women at their request, and the intention is

o occlude each fallopian tube. This ma

be achieved throu

h tubal sur

ical

xcision, application of a mechanical device, or electrocautery coagulation

Table 12.1). Where resources permit, the preferred and most widely estab

ished technique is laparoscopic tubal occlusion, which has, moreover, replaced

he earlier technique of performing female sterilization via minilaparotomy.

n t

e Unite

King

om, t

e Roya

ege o

stetricians an

Gynaeco

ogists

RCOG) recommends that laparoscopic sterilization be performed using either

ilshie clip or ring [1]. Tubal excision and separation and related techniques

e.g., Pomeroy procedure) are preferred if sterilization is performed at cesar

an delivery.

ysteroscopic sterilization may be considered a nonincisional, nonsurgi

al form of permanent contraception and is a promising alternative to lapa-

osco

ic tubal occlusion. The

rocedure involves the insertion of a small,

ﬂ

exible titanium microinsert into each of the fallopian tubes through the

ervix using a gui

ewire an

ysteroscope (Essure, Conceptus Inc.,

ountain View, Ca

). T

e proce

ure is usua

y per

orme

oca

anes

esia an

/or intravenous se

ation. A

oug

ysteroscopic steri

ization is

icensed in the United Kingdom, the National Institute for Clinical Excellence

NICE) consi

ers it to sti

e un

er eva

uation an

as state

at it s

be performed only in accordance with speciﬁ

c NICE guidance, particularly on

atient consent and coordinated follow-up [2]. This is mainly because there is

insufﬁ

cient evidence on long-term efﬁ

cacy (single case report of failure [3] and

per

oration [4]) an

ety o

ysteroscopic steri

ization, wit

e manu

acturer reporting 99.8% e

ectiveness at preventing pregnancy at 2-year

ow-up (

ttp://www.essure.co.u

) [5–7]. Furt

ermore, t

ere are no pu

ran

omize

contro

tria

s comparing Essure

irect

y wit

common

ema

e tu

occ

usion met

s [8]

https://t.me/med1917

12. Minimizin

the Risk of Sterilization Failure 107

ates of Ster

zat

on Fa

lure

once

tion that occurs after sterilization is termed sterilization failure and

can happen several

ears after the procedure. Publications have reported dif

ferences in sterilization failure rates

even with the same sterilization method.

uch variation is due to differences in the characteristics of the women under-

oin

sterilization; operator experience; operatin

center workload; steriliza

tion method chosen; and time interval to resumin

sexual activit

, and its

frequenc

, poststerilization [9].

he two lar

est studies that have examined failed sterilization have

reported the 10-

ear cumulative probabilit

of pre

nanc

to be 18.5 per 1000

procedures (US CREST stud

) [10] and 8 per 1000 procedures (Canada) [11].

The reason for the lower sterilization failure rate in the Canadian stud

com-

pared to the US CREST stud

be predominant use of the Filshie clip and

incorporation of nonteachin

hospitals in the Canadian data set. However,

both studies were also signiﬁ

cant in the following aspects:

. Utilizin

the superior and preferred life-table anal

sis method

cumulative probabilit

of pre

nanc

at serial time intervals since

terilization) for reportin

sterilization failure, rather than the less

ccurate crude failure or Pearl index outcomes that were re

orted

previous studies

le 12

Female Sur

ical Sterilization Techniques

Method Techni

ues Comments

Ligating tube with Pomero

Preferred option at minilaparotom

partial or complete Fimbriectom

but laparoscopic salpingectom

excision Sa

pingectom

an a

ternativ

Mechanical occlusion Filshie clip Less o

the tube is dama

ed,

of the tubal lumen Hulka-Clemens clip increasin

the chance of

ope ring reversi

astic rin

Coagulation-induced Unipolar diatherm

Not recommended as the

irst-lin

osure Bipo

iat

erm

met

in t

e Unite

King

e RC

steroscopic tu

Expan

ing meta

License

in t

e Unite

King

om an

occ

usion micro-insert im

ant un

er eva

uation

(Essure) Guidance

or usa

e in accordanc

Virtuall

no possibilit

reversal

ontrace

tive

recautions to continu

or at least 3 months

ost

rocedur

and x-ra

HSG con

irmation o

tuba

https://t.me/med1917

08 R. Varma and J.K. Gu

. O

tainin

ow-up

ata

or at

east 5 to 15

ears

owin

ste

is concept o

cumu

ative ris

pre

nanc

is particu

important

ose women steri

ize

at a

oun

e (w

o wi

e expose

to a ris

pre

anc

or a

reater time perio

) an

or t

ose w

ave

een steri

ize

methods of low short- and long-term efﬁ

cacy (because such methods, over

ertain time

rames, wi

acquire a

reater percenta

e o

tota

ures t

er more e

ective met

US an

Cana

ian

ata-set stu

ies [10,11] va

ate

is conce

t o

umu

ative ris

pre

nanc

. In t

e Cana

ian

ata set, t

e cumu

ative pro

pre

nanc

increase

rom 0.3% at 1

ear to 0.7%

ears an

0.9%

y 15 years [11]. T

is progression is

epicte

in Figure 12.1. It is t

ere

ore

mportant to quote women a 10-year ris

steri

ization

ure, in

ivi

ize

o eac

met

patient a

e, w

en counse

or t

e steri

ization

roce

ure,

earin

in min

at as

as a woman is

erti

e an

sexua

lly

ctive, s

e ma

continue to

e at ris

or steri

ization

ure.T

e RCOG

ecommen

a 10-

ear steri

ization

ure rate o

2–3 per 1000 proce

ures

e use

or t

e Fi

ie c

ip met

. However, t

is rate is

rawn pre

ominant

rom a retrospective questionnaire stu

, o

ear

ow-up, wit

an exa

erate

enominator [12]. Given t

is in

ormation, an

consi

ering t

e ot

eporte

ie c

ip stu

ies (Ta

e 12.2), 2–3 per 1000 ris

is more

y to

correspond to the ﬁ

rst year or even annual noncumulated absolute risk of

teri

ization

ure

Cumulative

Probability of

Pregnancy

% of Cases

1.5

Steep

Gradient

510

Years Since Sterilization

Initial

Non-occulusion

Predominates

Constant Rate of Tubal

Recannalization and Fistula

Formation, Combined with

Ovulatory Dysfunctional

Decline

Shallow Gradient

Age < 30

Age > 35

1.0

0.5

ure 12.1. Clinicopatholo

ical mechanisms proposed in sterilization failure based on

anadian data set

[

https://t.me/med1917

12. Minimizin

the Risk of Sterilization Failure 109

le 12

Filshie Cli

: Re

orted Sterilization Failure Rate

Peri

Is Collected Sterilizations Sterilization T

pe o

Stud

From Performed Method Outcome Stud

Peterson, US 1978–1986 10,685; Various Overa

, 18.5 per Prospectiv

orative Fi

ie c

met

s 1000 over 10 co

ort

Review o

was not Hulka

ears multicenter

Steri

ization use

, as it spring c

ip Hu

a, 36.5 pe

CREST

)

[10] was not

(

1595

)

1000

icense

in Si

icone Si

icone ru

e Unite

, 17.7 pe

States unti

(3329) 1000

1996

[

]

Trusse

[11] 1980–1999 311,960 Main

y 8 per 1000 Retrospectiv

laparoscopic (2496

ailures) multicenter

ie c

Kovacs [12] 1994–1998 30,000 A

ie 2.4 per 1000 Retrospectiv

(estimate) (73

ailures)* multicenter

Filshie [46] 1982–1992 First 202 All Filshie 2.3

er 1000 Case serie

res

onders (1 failure at

from a series 6 months

)

f 4

Birdsall [37] 1988–1989 1094 Mainl

12 per 1000 at Case serie

arosco

ic 12 months

†

Filshie cli

Sokal [45] 1984–1990 2746 Filshie clips 1.7 per 1000

or Randomized

vs rings (2 in

ring an

contro

eac

group Fi

ie c

became

roups at

pre

nant) 12 months

Domini

[44] 1984–1990 2126 Fi

ie c

ips At 12 mont

s: Ran

omize

vs Hulka 1.1 per 1000

or controlled

ips (11 Fi

ie c

ip; 6.9 tria

pregnancies per 1000

occurre

: Hu

a c

9 Hu

a, At 24 mont

2 Filshie) 9.7 per 1000

ie c

ip; 28.

per 1000

a c

* O

the 73

ailures noted in the Kovacs stud

, 14 cases were due to operator error, 29 were properl

app

lied cli

s, and 30 cases had unknown reason

ailure

† In the Birdsall stud

, registrars had a 1.3%

ailure rate and consultants had a 1.9%

ailure rate, and when

oth a consultant and registrar per

ormed the procedure, the

ailure rate was 0.7%. Eighty-six percent

(6/7) of failed sterilizations were due to operator error (wron

structure, initial nonocclusion).

https://t.me/med1917

10 R. Varma and J.K. Gu

ey Factors (Exclud

ng Operator Error) Ident

ed to

Alter Cumulative Probabilit

of Pregnanc

he failure rate for each sterilization method tends to stabilize over the

ong term (Figure 12.2) and may thus be represented as a constant lifetime risk

f sterilization failure (1 in 200 is

uoted for the Filshie cli

[1]). However, a

ore precise estimate would also be based on the patient’s a

e at sterilization

nd the subsequent number of fertile years during which the patient is at risk

f pre

nanc

. The Canadian data set showed that sterilization of

oun

women

ears of a

e) compared to older women

(

ears of a

e) was associated

an overa

increase

ute ris

pregnancy a

ter steri

ization (1.5%

s 0.4%), an

at t

is cumu

ative ris

sta

ize

ater in t

e younger age

roup [11]. T

is statistic is

epicte

in Figure 12.1

tivariate regression ana

ysis o

e CREST stu

y [10] s

owe

he following factors were associated with an increased risk of sterilization

ure:

. Sterilization method used (see Figure 12.2). Most effective were post

partum partial salpingectomy and laparoscopic unipolar coagula

tion at 7.5 pregnancies per 1000 procedures, but laparoscopic

spring-clip application had the highest risk of failure at 36.5 preg

nancies per 1000 procedures (Table 12.2)

. Age at steri

ization. T

e pro

ity o

ure

or women steri

ize

at ages

8 years is greater than that for women sterilized at ages

4 years for all methods of sterilization except interval partial

salpingectomy.

3. Race or ethnicity. Black non-Hispanic women were at signiﬁ

cantly

greater risk for sterilization failure than were white non-Hispanic

4. Study site. Substantial differences in procedure-speciﬁ

c failure rates

between sites were observed, likely representing variation in opera

tor experience, requirements to teach

uniors, and volume of steril

ization operations.

Notably, the US CREST study showed no statistically signiﬁ

cant associations

between risk of sterilization failure and history of pelvic inﬂ

ammatory disease,

istory of previous abdominal or pelvic surgery, or presence of any adhesions

ecorded at sterilization, although these factors have been assumed empiricall

y practitioners to affect the risk of sterilization failure.

Ster

zat

on Fa

lure and Subsequent Intrauter

ne or

ctop

c Pregnanc

verall, for all sterilization methods, studies have shown that ectopic pre

anc

occur in 4.3%–76.0% of failed sterilizations [1]. The relative risk of

ntrauterine to ectopic pre

nanc

occurrence in failed sterilization varies

https://t.me/med1917

12. Minimizin

the Risk of Sterilization Failure 111

accor

to t

e steri

ization met

time interva

rom t

e steri

ization

proce

ure. Women w

ave

een steri

ize

ave a consi

era

bly

ower

ute ris

an ectopic pre

nanc

compare

to nonsteri

ize

erti

women (as sterilization protects a

ainst both intrauterine and ectopic pre

nan-

cies); however, should pre

nanc

occur, the relative risk of it bein

ectopic

rather than intrauterine is hi

her in pre

nant women who have been sterilized.

Women should be counseled about such risks when decidin

the method o

ste

riliz

Cumulative Risk of Pregnancy per 1000 Sterilization Procedures

ears

ince

Steri

Bipolar

6.7

3.1

16.

18.3

20.7

23.3

2.3

5.9

8.3

6.1

9.1

0.6

6.3

7.5

2.5

ostpartum

salpingectomy

ie C

Estimat

)

234567891

rs S

nce Ster

ion

umulat

ve R

sk of Pregnancy

ipola

Silicone Band

Salpingectomy

ilshi

gure 12.2

Cumulative risk o

pregnancy by method extracted

rom US CREST study [10]

ie c

ip stu

ies [12,14]

epicte

in ta

e an

grap

ica

https://t.me/med1917

12 R. Varma and J.K. Gu

ere were 47 ectopic pre

nancies in t

e 10,685 steri

ize

women in t

S CREST stu

, w

equates to a 10-

ear cumu

ative pro

ectopic

nanc

or a

steri

ization met

s com

ine

7.3 per 1000 proce

ures

13]. Women steri

ize

ipo

ar tu

coagu

ation

ore t

e age o

30 years

a pro

ectopic pre

nanc

at was 27 times as

as t

at amon

omen o

simi

ar a

e w

o un

erwent postpartum partia

ectom

(31.9

s 1.2 ectopic pregnancies per 1000 proce

ures) [13].

lass

cat

on of Causes of Ster

zat

ailures: The Role of O

erator Error

Negl

gent Mechan

sm)

The mechanism of sterilization failure should be identiﬁ

ed through a sys-

ematic assessment of fallopian tube histolo

, x-ra

sterosalpin

raph

nd direct pelvic visual inspection. Neither of the ma

or observational studies

n sterilization failure reported on the underl

mechanism of sterilization

failure [10,11]. Our systematic review identiﬁ

ed only 81 cases in the world lit-

erature where the mechanism of sterilization failure had been conﬁ

rmed by

uch s

stematic methodolo

[9]

Sterilization failure may be classiﬁ

ed as arising from negligent or non-

ent mechanisms, which ma

be dependent or independent of the steri

ization method utilized

(

Table 12.3

)

. If the mechanism of failure is due to

ubal nonocclusion or wron

-structure sterilization, these are considered

negligent mechanisms, whereas spontaneous tubal recanalization or ﬁ

stu

ormation mechanisms of failure are considered nonne

ent

Several studies have shown operator error to represent a signiﬁ

cant

(

if not

he ma

or) cause of sterilization failure. One summative review showed that

e overa

10-

ear

ure rate

or wor

e Fi

ie c

ip steri

izations was

0.56% in 10,000 women but fell signiﬁ

cantly to 0.2% when cases caused by

perator error were excluded [14]. A questionnaire-based stud

examinin

ilshie cli

use in Australia showed that of the 73 sterilization failures from

30,000

rocedures, 14 were due to o

erator error, 30 were due to unknown

easons, and 29 occurred in the presence of a “properl

applied clip” [12].

nother stud

, which incorporated participants of the US CREST stud

eported that all 20 sterilization failures usin

sprin

clip and silicone rubber

and arose from im

er a

lication of the occlusive devices [15,16]. Of the

1 steri

ization

ures reporte

in our s

stematic review o

itera

ure [9], 57 cases were due to operator error (wron

structure “sterilized” and

initial tubal nonocclusion), and 24 were not due to operator error (ﬁ

stu

ation or recanalization). We have recentl

submitted an anal

sis of 131 cases

f sterilization failure, incorporatin

our s

stematic review, where 88 were

ent and 43 were nonne

ent sterilization failures [17]

echanical tubal occlusive methods have lower rates of tubo

eritoneal

stula formation than coagulation-based techniques [17–20]. This may be

ecause mechanical occlusion methods destro

much less tube (approximatel

https://t.me/med1917

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