Complications of diagnostic and operative hysteroscopy

What are the established rates

of complications associated with hysteroscopic surgery?

Different procedures have different complication rates. There have been numerous large-scale national audits performed (Table 48.3) (42-44).

Intraoperative complications

Vasovagal reflex

This commonly occurs when dilating the cervix or passing the hysteroscope. The prevalence of vasovagal reaction (1 in 300 cases) depends on the ability of the endoscopist and on the diameter of the scope.

Cervical trauma

Operative procedures can often be performed without the need to dilate the cervix, especially if the vaginoscopic technique described by Bettocchi et al. is used (45). However, operative hysteroscopy might require cervical dilatation. Trauma can be dealt with using pressure, silver nitrate, or sutures. It is best to avoid overdilating the cervix because this can result in leakage of the distending media of the cervix and around the hysteroscope.

Uterine perforation

Uterine perforation is a rare event; as previously mentioned, the inci­dence is higher in operative procedures. In a large systematic review of over 25,000 women only 4 cases (1 in 6000 women) of uterine per­foration occurred (46). The uterus may be perforated by a dilator, the hysteroscope, or an energy source. Management will depend upon the size, site of perforation, and whether there is a risk of injury to another organ. Perforation occurs more frequently at the level of the fundus, without significant bleeding. Simple perforation rarely causes any further damage and can be treated conservatively by ad­mission, observation, and appropriate broad-spectrum antibiotics. Laparoscopy might be considered to exclude bleeding. Complex perforations might be made with a mechanical or an energy source and therefore can be associated with thermal injury to adjacent structures including bowel or large vessels. However, energy sources used in the outpatient setting are usually bipolar (Versapoint) which reduces energy spread through the tissue during the procedure and hence provides high levels of safety.

It is important to be vigilant during the days after perforation as thermal injury to surrounding organs can present some days after the event due to ischaemic necrosis of thermally compromised tissue.

Haemorrhage

Intra- or postoperative bleeding can be caused by:

• the tenaculum (only used if dilating the cervix)

• uterine perforation

• the procedure.

Management will depend upon the site, severity, and cause of bleeding. Intrauterine bleeding occurring during the procedure should be immediately obvious and can usually be controlled by electrocoagulation. If coagulation fails to control the bleeding, the procedure may have to be abandoned and tamponade performed by inserting a Foley catheter and distending the balloon. The catheter should be left in situ for 4-6 hours after which the bleeding nearly always stops.

Table 48.3 Large-scale national audits

Complications with distention medium

Gas or liquid distension medium are essential for hysteroscopic surgery in order to keep the uterine wall separated and to obtain a clear view.

• Large or deep resections of large fibroids.

• Prolonged duration of procedure.

• High pressure used to maintain uterine distension.

• Uterine perforation.

• Anaesthetic used.

Three areas can be focused upon to prevent this complication or at least minimize the risk of permanent damage:

• Attention to the type of media used for performing hysteroscopic surgery.

• Minimization of absorption.

• Recognition and management of the problems promptly.

Delayed complications

• Infection: an incidence of 2:1000 per infection has been reported in over 4000 diagnostic hysteroscopies. Acute pelvic inflamma­tory disease following hysteroscopic surgery is rare, the diag­nosis is made from the classic symptoms and signs and treatment should be by appropriate antibiotics following culture of bloods and vaginal swabs.

• Vaginal discharge: vaginal discharge is common after any ab­lative procedure and can sometimes be prolonged (2-3 weeks) although it is usually self-limiting. Patients should alert their healthcare provider if the vaginal discharge becomes offensive or if they develop pyrexia, heavy bleeding, or severe lower abdominal pain.

• Adhesion formation: intrauterine adhesions are common es­pecially after myomectomy when two fibroids are situated on opposing uterine walls; in this case the myomectomy is better performed in stages to prevent adhesion formation. An IUD and 2 months of oral contraception can help prevent adhesion forma­tion following operative hysteroscopy.