Munro Dan Christiansen, 2015

CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 58, Number 4, 765–797

Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Complications of
Hysteroscopic and
Uterine Resectoscopic
Surgery
MALCOLM G. MUNRO, MD, FACOG, FRCS,*w
and LEE A. CHRISTIANSON, MDw
*Department of Obstetrics and Gynecology, David Geffen School of
Medicine at UCLA; and w Department of Obstetrics and
Gynecology, Kaiser-Permanente, West Los Angeles Medical Center,
Los Angeles, California
Abstract: Adverse events associated with hystero- previously undergone hysteroscopic surgery may be-
scopic procedures are generally rare, but, with increas- have in unusual ways, at least in premenopausal
ing operative complexity, it is now apparent that they women who experience menstruation or who become
are experienced more often. There exists a spectrum of pregnant. Fortunately, better understanding of the
complications that relate to generic components of mechanisms involved in these adverse events, as well
procedures, such as patient positioning, anesthesia, as the use or development of a number of innovative
and analgesia, to a number that are specific to intra- devices, have collectively provided the opportunity to
luminal endoscopic surgery that largely comprise perform hysteroscopic and resectoscopic surgery in a
perforation and injuries to surrounding structures manner that minimizes risk to the patient.
and blood vessels. Whereas a number of endoscopic Key words: hysteroscopy, electrosurgery, complica-
procedures require the use of distending media, the tions, distending media, risk reduction
response of premenopausal women to excessive ab-
sorption of nonionic fluids used for hysteroscopy is
somewhat unique, and deserves special attention on
the part the surgeon. There is also an increasing
awareness of uncommon but problematic sequelae
related to the use of monopolar radiofrequency ute- Introduction
rine resectoscopes that involve thermal injury to the Hysteroscopy is the process of visualizing
vulva and vagina. Furthermore, the uterus that has the cervical canal and endometrial cavity
with an endoscope. When used only for
Correspondence: Malcolm G. Munro, MD, FACOG, diagnosis, the procedure is limited to vis-
FRCS, Department of Gynecologic Services, Kaiser-
Permanente, Los Angeles Medical Center, 4900 Sunset ualization with or without targeted sam-
Blvd, 3rd Floor, Los Angeles, CA. E-mail: pling. However, hysteroscopy is also used
mmunro@ucla.edu to guide the performance of a spectrum of
M.G.M. is a consultant to the following entities: Boston intrauterine surgical procedures that in-
Scientific Corp, Hologic Inc., Karl Storz Endoscopy
America. L.A.C. declares that there is nothing to clude adhesiolysis, metroplasty, myomec-
disclose. tomy, polypectomy, sterilization, and
CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 58 / NUMBER 4 / DECEMBER 2015
www.clinicalobgyn.com | 765
766 Munro and Christianson
TABLE 1. Complications and Adverse Such an approach is designed to minimize

Events With Hysteroscopy the risk of such adverse events and to
Adverse Event Adverse Events
facilitate early recognition and prompt
Category Subcategory management should they occur. Risk
management starts with patient counsel-
Patient Neurological
positioning Compartment syndrome
ing that includes a thorough discussion of
Anesthesia General both diagnostic and therapeutic treat-
Regional ment options, addressing the spectrum
Conscious sedation of adverse events that may occur with
Local each. Counseling should be tailored ap-
Access Cervical trauma
Perforation
propriately to fit the risk profile of the
Distending Gas emboli patient.
media Fluid overload
Electrolyte disturbances
Gas emboli CO2
Air
General Considerations
Perforation Uterus only
Hysteroscopic procedures are associated
Adjacent structures (bowel, with a low number of adverse events with
bladder, vessels) an incidence, reported from The Nether-
Bleeding Cervical lands, of 0.28% of 13,600 procedures2 and
Endomyometrial Germany of 0.24% of 21,676 cases.3 In
Pelvic vessels
Electrosurgical Local (active electrodes)
general, it is apparent that more compli-
Remote (current diversion) cated procedures are associated with a
Infection Endomyometrics much higher operative risk. For example,
Peritonitis metroplasty and myomectomy are asso-
Late Intrauterine adhesions ciated with a complication rate of as high
complications (synechiae)
Pregnancy related (uterine
as 10%.4 Even resectoscopic endometrial
rupture, placenta accreta/ ablation, a procedure that is of relatively
increta, etc.) low risk, is associated with a higher in-
cidence of intraoperative complications
when a loop electrode is used compared
with simple rollerball coagulation.5
endometrial ablation. Such procedures Operative hysteroscopy is associated
are performed in the context of uterine with a spectrum of perioperative and late
distension with one of a number of gas or postoperative complications (Table 1).
fluid media, using one or a combination of Perioperative risks are those related to
mechanical and energy-based instruments patient positioning, anesthesia, and ac-
that are externally manipulated by the cess to the endometrial cavity that include
surgeon. With appropriate understanding cervical trauma and uterine perforation
and care of these instruments, in conjunc- and their sequelae. Such adverse events
tion with attention to meticulous techni- also include gas (especially air) emboli,
que, hysteroscopy is extremely safe with intraoperative bleeding, fluid and electro-
many procedures even suitable for per- lyte disturbances related to excessive ab-
formance under local anesthesia in an sorption of distention media, and lower
office-based environment. However, genital tract injuries related to diversion
since its introduction to the literature in of radiofrequency (RF) current during
1869,1 it has become apparent that there electrosurgery with monopolar instru-
exist a variety of potential complications mentation. Early postoperative complica-
that, although rare, collectively mandate tions include infection and postoperative
a systematic approach to each procedure. bleeding, whereas late complications may
www.clinicalobgyn.com
Complications of Hysteroscopic Surgery 767
be related to sequelae such as intrauterine adhesions, hematometria, and, in the

adhesions and uterine rupture during event of pregnancy, uterine rupture, that
a pregnancy. The next section will be may present unique challenges for both
organized around the competencies the patient and the surgeon.
required to perform hysteroscopy to
facilitate discussion of these adverse
events, including early detection, manage- Complications Related to
ment, and risk reduction for specific
complications. Patient Positioning
ADVERSE EVENTS
Specific Complications Nerve trauma, direct trauma, and com-
In the operating room environment, ad- partment syndromes are the most com-
verse events can be a result of suboptimal monly encountered complications of
or incorrect patient positioning that is patient positioning at laparoscopy. It is
particularly an issue when regional or likely that the vast majority of these ad-
general anesthesia preclude ‘‘real-time’’ verse events occur in women undergoing
patient feedback. The first uniquely re- prolonged general or regional anesthesia
quired competency of hysteroscopy is that in the lithotomy position.
of access to the endometrial cavity; when
this process goes wrong, the operation BACKGROUND
cannot even begin. The next component Complications of the lithotomy or modi-
of a hysteroscopic procedure is transition- fied lithotomy positions are not unique
ing the potential space that is the endo- to hysteroscopy, but must be respected
metrial cavity into a working space that when performing intrauterine endoscopy,
allows the surgeon to manipulate the in- particularly when general or regional
trauterine instrumentation safely and ef- anesthesia is used. When anesthesia is
fectively. This requires the infusion of any provided by local technique, for example
of a number of distending media, each of in the office setting, patients can report
which is encumbered with potential issues discomfort associated with positioning
that can result in undesired outcomes. thereby reducing if not eliminating the
The use of surgical instruments, including risk of positioning-related events.
the resectoscope, can result in perfora-
tion, which has the potential to result in Acute Compartment Syndrome
damage to surrounding organs including The dorsal lithotomy position has been
bowel, bladder, and nearby blood vessels. associated with the development of post-
Although operative bleeding is rarely operative compartment syndrome in the
catastrophic, its presence can frequently lower legs. Compartment syndrome oc-
compromise visualization and thus per- curs when the pressure in the muscle of an
formance of the procedure. Infection is osteofascial compartment is elevated to
thought to be a rare postoperative com- the extent that it compromises local vas-
plication. There are a number of concerns cular perfusion.6–8 This period of ische-
regarding use of RF electrical energy that mia is followed by reperfusion, leading to
are unique to hysteroscopy, and our capillary leakage from the ischemic tissue,
understanding, although limited, now al- and a further increase in tissue edema. If
lows us to better recognize and perhaps this ongoing cycle continues untreated,
prevent adverse outcomes related to this compartment syndrome can ultimately
modality. Finally, there are a number of result in neuromuscular compromise that
late complications, such as intrauterine can cause rhabdomyolysis and serious
sequelae, including permanent disability. them susceptible to stretch injury.12 There

In the lithotomy position, there exist a are 2 orientations that create maximal
variety of intraoperative events that may stretch at these points; flexion of the hip
facilitate this process; leg holders, pneu- with a straight knee that essentially posi-
matic compression devices, and other tions the entire leg vertically; and extreme
sources of direct pressure may increase external rotation of the thighs at the hip.
intramuscular pressure. Leg perfusion is The sciatic nerve can also be traumatized
inherently reduced in the lithotomy and with excessive hip flexion. The common
low lithotomy position, which may be peroneal nerve is also susceptible to com-
enhanced by extreme hip and knee flex- pression injury where it separates from
ion. Acute compartment syndrome has the sciatic nerve and courses laterally over
been shown to be more common in indi- the head of the fibula. Positioning, which
viduals with high body mass index and in results in excessive pressure over the head
cases that are prolonged, usually >3 of the fibula may result in neurological
hours in duration.9 Additional risk fac- injury, which manifests with foot drop
tors include intraoperative hypotension, and lateral lower extremity paresthesia.
hypovolemia, diabetes mellitus, and pe-
ripheral vascular disease.8 RISK REDUCTION, RECOGNITION,
AND MANAGEMENT OF ADVERSE
Neurological Injury EVENTS RELATED TO PATIENT
The principal motor nerves arising from POSITIONING
the lumbosacral plexus (T-12 to S-4) are Because it appears that neurological in-
the femoral, the obturator, and the sciatic jury and compartment syndrome are both
nerves, whereas the numerous sensory related to preoperative patient position-
nerves include the iliohypogastric, ilioin- ing and the length of surgery, there is an
guinal, genitofemoral, pudendal, femoral, opportunity to reduce the risk with a
sciatic, and lateral femoral cutaneous number of consistently applied steps and
nerves. Injury to one or more of these precautions. Ideal lithotomy positioning
nerves can occur in association with hys- requires that flexion at the knee and hip be
teroscopic surgery as it is performed in the kept moderate, with limited abduction
lithotomy position. Regardless of the and external rotation. This approach re-
mechanistic problem with patient posi- duces the stretch or compression on the
tioning, the risk of neurological injury femoral and sciatic nerves. When the legs
increases with prolonged operative are positioned in stirrups, it is important
time.10 to avoid pressure on the femoral head,
Femoral neuropathy can occur in a which can damage the common peroneal
number of settings including excessive nerve. All members of the operative team
hip flexion, abduction, and external hip should avoid leaning on the thigh of the
rotation that individually or collectively patient, an activity that can stretch the
contribute to extreme angulation (>80 sciatic nerve.
degrees) of the femoral nerve beneath Surgeons must also recognize the rela-
the inguinal ligament resulting in nerve tionship between leg positioning and the
compression.11 While in general these in- development of compartment syndrome,
juries resolve, it may take several months especially in prolonged cases. The use of
with intensive physical therapy, to regain knee and upper calf supporting leg hold-
normal baseline function. ers should be avoided for women under-
The sciatic and peroneal nerves are going regional or general anesthesia. In
relatively fixed at the sciatic notch and addition, steps should be taken to posi-
neck of the fibula, respectively, making tion stirrups or boots so that as much of
the weight as possible is borne by the foot. systemic analgesics alone or in combina-
Time in classic lithotomy and Trendelen- tion are often called ‘‘conscious’’ sedation
burg positions should be minimized while and also will not be dealt with. Although
maintaining leg position at or below the regional anesthesia is infrequently used
level of the right atrium.8 for hysteroscopic procedures, a recent
For any of these adverse events, it is case series supports the use of low-dose
important to make a prompt diagnosis to spinal anesthesia as a feasible technique
minimize the risk of permanent and for operative hysteroscopy in women with
serious neurological injury. With com- high surgical risks.13 The reader is re-
partment syndrome, decompression tech- ferred to the recent American College of
niques can prevent both local and Obstetricians and Gynecologists guide-
systemic long-term sequelae. In the event lines on the subject.14
of a neurological injury, it is important to
introduce appropriate physical therapy Local Anesthesia
early to reduce the chance of long-term Local anesthetic agents may be adminis-
or permanent muscle atrophy, thereby tered by the surgeon to supplement the
facilitating the ultimate return of normal effect of systemic analgesia provided by
function. an anesthesiologist who can provide as-
sistance should adverse events occur.
However, in most office settings, locally
Anesthesia administered agents are the sole source of
anesthesia, and the surgeon is usually the
ADVERSE EVENTS only physician in the room. Despite these
Any surgical procedure performed under limitations, a broad spectrum of diagnos-
regional or general anesthesia has the tic and operative hysteroscopic proce-
potential for a spectrum of generic com- dures can be performed in an office
plications that, in some instances, can be setting using a multimodality approach
catastrophic. Allergy, systemic injection, to local anesthesia.15 Consequently, it is
and overdose comprise the main adverse incumbent on the surgeon to understand
events associated with the use of local the prevention and management of com-
anesthesia. plications related to these locally active
anesthetics.
BACKGROUND Locally active anesthetic agents are
generally either from the amino amide or
Regional and General Anesthesia amino ester class, the latter being modi-
It is beyond the scope of this section to fied versions of para-aminobenzoic acid
deal with the spectrum of complications (PABA). These agents alter neuronal de-
that relate to regional and general anes- polarization by blocking sodium channels
thesia. However, it is important for the in the cell membrane, most commonly
anesthesiologist to be aware of issues that those of sensory nerves, thereby prevent-
may be first appreciated from their per- ing transmission of the sensation of pain
spective. Included in this list are fluid to the higher neurons. In large part, these
overload and electrolyte disturbances agents are metabolized in the liver with a
and gas embolization with either room half-life that varies according to the spe-
air, the products of tissue vaporization, cific agent and a number of factors dis-
or distending gases such as carbon dioxide cussed below, but typically is in the range
(CO2). Each of these situations will be of 1.5 to 2 hours.
discussed later in this manuscript. Issues With judicious and careful use, serious
relating to the use of anxiolytics and adverse reactions to injectable anesthetics
are uncommon, but they have been de- intravascular injection is avoided and by
scribed in relationship to high plasma not exceeding the maximum recom-
concentrations that are secondary to one mended doses (lidocaine, 4 mg/kg; mepi-
or a combination of: (1) inadvertent intra- vacaine, 3 mg/kg). The use of a
vascular injection; (2) excessive dose; and vasoconstrictor reduces the amount of
(3) delayed clearance/metabolism.16 The systemic absorption of the agent, almost
potential central nervous system side ef- doubling the maximum dose that can be
fects of high plasma levels include oral used.17 Complications of intravascular
paresthesias, tremor, dizziness, blurred injection or anesthetic overdose include
vision, and seizures and can culminate in allergy, neurological effects, and impaired
respiratory depression and apnea. Cardi- myocardial conduction.
ovascular side effects are those of direct Allergy is characterized by the typical
myocardial depression—bradycardia and symptoms of agitation, palpitations, pru-
potential cardiovascular collapse—an ad- ritus, coughing, shortness of breath,
verse event more commonly described in urticaria, bronchospasm, shock, and con-
association with bupivacaine. Allergic re- vulsions. Treatment measures include
actions are generally IgE mediated and administration of oxygen, isotonic intra-
are usually associated with the ester class venous fluids, intramuscular or subcuta-
of anesthetics, related to the immunoge- neous adrenaline, and intravenous
nicity of PABA. Amino amide anesthetics prednisolone and aminophylline.
do not contain PABA, a circumstance Cardiac effects related to impaired my-
that markedly reduces the risk of allergy, ocardial conduction include bradycardia,
making the amides by far the most com- cardiac arrest, shock, and convulsions.
monly used agents. Emergency treatment measures include
Topical agents can also be associated the administration of oxygen, intravenous
with adverse events, including systemic atropine (0.5 mg) and epinephrine, and the
absorption that may be facilitated when initiation of appropriate cardiac resusci-
the agent is applied to disrupted epithelial tation. The most common central nervous
surfaces. The local effects may be limited system manifestations are paresthesia of
to burning or stinging, whereas systemic the tongue, drowsiness, tremor, and con-
effects mirror those associated with inject- vulsions. Options for therapy include in-
able agents, although serious and severe travenous diazepam and respiratory
manifestations are extremely rare. support.
RISK REDUCTION, RECOGNITION,

AND MANAGEMENT OF LOCAL Access
ANESTHESIA-RELATED ADVERSE
EVENTS ADVERSE EVENTS
The adverse events associated with the use The most commonly encountered adverse
of injectable local anesthetic agents are events related to accessing the endome-
virtually eliminated by screening for al- trial cavity are cervical laceration and
lergy, and with strict attention to both perforation of the cervix and/or uterine
total dosage (in mg/kg) and injection corpus, the latter frequently resulting in
technique, taking care to avoid intravas- premature termination of the procedure.
cular injection. The use of solutions with Operative hysteroscopy is associated with
dilute epinephrine reduces the risk and a cervical laceration rate ranging from 1%
extent of systemic absorption. to 11%.18 Although rare, another poten-
The risk of local anesthetic systemic tial complication is air embolism, which
toxicity is reduced by ensuring that may occur at the time of uterine access,
and will be discussed separately in the dilators, partial or total perforation may
section on gas embolism. result, thereby compromising completion
of the procedure itself. Even partial per-
BACKGROUND forations may set the stage for increased
It goes without saying that if the objective systemic absorption of distending media
lens of the hysteroscope cannot be placed that is the subject of a later section.
through the cervical canal into the endo-
metrial cavity, hysteroscopic procedures RISK REDUCTION, RECOGNITION,
cannot be accomplished. Dilation of the AND MANAGEMENT OF ACCESS-
cervix is frequently not necessary, de- RELATED ADVERSE EVENTS
pending in part on the parity of the wom- The risk of complications with access may
an and in part on the outer diameter of the be largely reduced by any of a number of
hysteroscopic system. However, in some preoperative or intraoperative measures.
instances, active dilation is required to If a stenotic cervix is anticipated, there
access the endometrial cavity. In such may be value in the use of preprocedure
circumstances, the cervix has the potential techniques to facilitate or initiate cervical
to be traumatized, which may result in dilation. One approach is the use of a
lacerations and bleeding that require sur- natural or synthetic laminaria tent, in-
gical repair. serted through the cervical canal 3 to 8
Access to the endometrial cavity may be hours before the procedure. However,
compromised by intrinsic anatomic varia- positioning of even a thin laminaria re-
tion, by acquired anatomic abnormalities quires at least some degree of cervical
of the cervical canal, or by suboptimal dilation for placement all the way through
technique. Acute version and/or flexion the internal cervical os, a feature that
of the uterus are anatomic circumstances frequently limits the utility of this ap-
that can set the stage for difficult access. proach. Furthermore, if laminaria are left
The cervix may also be stenotic relating to in place too long in the nonpregnant
one or a number of factors that include cervix (eg, >24 h), the cervix may over-
nulliparity, postmenopausal status, and dilate, which is particularly counterpro-
previous surgery, such as Cesarean section ductive for maintenance of the distending
or previous cervical procedures such as media.
cryotherapy, large loop excision, or tradi- Another approach is the use of pharma-
tional conization. The stenosis may man- cologic agents such as prostaglandin E1
ifest at the level of the exocervix, more (misoprostol) administered 12 to 24 hours
common with cervices that have been before the procedure. Misoprostol may be
treated with cryotherapy, or at the level administered by various routes and dos-
of the internal os, more frequently encoun- ages; the most commonly prescribed regi-
tered in the setting of a previous Cesarean mens are 400 mg orally, 400 mg sublingual,
section. Our experience is that access can or 200 mg vaginally. There exists high-qual-
be made difficult secondary to otherwise ity evidence demonstrating the efficacy of
asymptomatic large nabothian cysts or misoprostol in reducing the need for
leiomyomata that alter the path of the cervical dilation and the incidence of dila-
cervical canal. tion-related cervical trauma.19–21 Adminis-
If dilation of the cervix is required, the tration in close proximity to the procedure
most common approach is to use cervical may result in a suboptimal response, even if
dilators; either the tapered semirigid ‘‘os administered sublingually.22 It is important
finder’’ for exocervical stenosis or rigid to note that misoprostol may be ineffective
standard dilators for stenosis at the level as a cervical ripening agent in postmeno-
of the internal os. Particularly with rigid pausal women,21,23 however, the addition
of systemic estrogen administration for 2 properly, and provided vaginoscopic

weeks before the procedure may provide technique is not used, the cervix is exposed
results similar to those reported for preme- with a speculum, and the need for cervical
nopausal women.24 In addition, there exists dilation determined. In many instances, a
high-quality evidence that cervical ripening 3 to 5 mm outside diameter sheath can be
with sublingual administration of 400 mg passed without active dilation, or with use
misoprostol is more effective in postmeno- of ‘‘hydrodilation,’’ the pressure exerted
pausal women compared with alternative by the distending media itself.
routes of administration.25,26 If dilation is required, the surgeon
There are emerging data regarding the should avoid the use of force as perfora-
use of vaginal prostaglandin E2 (dinopro- tion may result. If a dilator cannot be
stone) in reproductive aged women before easily passed through the internal os,
hysteroscopic procedures. In a double positioning a hysteroscope in the cervical
blinded randomized controlled trial of a canal may be especially useful. Fre-
total 49 patients, 10 mg of vaginal dino- quently, the canal is revealed to be sten-
prostone was reported to be a more effec- otic or tortuous, and visually directed
tive cervical priming agent than both navigation using the hysteroscope often
placebo and 400 mg vaginal misoprostol.27 allows access to the endometrial cavity. In
Additional investigation in a larger pa- the circumstance of previous access fail-
tient population is necessary to determine ure, we have found that adhesions or
the most effective cervical priming agent synechiae in the canal frequently exist.
and route of administration before hys- In this setting mechanical scissors can be
teroscopic procedures. passed through the hysteroscope’s oper-
If cervical stenosis is encountered, and ating channel and used to divide the ad-
prostaglandins or laminaria have not hesions under direct visualization.
been used or were ineffective, there is Another approach, if available, is the
evidence that deep intracervical injection use of a flexible hysteroscope that may
of dilute vasopressin (0.05 U/mL, 4 mL at facilitate access to the endometrial cavity
4 and 8 o’clock on the cervix) substan- in the setting of acute flexion or version.
tially reduces the force required for Although flexible hysteroscopes generally
cervical dilation.28 Caution must be exer- do not permit the performance of oper-
cised with the use of vasopressin, partic- ative techniques, this approach allows the
ularly in an unmonitored environment, as surgeon the ability to determine the angle
systemic injection can result in a number of inclination of the cervix and the re-
of cardiorespiratory complications. Con- quired trajectory taken when cervical di-
sequently, the use of vasopressin should lation commences.18
be reserved for hysteroscopy in a setting If dilators are required, every attempt
where appropriate resuscitative measures should be used to complete the process in
can be taken should an adverse reaction an atraumatic manner. It is best to avoid
occur. use of a uterine sound because it can
In the procedure or operating room, traumatize the canal or the endometrium,
the surgeon should perform a bimanual causing unnecessary bleeding and/or ute-
examination to assess both the version rine perforation. Difficult cases may be
and flexion of the uterus. In the setting aided using ultrasound guidance, by
of extreme anteflexion, positioning the transabdominal technique with the blad-
buttocks off the table is essential to allow der adequately filled to function as a
adequate spacial orientation of the hys- sonic-viewing ‘‘window.’’ For obese pa-
teroscope for access to the endometrial tients, transrectal ultrasound may be
cavity. Once the patient is positioned preferable.
At the end of the procedure, the cervix can enter the systemic circulation, partic-
should be inspected for laceration and ularly when myometrial dissection results
bleeding. Minor bleeding may be man- in the transection of larger veins. Patients
aged with tamponade and time, while can develop severe hyponatremia, right
larger tears, or those for which bleeding heart failure, and pulmonary and cerebral
is not managed successfully by manual edema with resulting neurological injury
pressure, may require the placement of a and potentially death. There is evidence
delayed absorbable suture. that cerebral edema may be detectable
with as little as 500 mL absorption into
the systemic circulation.29,30 Conse-
Distending Media quently, it is critical to take measures to
reduce the risk of systemic absorption, to
ADVERSE EVENTS monitor the volume of fluid absorbed,
Rarely, adverse reactions to selected dis- and to manage the patient promptly and
tending agents can be encountered and effectively if excess absorption is sus-
gas embolization may, in some instances, pected or detected.
be a serious complication. More com- Calculation of systemic absorption can
monly, especially with nonphysiological be complicated by a number of factors. It
distending media, fluid and electrolyte can be difficult to capture of all the media
disturbances may result from excess sys- that exits the uterus, including that which
temic absorption. Excessive absorption of may saturate the sterile drapes and/or fall
hypotonic fluids can result in fluid over- on the floor of the procedure or operating
load and hypotonic hyponatremia, which room. Furthermore, there is frequent in-
may cause permanent neurological com- consistency with the actual volume of
plications or death. media solutions packaged in large 3-L
bags that have a volume typically 3% to
BACKGROUND 6% more than that indicated on the la-
Distention of the endometrial cavity is bel.31 The amount of distending media
necessary to create a viewing space for absorbed is also related to the intracavi-
both visual diagnosis and for the perform- tary pressure, which when exceeds the
ance of surgical procedures. The media mean arterial pressure may facilitate ab-
choices include gaseous CO2, high-viscos- sorption into the systemic circulation.32
ity 32% Dextran 70, and a number of low-
viscosity fluids, including nonelectrolytic ISSUES RELATED TO TYPE OF
solutions of glycine, sorbitol, mannitol, DISTENDING MEDIA
and dextrose in water, and electrolyte-
containing isotonic solutions such as nor- CO2
mal saline (NS). For diagnostic and sim- CO2 gas can be used as a distending
ple procedures this is rarely a concern, medium for diagnostic hysteroscopy. The
however, during many operative proce- gas is transmitted to the endometrial cav-
dures these agents can gain access to the ity through the sheath of the hysteroscopic
systemic circulation, if and when the in- system that, in turn is attached to an
tegrity of the uterine venous circulation is insufflator specially designed for the pro-
breached. In the extreme, fluid overload cedure, with rubberized or other suitable
may occur, and with the use of nonphy- connective tubing. Although appropriate
siological fluids, electrolyte disturbances for diagnostic purposes, CO2 is unsuitable
typically result. both for operative hysteroscopy and for
It comes as a surprise to many how diagnostic procedures in the setting of
quickly large volumes of distending media endometrial bleeding because there is no
effective way to remove blood and other Low-Viscosity Fluids

debris from the endometrial cavity. There The so-called ‘‘low-viscosity’’ media that
is high-quality evidence from randomized include 3% sorbitol, 1.5% glycine, 5%
trials comparing CO2 with liquid media mannitol, and combined solutions of sor-
that demonstrate increased patient dis- bitol and mannitol are commonly em-
comfort, reduced patient satisfaction, ployed when RF electrosurgery is to be
and longer procedural times with the gas- performed using monopolar instruments
eous media.33,34 For these reasons CO2 gas because they are nonionic, and, therefore,
is not commonly used in most hystero- do not disperse current. However, these
scopic centers. hypoosmolar, electrolyte-free media can
create fluid and electrolyte disturbances if
absorbed in excess.30,38 Neurological ad-
verse events including hypotonic ence-
phalopathy have been reported more
High-Viscosity Fluids often in reproductive aged women than
In current practice, high-viscosity fluids in postmenopausal women.37 The so-
are rarely used for hysteroscopy. The most dium-potassium ATP-ase pump is re-
frequently used high-viscosity fluid is 32% sponsible for shunting sodium and,
Dextran 70, usually marketed as Hyskon indirectly, water out of the cell. In preme-
(CooperSurgical Inc., Pleasanton, CA), nopausal women, the ATP-ase pump is
which is a hyperosmolar fluid. Dextran inhibited by female sex steroids, an effect
70 is most useful for patients who are that is reversed by the administration of
bleeding in the endometrial cavity, be- GnRH agonists.39 This circumstance
cause it does not mix with blood thereby makes hyponatremia a more risky prop-
facilitating visualization in these circum- osition in premenopausal women, at least
stances. However, Dextran 70 can induce those who undergo resectoscopic surgery
an allergic response, coagulopathy, and, if without the use of GnRH agonists.40 In-
sufficient volumes are infused, vascular deed, a number of deaths have been re-
overload and heart failure.35,36 Because ported associated with the use of glycine
Dextran is hydrophilic, it can draw 6 times or sorbitol for operative hysteroscopic
its own volume into the systemic circula- surgery.41
tion, resulting in fluid overload and elec- Glycine is metabolized in the liver to
trolyte disturbances with relatively small ammonia and free water, which can result
absorbed volumes. The manufacturer has in further reductions of serum osmolal-
suggested that the maximum volume of ity.37 Hyperammonemia has been re-
infused Dextran should be 500 mL.37 ported to be an independent cause of
However, given the osmolality of this death associated with resectoscopic sur-
solution, we would suggest that the in- gery of the prostate, but the incidence of
fused volume of this agent should be lim- this complication is extremely rare and it
ited to no more than 300 mL. has not been described associated with
Another issue with Dextran 70 is that it resectoscopic surgery in the uterus. Ani-
tends to ‘‘carmelize’’ on instruments, mal studies suggest that hyperammone-
which must be disassembled and thor- mia likely plays a minor role in morbidity
oughly cleaned in warm water immedi- and mortality in cases of fluid overload.42
ately after each use. Failure to do so may Hypoosmolarity and hyponatremia are
result in irreversible damage to the hys- more likely to induce the greatest degree
teroscopic system. Because of this, Dex- of morbidity; whether or not 5% manni-
tran 70 should never be used with flexible tol (osmolality 274 mOsmol/L) by virtue
endoscopes. of its near isosmolar composition (normal
osmolality 280 mOsmol/L) is a safer absorption. This volume can be estimated

choice than either 1.5% glycine (200 mOs- manually, by capturing, measuring, and
mol/L) or 3% sorbitol (179 mOsmol/L) then subtracting that collected from the
has not been determined and remains only volume infused, or it can be continuously
a theoretical advantage. In a Korean calculated using devices that measure the
comparative study of 2.7% sorbitol- difference between the weights of media
0.54% mannitol and 5% glucose distend- infused from that collected.
ing media, there were no differences in
intraoperative and postoperative levels of Media Delivery
serum sodium, potassium, chloride, glu- CO2 Insufflators: For instillation of gas
cose, and osmolality between groups.43 (CO2) media, the insufflator must be es-
Unfortunately, this study of a still hypo- pecially designed for hysteroscopy; the
osmolar solution does not answer the use of laparoscopic insufflators should
question about the relative safety of 5% be absolutely avoided. Such an approach
mannitol. has been associated with massive CO2
NS is a useful and safer medium, for embolism and death as laparoscopic in-
even if there is absorption of a substantial sufflator flow rates cannot be reliably
volume of solution, NS does not cause adjusted <1000 mL/min.
electrolyte imbalance and, consequently is Syringes: Large-capacity syringes can
a good choice for minor procedures per- be used for office diagnostic procedures,
formed in the office. The development of but are most practicable for infusing Dex-
bipolar RF instrumentation for hystero- tran 70 solution. The syringe can be oper-
scopic surgery has allowed the application ated by either the surgeon or an assistant
of saline as a distending medium in even and is either connected directly to the
more advanced and complex procedures. sheath or attached by connecting tubing.
Ringer lactate possesses properties similar Gravity-based Systems: Continuous hy-
to NS and consequently would be drostatic pressure is effectively achieved
expected to have a similar risk profile; by elevating the vehicle containing the
however, no studies have specifically eval- distention media above the level of the
uated the use of Ringer lactate for hys- patient’s uterus using an IV pole or other
teroscopic applications.37 suitable adjustable device. The achieved
pressure is the product of the width of the
MEDIA DELIVERY AND connecting tubing and the elevation—for
MANAGEMENT SYSTEMS operative hysteroscopy with 10 mm tub-
Media delivery systems refer to the meth- ing, intrauterine pressure ranges from 70
od whereby the fluid is delivered to the to 100 mm Hg when the bag is between 1
endometrial cavity. There exist a number and 1.5 m above the uterine cavity. The
of media delivery systems, ranging from tubing is connected to the endoscope in-
simple gravity to automated pumps that flow port using wide caliber connector
maintain a preset pressure. that allows for the creation of adequate
Distending media management sys- pressure.
tems apply only to fluid media, and are Pressurized Delivery Systems: The sim-
designed to measure both the volume of plest pressurized delivery system can be
fluid delivered and the amount that leaves created by positioning a pressure cuff
the endometrial cavity thereby providing around the infusion bag. Such an ap-
the opportunity to continuously calculate proach does not allow precise control of
a fluid deficit. The goal of these systems is the pressure, so that in prolonged cases,
to continuously and accurately monitor specifically those associated with viola-
and measure the amount of systemic tion of the myometrium, excessive
extravasation could occur, especially if patient and continuous measurement of

intrauterine pressure is sustained above return to the system from the hystero-
the mean arterial pressure. scope or resectoscope, plus measured
In current practice, infusion pumps are losses, if any on the floor. These data
almost always included in media manage- allow for continuous calculation of an
ment systems designed specifically for imputed volume of systemic absorption.
operative hysteroscopic procedures. A va- (Figs. 1A, B). These systems compensate
riety of isolated infusion pumps are avail- for the variable volume in the infusion
able, ranging from simple devices to bags by using either fluid weight or quan-
instruments that maintain a preset intra- tified infused volume to calculate the
uterine pressure. Simple pump devices amount of fluid delivered to the endome-
continue to press fluid into the uterine trial cavity. Complete collection of all
cavity regardless of resistance, whereas fluid escaping or removed from the endo-
the pressure-sensitive pumps reduce the metrial cavity ensures that total weight or
flow rate when the preset level is reached, volume can be subtracted from infused
a design that is preferred because of this weight or volume allowing for calculation
safety feature.44 One disadvantage of al- of systemic absorption. Many of these
most all available systems is that pressure systems now allow simultaneous real-time
is not measured directly from the endo- intravasation rate and fluid-deficit mon-
metrial cavity. Instead, intrauterine pres- itoring via a LED display. This allows the
sure is estimated by measurement of the surgeon to essentially eliminate the com-
pressure proximal to the hysteroscope in plications associated with excess absorp-
the controller unit. Some newer systems tion of distending media.46
are providing the surgeon with direct
measure of intrauterine pressure, a cir- RISK REDUCTION, RECOGNITION,
cumstance that may provide better con- AND MANAGEMENT OF MEDIA-
trol and reduce systemic absorption. RELATED ADVERSE EVENTS
Although there is little value in using these Risk reduction of media-related compli-
systems in the diagnostic setting, mainte- cations begin well before the procedure
nance of a standard intrauterine pressure starts. Recognition of the types of proce-
is essential for operative interventions, dures that are prone to excess media
especially those that are prolonged and absorption is important as a number of
involve entry into the myometrium. preoperative measures can be taken to
reduce risk. For example, diagnostic hys-
Measurement of Systemic Absorption teroscopy and simple procedures that do
The most basic mechanism for measure- not involve the myometrium are low risk
ment of systemic media absorption is the for media-related complications. In con-
manual measurement of inflow and out- trast, procedures at higher risk include
flow that captures fluid from 3 sources: those that are anticipated to require lon-
the resectoscope, the perineal collection ger operative time, particularly those that
drape, and the floor. Unfortunately, the involve dissection in the myometrium
variable volume in the media containers such as resection of type I or type II
and the rapidity of fluid dynamics make leiomyomas. Indeed, there is evidence
this a very clumsy and frequently inaccu- that the risk of fluid overload in resecto-
rate methodology that does not provide scopic myomectomy is directly related to
‘‘real-time’’ metrics.45 The preferred ap- the duration of the procedure, the dia-
proach is the use of an automated fluid meter of the lesion(s), and the proportion
measurement system that takes into ac- of the leiomyoma within the myome-
count the fluid media delivered to the trium.47 Recognition of the volume of
FIGURE 1. Automated fluid management systems (A). The system comprises a pump and a
mechanism for determining the amount of fluid absorbed by the patient. The pump both infuses
distending media and controls intrauterine pressure at a setting determined by the surgeon. (B),
This schematic shows the mechanism of action of an automated fluid management system. The
distending media (A) is placed on the pole while canisters for collecting evacuated fluid are
attached to a separately mounted collection platform that can weigh the contents (B). The
distending media is infused through tubing to the pump attached to the microprocessor-based
controller (C). The pump is then connected to the hysteroscopic system with tubing (D) that is
depicted here passing through the vagina and the cervix into the endometrial cavity. Fluid within
the endometrial cavity is evacuated via tubing (E) into the collecting canisters. Fluid that leaks
around the resectoscope into the vagina is captured either in a specially designed pouch (F), or, if
it falls on the floor by a floor mat, each of which are connected to the collecting canister with
tubing (G and H). The collection platform is electronically connected to the controller (C) and
provides a continuous measurement of the weight of the collected fluid that is converted to
volume by the microprocessor. The ‘‘volume in’’ of the infused fluid is measured either by a
peristaltic pump (pictured) or indirectly by the weight of the fluid lost from the platform. The
microprocessor subtracts the collected fluid (out) from the infused fluid (in) to calculate the fluid
balance—the net systemic absorption.
systemic fluid absorption requires that a Preoperative

media management protocol is in place, For premenopausal women, the volume
preferably one that includes an auto- of systemically absorbed distension media
mated fluid management system previ- may be reduced with the preoperative use
ously described. There should also be of GnRH analogs39,48 and, as previously
predetermined thresholds for the intra- discussed, such an approach may lessen
operative measurement of electrolytes, the morbidity associated with excess ab-
use of diuretics, and for expeditious ter- sorption of nonionic hypoosmolar fluid
mination of the procedure should excess should it occur. Nevertheless, the value of
fluid absorption be detected. routine GnRH analog administration
before uterine resectoscopic surgery for Continuous measurement of the volume

this purpose has not been clearly deter- of medial absorbed systemically can prevent
mined, thus administration is left to the fluid overload, if combined with a protocol
discretion of the surgeon considering an- that stops the procedure at a predetermined
ticipated complexity of the procedure.49 threshold. Calculation of the absorbed me-
Another approach that can be used im- dia should take place in a closed and pref-
mediately before cervical dilation is the erably automated system. If an automated
preoperative administration of dilute vas- system is not available, the volume should
opressin 4 mL (total of 8 mL) of a dilute be measured and deficit calculated every 5 to
solution (0.01 U/mL) injected deeply at 4 10 minutes. Whereas automated systems are
and 8 o’clock in the cervix.50–52 Vaso- generally unnecessary for diagnostic hys-
pressin administration has been shown teroscopy and simple procedures such as
to significantly reduce systemic fluid ab- polypectomy or tubal sterilization, they
sorption by up to 50% in the available may be lifesaving in the context of more
studies.50,52 This is the same technique advanced resectoscopic procedures such as
that has been demonstrated to reduce myomectomy of lesions involving the my-
the force required for dilation of the ometrium. The American Association of
cervix. Gynecologic Laparoscopists has produced
guidelines on the subject as an aid to patient
Gaseous Media management.55
The management of recognized intra-
CO2 is highly soluble in blood and, con-
operative excessive fluid intravasation
sequently, even if emboli occur, they are
varies according to the amount and type
rarely clinically significant. These adverse
of fluid, the patient’s baseline medical
events are discussed in the section on gas
condition, intraoperative assessment,
emboli.
and the status of the procedure. If the
deficit reaches a predetermined limit, the
Intraoperative Fluid Media Management procedure should be expeditiously termi-
Before undertaking a procedure using the nated. For electrolyte-free media this
resectoscope, baseline serum electrolyte would range from 750 to 1000 mL, where-
levels should be measured. Women with as for NS the range is 1500 to 2500 mL,
cardiopulmonary disease should be eval- amounts that vary depending on the pa-
uated carefully for preoperative shifts in tient’s baseline functional status.55 If the
fluid volume. Absorbed volumes toler- predetermined deficit is approached or
ated by healthy women may be cata- reached when using electrolyte-free me-
strophic in the context of compromised dia, serum electrolytes should be meas-
cardiac function. ured and furosemide given intravenously,
The extent of systemic intravasation in a dose of 10 to 40 mg depending on
can be reduced by operating at the lowest renal function. Although measurement of
effective intrauterine pressure (50 to electrolytes may not be necessary for
80 mm Hg), if possible below mean arte- women who approach the upper limit of
rial pressure, and completing the proce- saline media absorption, careful evalua-
dure as quickly as possible. There is also tion for signs of clinical overload will
evidence that use of bulk vaporizing elec- assist medical management.
trodes is associated with reduced systemic Postoperatively, management of clini-
absorption when compared with the re- cally significant fluid and electrolyte dis-
section loops, apparently because of the turbances should involve the support of a
greater degree of electrocoagulation asso- consultant with expertise in critical care.
ciated with bulk vaporization.53,54 Patients may manifest with one or a
combination of cerebral edema, pulmo- a characteristic that is responsible for its

nary edema, and right heart failure and relative safety. However, should large
could require ventilatory support, the use volumes of CO2 enter the systemic circu-
of diuretics and inotropic agents, and lation serious intraoperative morbidity
the judicious use of hypertonic saline and even death may result.64–66
solutions. It is now clear that gaseous emboli may
occur without symptoms or adverse clin-
ical events and that they may be virtually
Gas Emboli ubiquitous when performing resecto-
scopic surgery in the uterus.67 The recog-
ADVERSE EVENTS nition that the products of RF
Venous gas emboli can result in rare electrosurgical vaporization may enter
catastrophic events including death. In the systemic circulation engendered our
most instances, these emboli are derived evaluation of the components of the gases
from room air, however, such emboli may generated by both unipolar and bipolar
be caused by gaseous distension media electrosurgical instruments. One of the
or the products of electrosurgical authors (M.G.M.) was part of a group
vaporization. that was able to determine, as expected,
that the volume of gas produced by these
BACKGROUND instruments was similar, and the gaseous
During intrauterine surgical procedures, products of vaporization largely com-
relatively large uterine veins may be prised hydrogen, carbon monoxide, and
broached providing an entry point for CO2, all of which are rapidly soluble in
gaseous substances into the venous sys- blood.68,69 This information allows one to
temic circulation provided the pressure conclude that the frequently encountered
head of the gas exceeds that in the vein. gas emboli that appear to be the products
The gas may gain access to the vena cava of tissue vaporization are rapidly dis-
then travel to the right heart, the pulmo- solved in blood, making it difficult to
nary arteries, and then to the lungs. If the attain a volume that has clinical signifi-
embolized gas is of sufficient volume, it cance. There are circumstances where
may interfere with gaseous exchange and such gas emboli secondary to RF vapor-
subsequently result in cardiac arrhyth- ization may become clinically relevant.
mias, pulmonary hypertension, and ulti- For example, there may be a greater
mately decreased pulmonary venous amount of systemic accumulation in pro-
return and reduced cardiac output. When longed procedures70 and even small em-
gas embolism occurs in association with boli may have greater clinical significance
a uterine surgical procedure such as in individuals who have compromised
Cesarean section, room air seems to be cardiopulmonary function.
the obvious origin of the embolic materi- Room air, largely comprising nitrogen
al.56 During hysteroscopy, there are a and oxygen, is far less soluble in blood,
variety of gaseous substances that could thereby presenting a much greater risk to
gain access to the venous circulation and the cardiovascular integrity of the surgical
in some instances contribute to cardiovas- patient. During hysteroscopy, air can be
cular compromise and even death.57–62 introduced into the endometrial cavity
Room air is not soluble in blood and a either through the fluid or gas delivery
volume as low as 50 mL has the potential system, or through the cervix, perhaps
to be fatal.63 In contrast, CO2, the dis- aided by factors such as the introduction
tending media used for diagnostic hys- (and reintroduction) of dilators or hys-
teroscopy, is extremely soluble in blood, teroscopic instruments that may function
like a piston. If the patient is in Trende- (Durant maneuver), an orientation that

lenberg position, the pressure differential may reduce the risk of air occluding the
between the endometrial cavity and the outflow tract by placing the right ventricle
right heart increases, thereby facilitating more superiorly.73 The administration of
the passage of air in the endometrial 100% oxygen should be initiated, and a
cavity gaining access to the uterine veins central venous catheter or direct needle
and subsequently the systemic venous puncture of the right heart should be used
circulation. to identify and remove the air or other
gas.74 Cardiopulmonary resuscitation
RECOGNITION, MANAGEMENT, AND and inotropic support are frequently nec-
RISK REDUCTION essary measures and should be readily
The conscious patient experiencing an air available.
embolus will often report dyspnea or Risk reduction starts with education of
chest pain and may display signs of acute the staff included in the procedure, espe-
bronchospasm and pulmonary edema. cially the surgeon, and the anesthesiolo-
The anesthetized patient will not have gist if one is participating in the case.
symptoms, making intraoperative moni- Measures should be taken to minimize
toring the principle method of diagnosis. the effort needed to dilate the cervix as
The most sensitive, but relatively nonspe- many emboli are related to the process of
cific diagnostic test is measurement of access itself, discussed elsewhere in this
end-tidal CO2, which may signify air em- paper. It is best to avoid positioning the
bolism with a reduction of as little as 2 mm patient in Trendelenberg position because
Hg. However, if pulse oximetry is used, a of the potential for increasing the pressure
substantial proportion of patients will head in the endometrial cavity compared
have reduced oxygen saturation.71,72 Oxy- with the right heart.
gen desaturation in conjunction with re- Reducing the risk of clinically signifi-
duced end-tidal CO2 is highly suggestive cant emboli when CO2 is used as a dis-
of air embolism. Whereas there are a tending media requires that the surgeon
number of nonspecific electrocardio- use only an insufflators, specifically de-
graphic changes including premature ven- signed for hysteroscopy. Even the lowest
tricular contractions, heart block, and settings on laparoscopic insufflators
ST-segment depression, a more specific would pump dangerous volumes of gas
finding is the detection of air in the right into the endometrial cavity. Ensuring that
heart by precordial auscultation, prefera- the insufflation pressure is <100 mm Hg
bly with Doppler ultrasound seeking the and the flow rate <100 mL/min can es-
typical ‘‘millwheel murmur.’’ Transeso- sentially eliminate these risks. As previ-
phageal echocardiography is more sensi- ously stated, CO2 should be avoided if
tive, but the technique is not routinely operative procedures are performed.
used during hysteroscopic procedures be- As previously discussed, there is near
cause of its expense, technical demands, ubiquitous production of soluble gases
and relatively invasive nature.62 (CO2, CO, H2) with intrauterine proce-
If air embolism (or clinically significant dures that use RF electrical energy. Be-
gas embolism) is suspected, the location of cause these gases are so soluble in blood,
suspected gas entry should be identified embolization is unlikely to have clinical
and closed, which generally means remov- significance. However, in prolonged cases
ing any instruments from the uterus and with relatively high systemic absorption,
clamping closed the cervical canal. The the absorbed gases may attain a volume
patient should be placed in Trendelenberg that has clinical significance.70 Conse-
position, and rolled onto the left side quently, every effort should be made to
complete each case expeditiously, to re- however, the complication may be a result
spect predetermined intravasation limits, of the hysteroscopic or resectoscopic pro-
and for anesthesiology to recognize that cedure itself. Complete perforations are
such emboli could impact blood gas meas- generally thought to result in inability to
urements and cardiac monitor findings. distend the endometrial cavity, or, if the
The process of reducing the risk of air injury occurs following establishment of a
emboli is clearly multifactorial. Before working space, by otherwise unexplainable
inserting the hysteroscopic system into loss of distension. In either instance, the
the endometrial cavity, the tubing and surgeon is generally unable to continue the
hysteroscope should be purged of room procedure.
air even if the distention medium is CO2. When complete perforation occurs as a
The number of instrument exchanges result of dilation of the cervix, there are
should be minimized, as, for example, usually no other injuries. However, if the
each removal and reinsertion of the resec- uterus is perforated by a sharp hystero-
toscope provides an additional opportu- scopic instrument, or with the activated
nity for the piston-like action of the tip of a laser or an RF electrode, there is a
hysteroscope assembly to push air into risk for injury to the adjacent blood ves-
the systemic circulation.70 Finally, leaving sels or viscera. Without further measures,
the cervical canal open to the air may such injuries are frequently complicated
facilitate the access of room air to the by delayed diagnosis, which is a particular
systemic circulation, so a dilator or other problem for small bowel injury, where
occlusive instrument should always be left mortality is high.76,77 In rare cases, unrec-
in the canal following the process of ognized uterine perforation can present as
dilation. abdominal compartment syndrome sec-
ondary to irrigation fluid moving from
the uterine cavity into the peritoneal
Perforation space.78
ADVERSE EVENTS PREVENTION, RECOGNITION, AND

Although complete uterine perforation
usually results in an inability to maintain MANAGEMENT
a distended uterus, thereby resulting in As most perforations occur at the time of
premature termination of the procedure, dilation of the cervix, it is important to
the serious consequences of perforation reduce risk by taking the steps previously
relate to damage to surrounding viscera described in the section on access before
and blood vessels. and during the procedure.
When using a resectoscope, the opera-
BACKGROUND tor should not advance the electrode while
Perforation of the uterus may be either it is activated. Such an approach should
partial or complete and is, overall a rela- essentially eliminate RF electrosurgically
tively uncommon event. In a retrospective induced damage to large blood vessels
study of 5474 hysteroscopies, uterine per- and the viscera that surround the uterus
foration occurred in 15 cases (0.27%), in the pelvis, including the bowel, ureter,
however, although the perforation rate and the bladder. The exceptions to this
was 0.06% for cases of diagnostic hystero- rule are the division of a uterine septum
scopy, it was 1% for those procedures and bulk vaporization of leiomyomas,
categorized as ‘‘operative hysteroscopy.’’75 particularly when they are located at the
Frequently, perforation occurs during ute- uterine fundus. Perhaps a more tenable
rine sounding or dilation of the cervix, rule would be to avoid any forward
FIGURE 2. Ultrasound-guided intrauterine surgery. Transabdominal ultrasound can be used, in

combination with hysteroscopy, to reduce the risk of perforation. In sequence A, there is
occlusion of the cervix (Asherman syndrome) by adhesions; the 5-Fr scissors are seen hyster-
oscopically (A1) and the simultaneous transabdominal image is shown in A2 with the scissors
(arrows), and the well-defined endometrium (EC), and surrounding myometrium and uterine
serosa. In sequence B, the 5-Fr mechanical scissors are shown hysteroscopically (bidirectional
arrows) in B1 and their echogenic image within the distended cavity is easily visualized in B2.
movement of an activated electrode while viscera and blood vessels. Transabdomi-

in the endometrium or myometrium. nal ultrasound, in most instances, allows
An area very susceptible to perforation for visualization of the distended endo-
is the uterine cornu where myometrial metrial cavity filled with the sololucent
thickness may be as little as 4 mm. Con- contrasting fluid media and the myome-
sequently, the surgeon should be extreme- trium with the surrounding echogenic
ly careful when performing resection in serosal surface (Fig. 2). Within this flu-
this region. If resectoscopic endometrial id-filled space the hysteroscope and, if
ablation is being performed, it may be best appropriately aligned, the electrode or
to use careful rollerball-based electrosur- scissors can usually be seen, a view
gical desiccation in this region. that allows the surgeon to reduce the
In select cases, there may value in per- risk of perforation. This approach may
forming simultaneous ultrasound and/or be of particular value for selected metro-
laparoscopy to reduce the risk of perfo- plasties, when performing myomectomy
ration and/or injury to surrounding on deep type 1 or type 2 lesions, or
for directing adhesiolysis in cases of Bleeding

Asherman syndrome when the usual
intracavitary landmarks may be ob-
ADVERSE EVENTS
scured. This technique has been shown
to be the optimal means of assisting Intraoperative bleeding may emanate
difficult hysteroscopic surgeries, specifi- from the endometrium, myometrium, or
cally the transection of synechiae and from damage to surrounding vessels. In
septa.79 most instances, bleeding will be recog-
Simultaneous laparoscopy does not nized intraoperatively, however, in some
provide the same value in preventing per- cases presentation will be delayed for a
foration, but can ensure that bowel or number of days.
bladder is not attached or adjacent to
the area of dissection, usually simply by BACKGROUND
virtue of the intraperitoneal gas and lap- The uterus is endowed with a rich blood
aroscopically directed positioning of the supply that originates from the uterine
uterus. Performing laparoscopy may be of and ovarian arteries with the largest cali-
particular value in circumstances where ber myometrial vessels increasing in dia-
perforation is a substantial risk and trans- meter as one works from the endometrial
abdominal ultrasound is not available or to serosal surfaces.
successful because of body habitus or The uterine artery originates from the
uterine configuration or orientation. internal iliac artery then bifurcates, usu-
There is also value in simultaneous lapa- ally near the uterine isthmus within the
roscopy in the context of previous uterine broad ligament, resulting in a descending
surgery, such as laparoscopic or laparo- cervical branch and an ascending branch
tomic myomectomy when adhesions to that anastomoses with the ovarian artery
the uterine serosa could place bowel at near the fundus. As the ascending
increased risk for injury. branches course cephalad, they give rise
If a perforation has occurred and there to 6 to 10 arcuate arteries, both posteri-
is evidence of bleeding or presumed vis- orly and anteriorly, each of which anas-
ceral injury (especially with the activated tomose with corresponding vessels from
tip or a laser or electrosurgical electrode), the contralateral side, thereby forming a
laparoscopy or laparotomy should be stacked series of vascular rings. The my-
performed. Injury to the uterus is ometrium receives its blood supply from
relatively easy to detect with a laparo- centrifugal and centripetally oriented
scope. However, mechanical or thermal branches of the arcuate arteries that are
injury to the bowel, ureter, or the bladder oriented in a radial manner, perpendicu-
is more difficult and may require laparot- lar to the serosal surface. When the cen-
omy for complete assessment. If the tripetally oriented radial arteries cross the
patient’s condition is managed expect- endomyometrial junction they give rise to
antly, overnight admission should be the smaller caliber basal arteries. These
considered, and she should be asked basal arteries continue on toward the
to report any symptoms of visceral trau- endometrial surface as the spiral arteries
ma such as fever, increasing pain, nausea, that provide blood supply to the functio-
and vomiting. Thermal injury to the in- nalis layer of endometrium. Bleeding that
testine or ureter may be difficult to diag- occurs during or after operative hystero-
nose, and symptoms may not occur for scopic procedures, especially resecto-
several days to 2 weeks. Further manage- scopic surgery, generally results from
ment of these injuries is beyond the scope trauma to the myometrial vessels or, in
of this paper. the setting of uterine perforation, injury
to uterine arteries or other vessels in the near the uterine isthmus, where RF va-
pelvis. porization or electrodessication techni-
ques should be considered.
PREVENTION, RECOGNITION, AND When intracavitary bleeding is encoun-
MANAGEMENT tered during resectoscopic procedures,
Anemic patients who have low tolerance temporary elevation of the intrauterine
for intraoperative blood loss can be ren- pressure may reduce the blood flow suffi-
dered amenorrheic before surgery with cient to improve operative visualization.
GnRH analogs, and, provided adequate This in turn allows targeting of a large
iron therapy, generally increase their pre- caliber ball electrode for compression that
operative hemoglobin and iron stores. If, is followed by electrosurgical desiccation.
for some reason, such a surgical delay is Intractable bleeding may respond to the
not feasible, preoperative blood transfu- injection of diluted vasopressin deep into
sion can be considered. Another consid- the cervical stroma, again in doses and
eration, particularly when planning techniques described previously.52 An-
operations that involve deep myometrial other approach to the management of
resection, is the preoperative collection intracavitary bleeding recognized at the
and storage of autologous blood. end of a procedure (often secondary to the
Arteriovenous malformations are rare, loss of intrauterine tamponade effect
and may be confused with leiomyomas. from the distending media) is the inflation
Should resection be attempted on such a of a 30-mL Foley catheter balloon or
vascular lesion, massive bleeding may en- similar tamponade device.80 Such bal-
sue. Consequently, should there be any loons can easily and safely be inflated to
suspicion that a focal lesion involving the 50 mL if deemed necessary.
myometrium is an arteriovenous malfor- Management of suspected intraperito-
mation; preoperative assessment with neal bleeding, secondary to perforation of
Doppler ultrasound or magnetic reso- the uterus, will require either laparoscopic
nance imaging is advised. evaluation or laparotomy depending on
The risk or extent of intraoperative the clinical situation. Again, detailed
bleeding may also be reduced by preoper- management of injury to major vessels is
ative administration of GnRH analogs beyond the scope of this paper.
and/or the intraoperative (just before cer-
vical dilation) injection of diluted vaso-
pressin into the cervical stroma in the
same concentrations, doses, and techni- Electrosurgery
ques described previously to reduce the
force of dilation.51 The duration of action ADVERSE EVENTS
of dilute vasopressin is about 20 minutes, Thermal injury can occur to intraperito-
thus repeat dosing as appropriate may be neal structures, especially bowel, if an
of value. It is important to avoid intra- activated electrode perforates the myome-
vascular injection and to advise the anes- trium. Such an injury could also occur
thesiologist in advance of such injections without actual perforation if bowel was
to facilitate recognition of rare but im- adherent to the serosal surface and deep
portant adverse events such as hyperten- myometrial electrosurgical techniques are
sion and bronchospasm. used. Injury may also occur at the site of
The risk for injury to the larger caliber, placement of the dispersive electrode if it
myometrial branches of the uterine artery is improperly placed or dislodged. Rarely,
can be reduced by limiting the depth of with monopolar instrumentation, current
resection in the lateral endometrial cavity diversion may occur causing injury to one
or a combination of the cervix, vagina, as is the case for laparoscopic sealing

and/or vulva. forceps, but for bipolar hysteroscopic sys-
tems, the second electrode functions to
BACKGROUND disperse current.
When the RF electromagnetic energy is
Principles of RF Electrosurgery applied to tissue, it is first converted to
Electrosurgery refers to the application of intracellular mechanical energy manifest-
RF alternating current to elevate intra- ing in oscillation of intracellular proteins.
cellular temperature resulting in tissue Then, as a result of the frictional forces
vaporization or the combination of desic- generated from these rapidly moving mol-
cation and coagulation. The incumbent ecules, the mechanical energy is trans-
requirement to apply energy in a fluid formed to thermal energy. If the energy
environment presents a number of chal- is focused and the cell is heated rapidly,
lenges both to surgeons and to the manu- beyond the boiling point of water (100C1),
facturers of hysteroscopic surgical the cellular water turns to steam, rapidly
equipment. The surgeon should be famil- and massively expanding the intracellular
iar with electrical principles as they apply volume that quickly results in cell rupture;
to the equipment, thus ensuring that the a process called vaporization. If the intra-
desired tissue effect is achieved and risks cellular temperature is sharply elevated
of complications are minimized. above 60C1, but remains below the boil-
RF electrosurgery requires the creation ing point of water, the intracellular water
of a circuit for the passage of electrons is lost by the process of dehydration or
that includes 2 electrodes, the patient, the desiccation. Simultaneously, the molecu-
electrosurgical generator or unit, and the lar bonds of collagenous tissue are hyper-
connecting wires.81 All RF electrosurgical thermally broken then haphazardly
systems require 2 electrodes, a feature that reformed when the tissue cools, creating
makes all electrosurgery, in effect, ‘‘bipo- a homogenous coagulum in a process
lar.’’ Monopolar instruments have only called coagulation. The type of tissue
an active electrode for concentrating and effect is generally determined by the area
delivering the current to the target tissue, of the electrode-tissue interface, the most
whereas the second large electrode is at- important factor in determining current
tached remotely on the patient. While density, but is also importantly related to
many call this electrode a ‘‘return’’ elec- the waveform and the voltage and current
trode, the appropriate name is the disper- output of the generator, the product of
sive electrode as it, in effect, defocuses or which is expressed in Watts.
diffuses the current at the contact point,
thereby preventing a local tissue effect. Electrosurgery in the Uterus
Monopolar instrumentation is designed The hysteroscopic intrauterine environ-
so the entire patient is involved in the ment presents the challenge of establish-
circuit, a circumstance that provides a ing and maintaining electrosurgical
greater opportunity for current to be di- effects in the context of a fluid medium.
verted to undesirable locations. Because electrolyte-containing distention
Bipolar instruments are designed to media such as saline are effective conduc-
contain both electrodes. This circum- tors, they disperse the current from the
stance limits the portion of the patient active electrode of a monopolar instru-
involved in the circuit to the tissue that ment. Moreover, using monopolar active
is near to or interposed between the 2 electrodes with saline distending media
electrodes. Most bipolar instruments are prevents the creation of the zone of high
designed to have 2 active electrodes, such current density necessary to achieve the
desired electrosurgical tissue effect. Con- Resectoscopic RF Complications

sequently, for monopolar instrumenta- Active Electrode Injury: Active electrode
tion, it is necessary to use electrolyte-free injury can occur with either monopolar or
distention media, such as sorbitol, gly- bipolar instruments. Perhaps the most com-
cine, or mannitol that are nonconductive, mon active electrode injury is secondary to
and, in this case, nondispersive. inadvertent activation of the electrosurgical
Bipolar resectoscopic instruments are unit (ESU) when the resectoscope is in con-
generally designed with a distal active tact with the patient’s skin, the vulva, or the
electrode and a more proximal dispersive vagina. The other injuries largely relate to
electrode, a configuration that allows for perforation with an activated electrode that
the completion of a circuit in an electro- can subsequently injure bowel, bladder, or
lyte-rich medium like NS. Compared with other intraperitoneal structures including
monopolar systems, the distance between blood vessels. Bleeding may present acutely,
the 2 electrodes is dramatically decreased, but injury to bowel or bladder, and subse-
thereby reducing circuit impedance. This quent peritonitis, may not manifest for sev-
allows for completion of the circuit, and eral days, a circumstance that can have
the resulting process of intracellular ionic disastrous consequences for the patient.
oscillation and, with application to tissue, Current Diversion: Unique to monop-
the formation of a steam envelope when olar resectoscopes is the complication of
the electrosurgical generator or unit81 is current diversion that can result in injury
activated. Despite these features, there to the cervix, vagina, and/or vulva.
remain a number of design and construc- Understanding the mechanisms involved
tion issues that make bipolar resecto- in such complications is the key to reduc-
scopes less efficient than monopolar ing the risk of occurrence.
versions, a feature that makes many sur- Monopolar uterine resectoscopes al-
geons reluctant to switch despite the in- low transfer of RF energy from the active
herent safety issues provided by being electrode to the external sheath either by
able to work in NS distending media. direct contact (direct coupling) or without
The recent introduction of improved effi- such contact (capacitative coupling), the
ciency, narrow caliber resectoscopes, as latter related to the existence of an energy
narrow as 22 Fr, should facilitate the field around any circuit. Regardless of the
adoption of this safer approach to intra- amount of energy transmitted, provided
uterine RF-based surgery.82,83 there is an intimate contact between the
Both monopolar and bipolar instru- external sheath and the surrounding cer-
ments, when used to vaporize tissue, pro- vix, the diverted circuit will be completed
duce the same vapor cloud that, in fluid between the active and dispersive electro-
media, manifests as an array of bubbles des without the creation of an area of high
largely comprising hydrogen, carbon current density where an undesirable burn
monoxide, and CO2, each of which is could occur. However, if the intimate
highly soluble in blood.68 As previously relationship of the external sheath with
discussed, these products often enter the the cervix is lost, the current can be di-
blood and rapidly dissolve thereby mini- verted to another path that could result in
mizing the chance for a clinically signifi- a zone of high current density on the
cant cardiovascular event. However, vagina or vulva84 (Figs. 3A, B). These
prolonged cases may be associated with are the presumed mechanisms for the
higher volume emboli that have the po- growing series of vulvar and vaginal ther-
tential for clinical impact, especially in mal injuries reported in conjunction with
patients with compromised baseline car- the use of monopolar uterine resecto-
diopulmonary function. scopes.85
FIGURE 3. Current diversion and vulvar vaginal burns. A probable mechanism for vulvar and
vaginal burns is depicted. A, The external sheath contacts the entire surface of the cervical canal.
Current between the generator and the electrode (hatched line) that capacitatively couples to the
external sheath is prevented from forming a zone of high current density as it completes the
circuit with the dispersive electrode. However, in (B) the external sheath has been removed
preventing contact of the external sheath with the surface of the cervical canal. In this situation,
current coupled with the sheath will complete the circuit via the contact with the vagina, which, if
of sufficient low surface area, will allow generation of a zone of high current density that can
create an undesired electrosurgical effect.
The most obvious cause of direct cou- is the existence of tissue fragments, the
pling is a breech in the electrode’s insu- result of resection, that bridge the gap
lation that, when appropriately flexed, between the active electrode and internal
results in contact with the internal sheath and/or external sheaths.86 The risk of
or telescope with capacitative coupling capacitative coupling appears to be in-
(capacitative coupling is the transfer of creased with the use of high-voltage cur-
energy from one otherwise unconnected rents such as those that come from the
circuit to another by means of mutual ‘‘coagulation’’ side of ESUs.87 Capacita-
capacitance) completing the circuit with tive coupling is also more likely to occur if
the external sheath. However, another the surgeon keeps the electrode continu-
potential mechanism of direct coupling ously active while not in direct or near
contact with tissue, or when there are myometrium. Even in selected instances,
continuing attempts to coagulate al- such as metroplasty or bulk vaporization
ready-desiccated tissue. of a leiomyoma, the electrode should
The key mechanism in the generation never be advanced unless it can be easily
of vulvar and vaginal thermal injuries is seen and the relationship between the
likely the loss of contact between the electrode and the uterine serosa is clear.
external sheath and the cervix. The most The use of electrodes with damaged
probable explanations are some combina- insulation should be avoided consequently,
tion of overdilation, or ‘‘externalization’’ a new electrode should be used for each
of the external sheath, a circumstance that case. It is probably safer to use low-voltage
may occur more often when the cervical (cutting) current, minimizing or avoiding
canal is short or when the surgeon func- high-voltage (coagulation) waveforms, as
tions by withdrawing the entire sheath such waveforms probably facilitate these
while keeping the activated electrode fully complications. Even with resectoscopic
extended84 (Fig. 3). electrodessication, it is apparent that both
low-voltage and high-voltage outputs are
RISK MINIMIZATION, RECOGNITION, equivalent with respect to clinical outcome,
MANAGEMENT evidence that should lead surgeons to con-
The following principles serve to reduce clude that modulated high-voltage wave-
the risk of electrosurgical injuries. First forms are unnecessary for intrauterine
and foremost, the pedals controlling the surgery.88 It is also important for the sur-
electrode should not be placed in a loca- geon to maintain intimate contact between
tion that facilitates inadvertent activation. the resectoscope’s external sheath and the
In addition, we recommend keeping the entire length of the cervical canal by avoid-
ESU in a standby mode until the resecto- ing overdilation before starting the proce-
scope is within the endometrial cavity and dure and by keeping the external sheath
ready for use. fully in the cervix when operating. The
Bipolar resectoscopes eliminate the risk electrode should be activated only when
of current diversion, and hyponatremia near or in contact with the target tissue, and
while allowing a larger fluid-deficit the temptation to overdesiccate the tissue
threshold for termination of the proce- should be avoided. All of these steps min-
dure. However, for those who use monop- imize the risk of making the resectoscope
olar instruments, a number of safety into a capacitor with the potential to divert
measures must be considered. current and induce thermal injury to the
The dispersive electrode required of vulva or vagina.84
monopolar systems should be securely One sign of current diversion is the
affixed to the patient, usually on the thigh, absence of/or reduction of the electrosur-
in a location that is not disrupted by gical effect. Following determination that
previous surgery, trauma, or prosthesis, power to the ESU and connections in the
such as a previous graft or burn site or a circuit are intact, the temptation is often
prosthetic hip. Most ESUs possess an to increase the generator output. Care
impedance-based safety mechanism, both should be taken to ensure that potentially
to ensure that the dispersive electrode is traumatic current diversion is not taking
attached to the generator, and to detect place.
partial detachment, but older systems Any metallic object, such as a vaginal
may not have this important safeguard. speculum or a cervical tenaculum, can
As described in the section on perforation, serve to conduct current to locations in
advancement of an activated electrode the vagina and vulva following contact
should be avoided when in the with the external sheath. Care should be
taken to avoid contact of narrow caliber The first hysteroscopic electromechan-

instruments with the resectoscope as they ical morcellator was the Truclear (Smith
may conduct current through tissue re- & Nephew, Andover, MA) system that
sulting in unintended injury. Contact with was approved by the FDA in 2005.
a large area instrument like a weighted For optimal function, it is coupled with
speculum, may well serve to disperse cur- the high-flow Smith &Nephew fluid
rent, thereby preventing thermal injury. pump and media management device.91
The second system made available was
the Myosure Tissue Removal System
(Hologic Inc., Bedford, MA) that was ap-
Mechanical Morcellation proved by the FDA in 2009 and, while
there is an associated fluid and tissue man-
ADVERSE EVENTS agement system (Aquilex) produced by the
Currently, there are few available data same company, other systems can be
regarding complications specific to hys- adapted for use.91 The most recently ap-
teroscopic electromechanical morcella- proved device is the Symphion Tissue Re-
tors. On the basis of the FDA’s moval System (IoGyn/Boston Scientific,
MAUDE (manufacturers and users de- Marlborough, MA) that includes a probe
vice experience) database, hysteroscopic of similar structural design to the electro-
morcellators are associated with fewer mechanical systems described above but
life-threatening complications such as flu- one that is different in that the oscillating
id overload, uterine perforation, and blade is actually an RF electrode. This,
bleeding than is the case for RF resecto- coupled with other structures on the probe
scopes.89 These serious adverse events are that act as dispersive electrodes, create a
addressed in their appropriate sections of bipolar RF instrument that cuts tissue
this manuscript. which is then suction aspirated into a
collection mechanism on the proprietary
BACKGROUND fluid management system. One putative
Hysteroscopic electromechanical morcel- advantage of these systems is more rapid
lation remains a relatively new intrauter- completion of procedures, at least for
ine surgical technique with the basic appropriately selected patients, while us-
design of the currently available devices ing saline distention media. In a recent
derived from an orthopedic endoscopic randomized controlled trial, Truclear
shaving system.90 Each of the currently was found to significantly decrease the
available systems comprise a proprietary operative time for hysteroscopic polypec-
0-degree hysteroscope with a channel for tomy in the outpatient setting as com-
a single-use probe designed with a distal pared with polypectomy using a bipolar
side aperture and a contained reciprocat- needle and extraction tools, with higher
ing blade that together capture and rates of success at total removal of the
morcellate intrauterine polyps and leio- lesion.92
myomas while simultaneously aspirating Currently, there are few available data
the resulting tissue fragments into a res- regarding long-term outcomes and oper-
ervoir. Each requires the use of a fluid ative complications specific to these elec-
management system that includes a rela- tromechanical intrauterine morcellation
tively strong suction function for aspira- systems. A recently published evaluation
tion of the morcellated specimen. These of the FDA’s MAUDE database suggests
devices were developed to further reduce that hysteroscopic morcellation is compli-
adverse events that occur during tradi- cated by adverse events in <0.1% of
tional uterine resectoscopic surgery.89,90 cases, although such studies are extremely
limited due to the nature of voluntarily electromechanical morcellation. First of

reported data.89,93 However, another re- all, it may be stated that electromechan-
cently published systematic review of ical morcellation is simply one type of
1185 cases from publications through intrauterine morcellation; the use of a
August of 2014 seems to support the RF resectoscopic loop indeed is intrauter-
relative safety of this class of device.93 ine morcellation, a technique that has
Complications were uncommon (0.02% been in widespread use since the 1980s
in hospital; 1.6% office) and were gener- without apparent concern.
ally related to vasovagal reactions and Although there are currently no data
perforations that were limited to cases specifically addressing these concerns with
designed to remove placental remnants. electromechanical morcellation or any
other hysteroscopic morcellation techni-
RISK REDUCTION que, there are a number of reasons that
One of the advantages of hysteroscopic should reassure surgeons, patients, and
electromechanical morcellators is a reduc- regulatory agencies. First of all, there is a
tion in some of the serious adverse events long history of intrauterine tissue morcel-
associated with traditional resectoscopy. lation in the face of malignancy—indeed,
Intrauterine morcellation has been shown curetting endometrial cancer is a standard
to reduce operating time, the required for diagnosis of this disorder, an approach
volume of distension media, and the num- that in fact morcellates tissue in the endo-
ber of hysteroscope removals and inser- metrial cavity. Some have suggested that if
tions for the extraction of tissue.94 this is done in conjunction with hystero-
However, the potential for perforation, scopy prognosis might be compromised.
coupled with instrument activation, cre- However, the evidence does not support
ates the opportunity for injury to sur- such a contention including a randomized
rounding structures, most likely bowel. trial where 5-year outcomes of patients
As a result, the surgeon should avoid diagnosed hysteroscopically were equiva-
advancing an activated morcellating lent to those who were diagnosed with
probe into the myometrium, and should endometrial sampling alone.95 As a result,
not activate the oscillating blade when at this time there should be no reason to
it is not adequately visible via the avoid the use of hysteroscopic morcella-
hysteroscope. tion systems because of concern for po-
The usual absence of RF electrical en- tential malignancy.
ergy with electromechanical morcellators
perhaps increases the chance of surgical
bleeding, and limits access to electrodes- Infection
sication as a method for hemostasis. Con-
sequently, surgeons are advised to have a PROBLEM
strategy for management of intrauterine Infection of the endometrium or myome-
bleeding should it occur—this could in- trium (endometritis; endomyometritis)
clude having available bipolar electrodes following hysteroscopic procedures is
and a suitable ESU and/or Foley urethral rarely encountered.
catheters with 30-mL balloons suitable
for creating intrauterine tamponade. BACKGROUND
The current controversy concerning Despite the fact that hysteroscopy is per-
the use of laparoscopic power morcella- formed through the ‘‘contaminated’’ en-
tors and their potential impact should vironment of the vagina, the reported rate
malignant tissue be morcellated begs a of endomyometritis ranges from 0.01% to
similar question regarding intrauterine 1.42%.3,96,97 There is some evidence that
infection is more common following ad- predominance of neutrophils. The selec-

hesiolysis of uterine synechiae96 or when tion of antibiotics and their route of ad-
resectoscopic surgery is performed on ministration is based on the clinical
women with a history of pelvic inflamma- circumstances, including the patient’s pre-
tory disease.98,99 existing medical status, and the presumed
severity of the infection. For the patient
RISK REDUCTION, RECOGNITION, who is medically fit, with few findings,
AND MANAGEMENT and who is able to tolerate oral medica-
The low frequency of infection in the tions, cephalosporins or extended spec-
average patient makes it difficult to design trum penicillins will likely suffice. The
a study with sufficient sample size to patient should be evaluated in 48 to 72
determine the value of prophylactic anti- hours to ensure an appropriate clinical
biotics. Consequently, studies with surro- response. Patients with significant comor-
gate outcomes have been devised such as a bidities, who cannot tolerate or do not
randomized trial evaluating bacteremia in respond to oral antibiotics, or who dem-
patients receiving prophylactic intrave- onstrate evidence of more severe infection
nous amoxicillin-clavulanate.100 How- including sepsis, will likely require admis-
ever, the investigators were unable to sion and the use of parenteral antibiotics,
show that the prophylactic antibiotics using either single agents or multidrug
resulted in a reduction in the incidence therapy as appropriate.
of clinically significant bacteremia. The
authors of a Cochrane systematic review
were unable to reach conclusions regard- Late Complications
ing prophylactic antibiotics because there
were no available randomized trials with PROBLEM
clinically relevant outcomes.101,102 Not There are a number of potential late-onset
yet included in the Cochrane systematic sequelae of hysteroscopic surgery that may
review is a recently published multicenter, manifest as a result of adhesions within the
double-blind, randomized, placebo-con- cervical canal or endometrial cavity. In
trolled study of 1046 women undergoing addition, defects in the integrity of the
hysteroscopy.103 The reported rate of myometrium may leave the uterus suscepti-
postsurgical infection was 1.15% and no ble to rupture in a subsequent pregnancy.
difference was found between the group Finally, pregnancy following endometrial
who received prophylactic cefazolin com- ablation is almost always an undesired out-
pared with the group that received the come and can be associated with an in-
placebo control. Collectively, these find- creased incidence of complications.
ings support the current American Col-
lege of Obstetricians and Gynecologists’ BACKGROUND
guidelines that do not recommend routine Surgery within the uterus can result in the
prophylactic antibiotics for hysteroscopic development of adhesions that can have a
procedures, instead suggesting selective variety of consequences. For example,
prophylaxis only for women with a his- hematometria can develop following en-
tory of pelvic inflammatory disease.104 dometrial resection if cervical stenosis
Endomyometritis may present in the occludes the outflow of blood from the
days following the hysteroscopic proce- endometrial cavity. Another entity, called
dure with one or a combination of pain, posttubal ligation endometrial ablation
odorous discharge, fever, and tenderness syndrome has been described to occur in
on manual examination of the uterus. The the context of an endometrial ablation
patient may develop a leukocytosis with a performed in a woman who has had
previous tubal occlusion. Synechiae with- ablation are at increased risk for cesarean
in the endometrial cavity can prevent or gravid hysterectomy secondary to sig-
efflux of blood through the cervix, where- nificant hemorrhage.112,113
as the occluded tubes prevent passage of
blood into the peritoneal cavity, resulting RISK REDUCTION
in cyclic pain associated with endometrial Women who choose to undergo endome-
bleeding.105 It is not clear if such a syn- trial ablation should be strongly cau-
drome could follow transcervical sterili- tioned regarding possible longer-term
zation with devices such as Essure (Bayer adverse events. Continuing with an effec-
Essure Inc., Pittsburg, PA) or the now tive contraceptive method until meno-
withdrawn Adiana (Hologic Inc.) occlu- pause or at least to the age of 50 can
sion system that, nevertheless, is posi- largely prevent the complications associ-
tioned in tens of thousands of women. ated with gestation in the setting of pre-
A number of hysteroscopic procedures vious endometrial ablation. Should a
are designed to treat infertility, recurrent pregnancy ensue in such a woman, she
pregnancy loss, or to manage uterine should be appropriately counseled re-
bleeding while maintaining fertility. In garding the risks of continuing the preg-
the event of a pregnancy, uterine rupture nancy, and should the pregnancy
is a potential consequence of these proce- continue and reach viability, appropriate
dures, particularly if hysteroscopic sur- investigation and planning should sur-
gery has substantially violated the round the delivery.
integrity of the myometrium. Uterine per- For women who have already had a
foration and resection using monopolar sterilization procedure, at least those with
resectoscopes are well-known risk factors ligation, clips, rings, or electrodessication,
for subsequent uterine rupture during counseling before endometrial ablation
pregnancy.106 One review of the literature should include discussion of cyclic pain
involving pregnancy-associated uterine as a potential long-term adverse event.
rupture posthysteroscopic surgery identi- When intrauterine surgery is performed
fied 12 of 14 cases that had occurred to preserve or enhance fertility, the risk of
following hysteroscopic metroplasty.107 formation of postsurgical uterine adhesions
Although uterine rupture is most likely should be considered. Proposed interven-
to occur in labor, spontaneous rupture as tions to reduce the risk or extent of adhesion
early as 22 weeks of gestational age has formation include systemic estrogens and
been reported after an uncomplicated intrauterine barriers ranging from intrauter-
hysteroscopic myomectomy.108 ine contraception systems (IUDs), to Foley
Endometrial ablation can never be con- catheter balloons, to absorbable mechanical
sidered to be a ‘‘global’’ therapy. As a barriers.114 Estrogen therapy alone has not
result, pregnancy can result in women in been found to consistently prevent intra-
the reproductive years, where only the uterine adhesion formation or to improve
minority has an uncomplicated course, reproductive outcomes; in a number of
at least according to a review of 74 re- studies better fertility outcomes were asso-
ported cases collated and published in ciated with use of estrogen in combination
2006.109 Disorders of placental implanta- with other prophylactic methods.115,116 A
tion have been reported including both systematic review of 5 trials concluded that
placenta accreta and increta and a case of the use of an antiadhesion barrier gel is
uterine rupture resulted in a maternal associated with a decreased incidence of
death.110–112 Not surprisingly, available de novo intrauterine adhesions; however,
case reports suggest that pregnancies this did not translate to an increase in live
complicated by a history of endometrial birth rate.117 Another study comparing
reproductive outcomes after operative hys- 5. Overton C, Hargreaves J, Maresh M. A national

teroscopy suggested no difference in the use survey of the complications of endometrial
of absorbable barriers including sodium destruction for menstrual disorders: the MIS-
TLETOE study. Minimally Invasive Surgical
hyaluronate and carboxymethylcellulose
Techniques—Laser, EndoThermal or Endores-
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of pregnancy.118 lithotomy position. Ann R Coll Surg Engl. 2002;
There may be value in a ‘‘second-look’’ 84:170–171.
7. Cohen SA, Hurt WG. Compartment syndrome
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following the index procedure. At that tent compression stockings. Obstet Gynecol.
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CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 58, Number 4, 765–797

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 58 / NUMBER 4 / DECEMBER 2015

TABLE 1. Complications and Adverse Such an approach is designed to minimize

be related to sequelae such as intrauterine adhesions, hematometria, and, in the

sequelae, including permanent disability. them susceptible to stretch injury.12 There

RISK REDUCTION, RECOGNITION,

of systemic estrogen administration for 2 properly, and provided vaginoscopic

effective way to remove blood and other Low-Viscosity Fluids

osmolality 280 mOsmol/L) is a safer absorption. This volume can be estimated

extravasation could occur, especially if patient and continuous measurement of

systemic fluid absorption requires that a Preoperative

before uterine resectoscopic surgery for Continuous measurement of the volume

combination of cerebral edema, pulmo- a characteristic that is responsible for its

like a piston. If the patient is in Trende- (Durant maneuver), an orientation that

ADVERSE EVENTS PREVENTION, RECOGNITION, AND

FIGURE 2. Ultrasound-guided intrauterine surgery. Transabdominal ultrasound can be used, in

movement of an activated electrode while viscera and blood vessels. Transabdomi-

for directing adhesiolysis in cases of Bleeding

or a combination of the cervix, vagina, as is the case for laparoscopic sealing

desired electrosurgical tissue effect. Con- Resectoscopic RF Complications

taken to avoid contact of narrow caliber The first hysteroscopic electromechan-

limited due to the nature of voluntarily electromechanical morcellation. First of

infection is more common following ad- predominance of neutrophils. The selec-

reproductive outcomes after operative hys- 5. Overton C, Hargreaves J, Maresh M. A national

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