CONTEMPORARY MANAGEMENT OF ABNORMAL

UTERINE BLEEDING 0889-8545/00 $15.00 + .00

INTRAOPERATIVE AND EARLY

POSTOPERATIVE
COMPLICATIONS OF
OPERATIVE HYSTEROSCOPY
Jay M. Cooper, MD, and R. Michael Brady, MD

As hysteroscopy continues to proliferate as a diagnostic and management

tool for intrauterine disease, the importance of preventing, recognizing, and
appropriately managing hysteroscopic complications rises. This article describes
common and dangerous intraoperative and early postoperative complications of
operative hysteroscopy. Seven categories of complications are discussed: disten-
tion media-related complications} mechanical accidents, bleeding, anesthetic
complications, laser and electrical injury, infection, and air embolism.

COMPLICATIONS OF DISTENTION MEDIA

Currently available distention media are CO2 gas, high-viscosity fluid} and
low-viscosity fluid. CO 2 gas is mainly limited to diagnostic hysteroscopy because
it does not allow for clearing of debris from the intrauterine environment during
operative procedures. The most significant potential complication of CO2 is gas
embolism. Many times more soluble in plasma than room air, CO2 provides a
wide margin of safety from embolic complications.v Embolic phenomena are
discussed in a separate section.

High-viscosity Fluid: Dextran 70

Current use of high-viscosity fluid is limited to dextran 70 (Hyskon). Dex-

tran 70 is a dear, viscous solution of 32% dextran 70 in 10% dextrose in water.

From the Department of Obstetrics and Gynecology, University of Arizona, School of

Medicine, Phoenix Baptist Hospital (JMC); and S1. Joseph's Hospital and Medical
Center and Maricopa Medical Center, Phoenix Integrated Residency in Obstetrics and
Gynecology (RMB), Phoenix, Arizona

OBSTETRICS AND GYNECOLOGY CLINICS OF NORTH AMERICA

VOLUME 27 • NUMBER 2 • JUNE 2000 347

348 COOPER & BRADY

Dextran 70 possesses a high viscosity that renders it immiscible with blood,

which allows clear intrauterine visualization in the presence of moderate bleed-
ing and makes it the favorite distention medium of some hysteroscopists. The
dextrans have an average molecular weight of 70,000, with 90% of the molecules
having molecular weights between 25,000 and 125,000. Dextrans less than molec-
ular weight 50,000 are excreted by the kidney without difficultyv 61 Larger
molecules are metabolized to CO 2 and water by the liver and reticuloendothelial
systems. Such molecules have a half-life of several days? In patients with normal
renal function, 50% of dextran 70 is excreted into the urine within 24 hours.
Anaphylactic reactions, fluid overload, and coagulopathy are uncommon
but serious complications of dextran 70. Anaphylactic reactions occur with a
frequency of 1;1,500 to 1:300,000.14.51.74 Dextrans are branched chain polysaccha-
rides of high molecular weight found in certain vegetables and produced by
Leuconostoc mesenieroides bacterial common inhabitants of the oral cavity.'v 70
Anaphylactic reactions can occur even without prior exposure to dextran 70
because of IgG antibodies formed on prior exposure to naturally occurring
dextrans. Treatment consists of diphenhydramine, epinephrine, steroids, and
necessary fluid and ventilatory support as well as ensuring that all dextran
medium has been drained or irrigated from the patient's body. Hapten inhibition
by small amounts of dextran can all but eliminate anaphylaxis.v A 15% dextran
1 in 0.6% sodium chloride solution is available in 20 mL aliquots. Called Promit,
this product is available for intravenous administration just before dextran
infusion. The mechanism of action involves blocking reactive sites on antidextran
antibodies.
Multiple reports exist of pulmonary edema after laparoscopic or hystero-
scopic use of dextran 40 or dextran 70.48• 87. 93 Some authors have speculated that
dextrans have a direct toxic effect on the pulmonary capillary bed. Tulandi"
proposed a toxic effect on the vascular bed leading to pulmonary edema,
thromboplastin release, and potentially coagulopathy. Lukascko'" reported that
100 mL of Hyskon absorbed into the vascular space can expand intravascular
volume by 860 mL. It appears that pulmonary edema can occur with dextran 70
as a result of simple fluid overload from intravascular absorption or from a toxic
effect on pulmonary capillaries. Diuretics are likely to be ineffective with fluid
overload resulting from dextran 70 because the high-molecular-weight dextrans
are not excreted by the kidney but remain in the intravascular space and
exert oncotic pressure. Plasmapheresis may be needed to extract these high-
molecular-weight molecules.
The manufacturer recommends vigilance for pulmonary edema, especially
in the presence of procedures that last more than 45 minutes, absorption of
more than 250 mL of dextran 70, resection of large areas of endometrium, or
administration of intravenous fluids at more than a maintenance rate. Special
mention is made in the package insert of the importance of measuring the
running volumes of infused and recovered dextran 70 every 15 minutes to
remain cognizant of dextran absorption rates.
Dextrans have an anticoagulant effect that is not understood completely.
This effect has led to consideration of their use in deep venous thrombosis
prophylaxisY· 52 Coagulopathy has been reported after the hysteroscopic use
of dextran 70 distention media.w 64 Ellingson and Aboulafia'" described four
problems-acute hypotension, hypoxia, coagulopathy, and anemia-associated
with hysteroscopic use of dextran 70 and proposed a dextran syndrome. They
summarized 11 reported cases of hysteroscopic complications associated with
dextran use. Coagulopathy appeared in 9 of the 11. cases." Data and Nies28
reported that dextrans stick to vascular endothelial cell membranes, thus im-
 COMPLICATIONS OF OPERATIVE HYSTEROSCOPY 349

pairing platelet function. Dextrans can decrease levels of fibrinogen and factors
V, VIII, and IX to an extent not explained by hemodilution and can prolong
bleeding time, sometimes severely,"
Dextran 70 is not the ideal distention medium for operative hysteroscopy.
If the surgeon decides to use dextran 70 for such procedures, he or she must be
vigilant to prevent complications. Awareness of operative time, absorbed dextran
volume, and intrauterine pressures used is crucial. The surgeon must minimize
unnecessary trauma to the endometrium and consider use of continuous-pulse
oximetry as well as preoperative determinations of prothrombin time, partial
thromboplastin time, bleeding time, and type and screens on patients who
undergo operative hysteroscopy. Patients who require an extensive procedure
should be counseled to expect a two-stage procedure if the surgeon cannot
achieve all of the operative goals without risking excessive dextran absorption.

Low-viscosity Fluid

Low-viscosity fluids are the most commonly used distention media for
operative hysteroscopy because of their relative safety and compatibility with
the continuous-flow resectoscope. Continuous-flow systems have increased
greatly the range of procedures that can be performed by hysteroscopy. Conse-
quently, many more patients are exposed to both the benefits and the risks of
low-viscosity distention media. The major complications of low-viscosity media
result from excessive absorption and consequent fluid overload.
Low-viscosity media are best thought of in two groups based on their
tonicity and electrolyte content (Table 1): (1) hypotonic, electrolyte-free media
that can provoke potentially dangerous hypotonic fluid overload and (2) iso-
tonic, electrolyte-containing media that can provoke only isotonic fluid overload,
which is less dangerous and more easily treated.

Hypotonic, Electrolyte-free Distention Media

The hypotonic group includes glycine and sorbitol solutions. These solu-
tions are electrolyte-free and consequently relatively nonconductive. This feature
has made them the preferred distention media for use with conventional electro-
surgical instrumentation. Electrolyte-containing media conduct current and dis-
perse electrical energy, prohibiting conventional electrosurgical instruments from
achieving appropriate current densities for effective surgery.
Hypotonic, electrolyte-free distention media, when absorbed in large vol-

Table 1. OSMOLALITY AND SODIUM CONCENTRATION OF HYSTEROSCOPIC

DISTENTION MEDIA

Sodium
Osmolality Concentration
Medium (mOsm/kg H20) (rnEqlL)
Serum 290 135-145
Glycine 1.5% 200
Sorbitol 3% + mannitol 0.5% 178
Mannitol 5% 280
0.9% saline 308 154
Ringer's lactate 273 130
350 COOPER & BRADY

umes, cause hyponatremic hypervolemia. Initially described as the post-trans-

urethral resection of prostate syndrome, this complication manifests as nausea,
vomiting, headache, and agitation. If untreated, it may progress to bradycardia
and hypertension. Subsequent hypotension, pulmonary edema, cerebral edema,
and cardiovascular collapse can prove fata1. 54• 91 After intravasation by way of
vascular channels in the endometrium or myometrium, glycine and sorbitol are
both metabolized, effectively leaving free water in the intravascular space. This
free water then moves by osmosis into the extracellular space and the intracellu-
lar space. Free water accumulates in the brain tissue, which increases pressure
and causes cellular necrosis. Rapid recognition and treatment of fluid overload
facilitate complete recovery in most patients, but permanent neurologic sequelae
and death have been reported.
Premenopausal women are 25 times more likely than men or postmeno-
pausal women to die or have permanent brain damage should hyponatremic
encephalopathy occur," The immediate cause of death may be more a function
of hypoosmolality than hyponatremia.t" Central nervous system (CNS) neurons
compensate for the influx of free water by pumping osmotically active cations
into the extracellular space, thus decreasing cellular edema. Some data suggest
that this cation pump may be inhibited by sex hormones, accounting for the
marked increase in the morbidity of hyponatremia in premenopausal women."
Cerebral edema consequent to fluid absorption during hysteroscopic endometrial
resection has been demonstrated, with a reasonable correlation between the
amount of absorbed glycine, the degree of hyponatremia, and the likelihood of
cerebral edema."
Glycine, a nonessential amino acid, carries the additional potential complica-
tion of increasing free ammonia concentrations in the blood. Glycine is deami-
nated in the liver and kidney to glycolic acid and ammonia. This ammonia may
contribute to muscle aches, visual disturbances, and encephalopathy. L-arginine
has been suggested to be protective.
Recently, 5% mannitol has been suggested as a distention medium that is
electrolyte poor and compatible with conventional electrosurgical tools while
being isotonic (see Table 1) and carrying less risk for encephalopathy'? Phillips
et al73 reported a series of 122 women who underwent operative hysteroscopy
with either 1.5% glycine or 5% mannitol. Women in the mannitol group had
greater postoperative dilutional hyponatremia but no hypo-osmolality. Two pa-
tients in the mannitol group had postoperative sodium levels of 105 and 110
mmol/L, respectively, but normal osmolalities and no neurologic symptoms.
These data suggest that 5% mannitol may be a better choice when an electrolyte-
free distention medium is necessary.

Isotonic, Electrolyte-containing Distention Media

The isotonic media include normal saline and Ringer's lactate (see Table
1).67 As with the hypotonic media, excessive intravascular absorption is their
main complication. Their sodium content and, more importantly, their physio-
logic osmolalities, however, prevent hyponatremia or hypo-osmolality from ac-
companying this fluid overload. In general, conditions of hyponatremia and
hypo-osmolality are more likely to lead to cerebral edema, encephalopathy, and
permanent injury than with hypervolemia alone. Consequently, fluid overload
from normal saline or Ringer's lactate is less dangerous and treated more easily
than fluid overload from glycine or sorbitol solutions. Given their superior
safety profile, normal saline and Ringer's lactate long have been preferred for
 COMPLICATIONS OF OPERATIVE HYSTEROSCOPY 351

use during operative hysteroscopy in which mechanical, rather than electrosurgi-

cal, instrumentation is used.

Recognition and Treatment of Fluid Overload

Minimizing untoward outcomes from fluid overload requires awareness of
the risk factors for its occurrence, early recognition, and appropriate manage-
ment. Risk factors for excessive absorption of distention media include: excessive
intrauterine pressure; prolonged operating time; procedures that open vascular
channels on the endometrial surface, such as ablation or resection of endome-
trium, myomas, or septa; and uterine perforation or cervical laceration,"
Excessive infusion pressure that results in excessive intrauterine pressure is
likely the most important risk factor in fluid absorption. The lowest pressure
necessary to achieve a clear view of the uterine cavity should be used. Intrauter-
ine visualization can be achieved in almost all circumstances with 60 to 75 mrn
Hg of infusion pressure, which creates intrauterine pressures of approximately
10 to 15 mm Hg or less.55, 82 More than 100 rnm Hg infusion pressure never
should be necessary. The chance of fluid overload is markedly increased when
the mean infusion pressure exceeds the mean arterial pressure." Current resecto-
scopes do not offer a direct measurement of intrauterine pressure, although
there are tools in development with this feature. Even with such information,
the hysteroscopist should use the lowest infusion pressure necessary for good
visualization.P
Currently, infusion pressures are determined either by an infusion pump or
pressurized bag system or by the height of the distention medium source over
the uterus when a gravity feed system is used. When using the gravity feed
system, one can convert inches of water (or distention medium) to mm Hg with
the following equation:
Pressure (inches of H 20 ) = Pressure (mm Hg) X 13/25 mrn/in44
One can see that 75 and 100 mm Hg infusion pressures are achieved with a
bag of distention media suspended over the uterus at heights of 39 and 52
inches, respectively. These are good reference figures. It must be remembered
that a drip chamber in the inflow tubing complicates matters.v When there is
an air fluid level in the drip chamber, its height determines infusion pressure. If
the drip chamber fills, however, the infusion pressure is determined by the
height of the distention medium bag above the chamber. Such an event unknow-
ingly can increase infusion pressures and intravasation of medium.
Operative procedures that last more than 1 hour and incorporate resection
of large amounts of tissue are more likely to lead to fluid overload complications.
This fact must be taken into consideration by the surgeon who begins extensive
myomectomy, lysis of adhesions, endometrial resection, or other procedures that
open venous channels and facilitate fluid entry. The patient should be prepared
for the possibility of a two-stage procedure if the goals of the operation cannot
be achieved without Significant fluid imbalance. Traumatic cervical dilation or
uterine perforation likewise creates vascular rents and increases fluid absorption.
Expanding hydrophilic dilators (such as laminaria) may be considered preopera-
tively for the postmenopausal stenotic cervix. Many premenopausal cervices
require no dilation when a smaller-diameter hysteroscope is used. Every precau-
tion should be taken to ensure that uterine perforation does not go unnoticed.
Slowly advancing the hysteroscope with direct visualization of the endocervical
canal during each entry should be standard practice. Uterine perforation man-
dates termination of the procedure.
352 COOPER & BRADY

Vasopressin has a vasoconstrictive effect on the small vessels that provide

entry for distention media and has been associated with decreased intravasation
of fluid." Simultaneously, it has come under criticism because of its antidiuretic
effect, which may prove disadvantageous in those cases in which the patient
becomes most at risk.': 3. 4 Preoperative treatment with gonadotropin releasing
hormone (GnRH) agonists is also debatable. These agents have been associated
with decreased fluid intravasation," although some hysteroscopists believe that
they soften the myometrium and increase the risk of perforation.
Early recognition of potentially dangerous fluid imbalance depends on
recognition of a discrepancy between intake and output. Such measurements
have relied previously on makeshift collecting systems and the periodic manual
tabulation of input and output. These systems may be suboptirnally accurate and
logistically problematic. The 5% to 10% overfill that is common to commercially
packaged solutions and the losses to drapes and to the operating room floor
proved difficult to calculate. The operating room staff must stop other tasks to
perform periodic calculations, only to repeat the same procedure in 10 or 15
minutes. This burdensome procedure can be replaced by automated fluid
inflow/ outflow monitoring devices that provide accurate, continuously available
fluid balance figures to the physician (Fig. 1). When 1000 mL of fluid has been
absorbed, consideration should be given to obtaining serum electrolytes and
moving toward a rapid conclusion of the procedure, particularly if a hypotonic
medium is in use. A Foley catheter should be in place for intraoperative and
postoperative urine output monitoring. If the fluid deficit reaches 1500 mL or
the serum sodium is less than 125 mmol/L, the procedure should be terminated.
These parameters are of greater import than procedure time limit.
Automated fluid management systems and the continuous fluid balance
monitoring that they provide should lead to a decrease in the incidence of fluid
overload. They also may provide the physician with more information regarding
the precise timing of fluid shifts during prolonged or complicated procedures.
Treatment of posthysteroscopic fluid overload depends on the nature of the
intravasated fluid. Physiologic media-normal saline and Ringer's lactate-can
cause pulmonary edema but do not provoke hyponatremia or hypo-osmolality
and do not cause cerebral edema and encephalopathy. Supplemental oxygen
and diuretics are likely to be the only treatment necessary.
Absorption of 5% mannitol, the isotonic fluid without sodium, leads to
hyponatremic hypervolemia without hypo-osmolality. As mentioned previously,
the absence of hypo-osmolality may be protective against the encephalopathy
that is typically associated with significant hyponatremia. These patients need
oxygen and strict monitoring of sodium, potassium, and calcium. Hypocalcemia
can accompany hyponatremia and calcium may be necessary. Hypertonic saline
is usually not needed in the absence of neurologic or cardiac dysfunction.
The hypotonic agents-glycine, sorbitol, and sorbitol with mannitol-
produce the most dangerous situation: hyponatremic hypervolemia with hypo-
osmolality. Seizures, permanent neurologic sequelae, and death have been re-
ported with serum sodium values as high as 116 mmcl/ L! Indman et aIM have
suggested that any patient with a serum sodium concentration less than 120
mmol/L that results from the absorption of glycine, sorbitol, or other hypotonic
fluid should be considered at risk for these injuries and treated in a critical care
setting until stabilized. If serum sodium is less than 120 mmol/L or if the patient
is symptomatic, she should be treated with 3% sodium chloride at a rate to
increase serum sodium by 1 mmol/L/h. Two ampules of sodium bicarbonate
(50 mEq each) may be used for initial replacement if 3% sodium chloride is not
 COMPLICATIONS OF OPERATIVE HYSTEROSCOPY 353

Figure 1. An example of a fluid management system (Flo-Stat [Gynecare, Somerville, NJ])

that measures and continuously displays the distention media deficit.

immediately available. Hypertonic saline administration should stop once serum

sodium is 130 mmol/L.

Prevention
Beyond recognition of risk factors and use of fluid management systems, the
prevention of fluid overload during operative hysteroscopy lies in meticulous
technique and new technology. Sanders'? has articulated several techniques that
have been advocated to help prevent iatrogenic hyponatremia. These techniques
include the use of low-pressure operating systems and atraumatic cervical dila-
tion with preoperative osmotic dilators. Atraumatic intrauterine technique, in-
cluding electrocoagulation rather than resection for endometrial ablation, has
been proposed to minimize fluid access to the vascular system.
Conventional electrosurgical hysteroscopic instrumentation uses monopolar
current. The active electrode is located on the intrauterine instrument, and the
dispersive electrode is located on the patient's thigh. Current density at the
operative site is adequate for cutting, coagulation, or desiccation. Current then
disperses through the patient's body and returns by way of the electrode on the
354 COOPER & BRADY

thigh. These systems require electrolyte-free media because electrolyte-con-

taining media disperse the current prematurely and render the device ineffective.
Technologic advances have furnished hysteroscopists with electrosurgical instru-
ments compatible with normal saline and Ringer's lactate. Consequently, the
hysteroscopist may offer the benefits of electrosurgical operative hysteroscopy
with dramatically decreased risk of hyponatremia or hypo-osmolality. Three
new instruments have been created that avoid the inherent complications of
hypotonic media by making use of physiologic distention media."
Versapoint (Gynecare, Somerville, NJ) is an example of a bipolar operating
system that conducts electric current between two electrodes that are in close
proximity in isotonic media. A 1.7-mm diameter bipolar electrode can be used
for desiccating or vaporizing tissue. The bipolar generator has three modes:
desiccation, vaporization, and blend. During desiccation the generator increases
the temperature around the electrode lip so as to create a vapor pocket. Energy
flows into the tissue and creates desiccation but not vaporization and the probe
is insulated. During vaporization, the generator heats the saline around the
active electrode to create an insulating vapor pocket. This high-impedance micro-
environment creates an activated electrode with a red glow, which can vaporize
tissue. Versapoint is useful for obliteration of small polyps, synechia, and small
septa. Its small size renders it impractical for resecting large myomas 01' per-
forming endometrial ablation.
The ERA sleeve (Conceptus, San Carlos, CAl is a disposable outer sheath
that fits over any standard resectoscope and functions as a return electrode in
isotonic media (Fig. 2). This monopolar system relocates the return electrode
from the patient's thigh to the hysteroscope shaft within the uterine cavity, thus
creating a short return path for the current and an efficient circuit with little loss
of energy into patient tissue, To begin operating, the loop must be activated by
placing it against vascular tissue and initialing current flow. The surgeon may
cut, dissect, or vaporize tissue with methods identical to those used in standard
resectoscopic practice. Higher power settings are required with use of the ERA
sleeve. With the resultant generation 01 increased bubbles observed in the opera-
tive field, a theoretical concern exists that this phenomenon could increase the
potential for gas emboli. Despi te this concern, no serious complications have
been reported with more than 500 procedures since the device's approval.

Figure 2. The tip of a monopolar hysteroscopic instrument that facilitates tissue Gutting and
coagulation in isotonic media. The return electrode is housed in the morcellator.
 COMPLICATIONS OF OPERATIVE HYSTEROSCOPY 355

The OPERA Star system (FemRx, Sunnyvale, CA) is another modification

of monopolar technology that facilitates tissue cutting and coagulation in iso-
tonic media. Additionally, this system features a morcellator that eliminates the
need to manually remove tissue chips shelled from myomas. This system allows
current to move from the active electrode through tissue to the return electrode,
which is located in the morcellator. The design of the system forces current
through tissue without allowing it to disperse in the surrounding isotonic media,
thus allowing cutting and coagulation to be achieved at low power settings
(85-100 W).

MECHANICAL COMPLICATIONS

The major mechanical complications associated with hysteroscopy are cervi-

cal laceration, uterine perforation, and the possible dissemination of malignant
endometrial cells.

Cervical Trauma

Often the most challenging part of a hysteroscopy is dilation of a difficult

or stenotic cervical os. A single-toothed tenaculum easily can tear the cervix and
create bleeding that impedes the procedure. A double-toothed tenaculum or ring
forceps often can provide a broader and less traumatic attachment to a friable
or fragile cervix.
The preoperative evaluation of a patient should include examination of the
cervix as well as historical questions that can identify risk factors for cervical
stenosis, diethylstilbestrol exposure, or a history of difficult cervical dilation.
Nulliparous and postmenopausal women are more likely to provide a challenge
to the surgeon because of difficulty with cervical dilation. Osmotic dilators
inserted the day before surgery should be considered for women in these groups.
Alternatively, the surgeon may take advantage of a small-diameter (:0;5 rom)
rigid hysteroscope or a flexible hysteroscope, commonly available in diameters
less than 5 rom. Such diminutive instrumentation often allows accomplishment
of the surgical goals with little or no cervical dilation.

Uterine Perforation

The 1993 membership survey of the American Association of Gynecologic

Laparoscopists identified uterine perforation as the most common complication
of hysteroscopy, occurring at the rate of 14 per 1000 cases." Uterine perforation
most commonly occurs during dilation of the cervix. Cervical stenosis, severe
uterine anteflexion or retroflexion, lower uterine segment myomas, synechiae,
Asherman's syndrome, and operator inexperience all increase the risk of perfora-
tion at this time. Perforation also may occur from trauma to the uterine wall
during intramural myoma resection, septa division, endometrial resection, or
adhesiolysis. Such perforations are less likely with increasing experience. A
survey of physicians training to perform endometrial resections reported that
33% of uterine perforations occurred during the surgeon's first procedure and
52% within the first five procedures." Visceral injuries occurred only when the
training physician lacked direct supervision. Proper management of uterine
perforation hinges on prompt recognition and appropriate investigation. The
356 COOPER & BRADY

extent of investigation necessary depends principally on the site of perforation

and the nature of the perforating instrument.
A fundal perforation with a uterine sound or a narrow dilator can be
managed expectantly with vigilant observation in the absence of bleeding. A
short course of antibiotics may be considered. Fundal perforations with detect-
able bleeding or those caused by larger dilators or hysteroscopes should be
considered candidates for diagnostic hysteroscopy to rule out significant bleed-
ing or visceral injury. Injury to large bowel, rectum, and occasionally small
bowel can occur when scissors or endometrial biopsy forceps perforate the
myometrium."
Perforations of the anterior or posterior uterine wall can occur when a false
passage is created through the myometrium of an anteflexed or retroflexed
uterus. Preoperative bimanual examination and knowledge of uterine position
can prevent such occurrences. Transabdominal ultrasonography during cervical
dilation can help to illustrate the course of the endocervical canal in an unusually
positioned uterus.
Anterior wall perforations may lead to bladder injury, which is recognized
either by spill of urine during attempted dilation or, after hysteroscope insertion,
on visualization of a large cavity with cloudy fluid and no tubal ostia. Repair is
not necessary if the defect is small but must be meticulous if it is large or
was created with electrical or laser energy. Cystoscopy should be performed if
uncertainty exists about the presence of bladder injury. Posterior wall perfora-
tions can involve the rectum or large bowel. If the uterine serosa is perforated,
diagnostic laparoscopy is warranted.
Ureteral injury can accompany posterior or lateral perforations, which are
more common during difficult endometrial resection or intramural myomec-
tomy. Vigilant laparoscopic inspection of the ureter and urologic consultation
may be required.
Perforations in the lateral uterine wall are most likely to cause vascular
injury. Iliac vessels, mesenteric artery, aorta, and presacral vessels have been
injured." Broad ligament hematomas or significant hemorrhage may result.
Diagnostic laparoscopy should be performed promptly.
Any perforation created with electrical or laser energy carries a significant
risk for concomitant visceral injury. Not only must the patient be explored
thoroughly with the laparoscope for evidence of damage to bladder, ureters,
bowel, and vessels but she also must be followed for days with serial white
blood counts, temperatures, and vigilance for any signs or symptoms of devel-
oping visceral injury. Laparotomy may be necessary to discount visceral injury
fully. Penetrating thermal injury has been managed successfully with primary
repair, obviating the need for bowel resection and reanastomosis."
Meticulous and gentle technique is the key to prevention of cervical lacera-
tion and uterine perforation. Preoperative consideration of osmotic dilators,
appreciation of uterine position, gentle dilation with traumatic instruments, and
investigation of any unusual findings can decrease the incidence and increase
the recognition of mechanical complications. Liberal use of concomitant Iaparos-
copy may prevent some perforations and certainly facilitates rapid recognition
and investigation. The hysteroscopic surgeon must be trained thoroughly in
each procedure undertaken. This includes understanding of the mechanism of
action and the depth of tissue penetration of each operative device used as well
as supervised experience before new procedures are attempted alone.
Several authors have reported cases of dissemination of endometrial carci-
noma at the time of hysteroscopy.w 75,76,81 No well-designed prospective trial has
identified that this phenomenon carries clinical significance, Some controversy
 COMPLICATIONS OF OPERATIVE HYSTEROSCOPY 357

exists regarding whether endometrial cancer should be considered a contraindi-

cation to hysteroscopy.

BLEEDING

Hemorrhage during or just after the procedure is the second most common
complication of hysteroscopy and occurs in 2.5 of every 1000 cases." Resection
of myomas particularly those with an intramural component, seems to carry the
highest risk of hemorrhage, which is 2% to 3%,51 Endometrial ablation or resec-
tion procedures can provoke hemorrhage. Rates range from 0.2% to 2.2%.8,57
Endometrial resection appears to be more likely to elicit bleeding than does
Nd:YAG laser or roller-ball ablation. Hemorrhage also can occur in association
with septal resection or from cervical or lower uterine segment trauma.
Preoperative evaluation of a patient with Significant bleeding or intramural
myomas should include consideration of a hemoglobin or hematocrit. A course
of oral contraceptives or GnRH agonist therapy can decrease bleeding and allow
the patient to recover some red cell volume before surgery.
Problematic bleeding during operative hysteroscopy is rare because the
pressure of the distention medium decreases blood loss from venous sources.
Particularly at the base of fibroids, arterial sources can deliver blood into the
distention medium to cloud the operative field. A wire loop, rollerball, or
rollerbarrel with 40 to 60 W of coagulating current generally can stop such
bleeding. Continuous-flow systems can flush clots and blood quickly from the
uterine cavity and facilitate continuation of the procedure.
Upon concluding an operative hysteroscopy, the entire cavity can be visual-
ized as the intrauterine pressure is reduced. Any occult bleeding should manifest
itself. Some bright red, bloody distention medium typically drains from the
cervical os just after removal of the hysteroscope. This discharge stops as the
uterus contracts, closing off venous channels on the endometrial surface. If
bleeding continues, a Foley catheter may be inserted into the uterus and its
balloon filled with 20 to 30 mL of saline." The balloon tamponades the bleeding
and may be removed in 2 to 24 hours at the discretion of the physician.
Vasopressin (20 U in 20 mL normal saline) may be injected into the cervix to
inhibit bleeding further from the lower uterine segment. If these methods fail,
misoprostol (prostaglandin E1 ) can be given rectally to provoke tonic uterine
contraction, or the uterus can be packed with vasopressin-soaked gauze. 86 If
hemorrhage is recalcitrant to all of these measures, consideration should be given
to uterine artery embolization by an interventional radiologist. Hysterectomy is
the definitive intervention if all others fail.

ANESTHETIC COMPLICATIONS

Operative hysteroscopy is commonly performed in a surgical suite in which

conscious sedation, regional or general anesthesia, and the presence of an anes-
thesiologist are available. At times operative hysteroscopy can be accomplished
with paracervical or intracervical anesthesia. The hysteroscopist must be aware
of the common and dangerous complications from such anesthesia.
Lidocaine is the most frequently used agent for paracervical block anesthe-
sia. Inadvertent intravascular injection or overdose of lidocaine can stimulate or
depress the CNS. Aspiration before injection of local anesthesia alerts the physi-
cian to the possibility of intravascular administration. Maximum recommended
358 COOPER & BRADY

dosages are 4.5 mg/ kg (not to exceed 300 mg) of lidocaine without epinephrine
or 7 mg/kg (not to exceed 500 mg) of lidocaine with epinephrine. For a 60-kg
woman, these guidelines allow maximum doses of 420 mg and 270 mg of
lidocaine with and without epinephrine, respectively. Usually no more than 200
mg, or 20 mL of a 1% solution, is necessary for a paracervical block.
Toxic reactions to lidocaine and all amide anesthesia may be acute or
delayed. The reactions are usually eNS, cardiovascular, or allergic in nature.
CNS toxicity usually presents with symptoms of eNS stimulation such as anxi-
ety, restlessness, dizziness, nausea, tremors, or seizures. Alternatively, hypoten-
sion, sinus bradycardia or other arrhythmia, cardiovascular collapse, and death
may occur. The remote possibility of such reactions mandates the presence of
resuscitation equipment and capable personnel on site.
Allergic reactions to lidocaine are varied and include rash, bronchospasm,
and status asthmaticus. Treatment begins with adrenaline 0.5 mL (1:1000) subcu-
taneously or intramuscularly and may require fuJI ventilatory support.

LASER AND ELECTROSURGICAL COMPLICATIONS

The important intraoperative or early postoperative complications from

laser and electrosurgical devices are thermal injuries. Thermal injuries to viscera
can have delayed manifestations that include peritonitis, sepsis, and death. The
imperative to detect and treat at surgery is obvious. Usually, but not always,
thermal visceral injuries are a consequence of uterine perforation.
The Nd:YAG laser provides a dependable 4- to 5-mm depth of endometrial
tissue penetration in all directions." Despite this predictability, thermal bowel
injury without perforation has been reported." Loffer" has articulated the con-
cept that a high-power setting of the Nd:YAG laser with slow movement of the
laser fiber could explain this injury because higher powers have been applied
safely.44
Electrosurgical thermal effects are more complex and not fully understood;
the best combination of power and waveform has yet to be determined." Many
investigators suggest that endometrial ablation with the roller-ball or roller-
barrel is safer than endometrial resection with the wire loop, however, thermal
bowel injury in the absence of uterine perforation has been reported after roller-
ball endometrial electrocoagulation."
The potential problems of monopolar radiofrequency electrical energy, as
used in laparoscopy, result from unrecognized energy transfer (stray current)
that can cause tissue damage outside the view of the scope. Such undesired
energy transfer is believed to occur by three main mechanisms'": (1) faulty
insulation of electrodes, (2) capacitative coupling, and (3) direct coupling. The
degree to which these three mechanisms apply to hysteroscopic surgery has not
been addressed.
Insulation breaks in the shaft of the active electrode can allow nearly all of
the current to exit the electrode and enter tissue outside the vision of the opera-
tor.
Capacitative coupling describes the situation when a laparoscopic (or poten-
tially hysteroscopic) operating system arrangement creates a capacitor. A capaci-
tor is defined as two conductors separated by a nonconductor. When the active
electrode of a monopolar device is electrically separated from the abdominal
wall by a nonconductive plastic sleeve, a capacitor exists. As the instrument is
used, a charge can build up between the active electrode and the patient's body.
Eventually this charge has the potential to induce current between the active
 COMPLICATIONS OF OPERATIVE HYSTEROSCOPY 359

electrode and other conductors. These other conductors could be other metal
instruments (during Iaparoscopy) or patient tissue. Because capacitative coupling
current is unpredictable and occurs out of the view of the scope, its culpability
in laparoscopic visceral injury has not been documented decisively. The danger
of capacitative coupling in hysteroscopy also has not been demonstrated.
Direct coupling describes unintended contact between the active electrode
and other metal instruments in the surgical cavity. Such contact can transfer
current through the other instruments into patient tissue. Direct coupling is not
an issue in single instrument operations such as hysteroscopy.
In both laser and electrosurgical work, the hysteroscopist must realize that
advancement of an activated electrode or laser should be performed only with
the tip in direct view. The penetrating ability of such activated appliances
permits them to traverse the myometrium rapidly, often with scant pressure.
Whenever thermal injury is suspected, diagnostic laparoscopy or laparot-
omy is necessary. The first goal should be to inspect thoroughly the surface of
the uterine serosa. The finding of blanched serosa suggests contact with the
operative instrument and should provoke the surgeon to proceed with laparot-
omy to inspect fully the bowel. The ureters and broad ligaments likely can be
visualized better laparoscopically.

INFECTION

Infection is an uncommon complication of operative hysteroscopy but occa-

sionally causes serious morbidity. A survey of general operative hysteroscopy
revealed an infection rate of 1.6%.59 Infection rates from hysteroscopic endome-
trial ablation are 0.3% to 0.4%.34,37,56
Most postoperative infections are uncomplicated cystitis, endometritis, or
parametritis, but more serious infections have been reported. Fatal toxic shock
syndrome after endometrial resection has been described." A broad ligament
abscess that required laparotomy after uterine perforation during operative
hysteroscopy also was reported" as well as tube-ovarian abscesses.w Pyometria
after endometrial resection and ablation that required an intrauterine drain and
parenteral antibiotics has occurred."
Several factors have been proposed to increase the risk of postoperative
infection": (1) lack of aseptic technique, (2) long operative procedures, (3) re-
peated insertion and removal of the hysteroscope through the cervix, (4) exten-
sive dissection in utero, (5) previous pelvic inflammatory disease, and (6) tissue
fragments left in utero.
Prophylactic antibiotics have not been demonstrated to reduce the incidence
of postoperative infection, perhaps because of the low incidence of such infec-
tions in the general population. Patients with a history of pelvic inflammatory
disease likely benefit from prophylactic antibiotics, however. McCausland et al60
reviewed 700 patients undergoing operative hysteroscopy. Two percent of the
patients had a history of pelvic inflammatory disease. Of the four previously
infected patients not given prophylactic antibiotics, three developed Significant
postoperative infections, including tubo-ovarian abscess. Of 10 previously in-
fected patients who were prescribed 200 mg of oral doxycycline twice daily that
was initiated after laminaria insertion, none developed postoperative infection.
Prophylactic antibiotics also should be used in patients with valvular heart
diseases that place them at risk for endocarditis. Additionally, some hysteroscop-
ists use prophylactic antibiotics in all infertility patients, reasoning that infection
360 COOPER & BRADY

in these patients could be particularly damaging. Other hysteroscopists use

prophylactic antibiotics whenever larninaria are used. 15
Postoperative cystitis and endometritis can be treated in a standard fashion.
Endometritis should prompt a pelvic ultrasound to rule out abscess and an
abdominal series to rule out free air in the peritoneal cavity (if no concomitant
laparoscopy was performed). Blood cultures and broad-spectrum antibiotics
should follow. Curettage typically is avoided because of fears of exacerbating
bacteremia or producing Asherman's syndrome.

AIR EMBOLISM

Air embolism is a rare but devastating complication of hysteroscopy that

rightly receives attention as a frightening, sudden, and potentially fatal hazard
in otherwise healthy women. First described in 1985,4° case reports began to
surface in the early 1990s" Brooks has reviewed seven cases of air embolism
with five fatalities. IS The hysteroscopist must understand the pathophysiology of
air embolism to prevent, diagnose, and manage most effectively this potentially
disastrous problem.

Physiology

In neurosurgery, air embolism is recognized as a constant threat when

cerebral venous channels are opened to room air,U, 85 particularly when the
brain is positioned above the level of the heart and diastole creates a negative
intravenous pressure. The brain is frequently bathed in saline solution to prevent
intravasation of room air into the venous circulation. A similar situation exists
in gynecology, in which venous channels in the cervix or endometrium can
allow ambient air or pressurized gas to enter the circulation. The intravasated
gas travels to the right side of the heart where its compressibility renders the
pump ineffective. As the right outflow tract is functionally occluded, pulmonary
blood flow drops acutely. Subsequently, cardiac output and blood pressure
drop, tachycardia and tachypnea develop, and electrocardiogram changes briefly
precede cardiovascular collapse. As pressure in the right side of the heart
increases, the foramen ovale can be reopened in 15% of adults, which results in
passage of air to the left side of the heart and paradoxic emboli through the
arterial tree to the brain and other organs." The characteristic heart murmur
of air embolism is variously described as metallic, machine-like, drum-like,
or slashing.
In the field of obstetrics and gynecology, air embolism has been reported
during cesarean section/9• 92 therapeutic abortion.f tubal insufflation." and oro-
genital sexual activity during pregnancy. IS Emboli have been reported with the
use of CO:u saline, glycine, and Ringer's lactate as distention media during
hysteroscopy. In some cases embolization occurred before any distention me-
dium was used, just after dilation and curettage."
Authors have disagreed as to the potential of CO2 to provoke clinically
significant emboli.w 30. 69 If gas embolization occurs when CO2 is being used for
uterine distention, one frequently indicts the distention medium. This indictment
may have no basis in fact. CO2 is much more soluble than room air in plasma
and may not pose as much of a danger to embolize. Corson et aP6 infused CO2

"References 17, 19, 23, 24, 27,30, 63, 65, 66, 69, 72, 78, 89.
 COMPLICATIONS OF OPERATIVE HYSTEROSCOPY 361

directly into the femoral veins of six ewes at flow rates up to 90 mL/min
and found some premature ventricular contractions in one animal as the only
significant cardiovascular effect. These data provide support for the concept that
C02/ with its high plasma solubility, provides a wide margin of safety compared
with room air.
Another cause of gas embolism during hysteroscopy is the use of air, C02/
or nitrous oxide to cool the coaxial fiber of the Nd:YAG laser,u· 21 Coaxial fibers
originally were developed to carry gas or fluid to cool the tip of a quartz fiber
during laparoscopy. If used with gas as a coolant for operative hysteroscopy, the
risk of intravasation is great. The flow rate of this gas does not vary with the
pressure created, and the risk of intravasation is high. Only liquid should be
instilled into the uterus through the coaxial laser fiber/"

Prevention

Prevention of air embolism relies on understanding the physiology as de-

scribed earlier and the risk factors associated with air embolism. Trendelenburg
position, difficult cervical dilation, and operative (rather than diagnostic) proce-
dures seem to be risk factors. Trendelenburg position places the uterus above
the heart and creates a venous vacuum with each diastolic relaxation, potentially
sucking air through the open venous sinuses. Difficult cervical dilation and
operative procedures such as myoma resection or endometrial resection create
more trauma and more potential portals of air entry. Rational preventive mea-
sures worthy of adaptation are as follows:
• Avoid Trendelenburg positioning or at least use the minimum possible.
Current video equipment obviates the need the see the cervix clearly
during operative hysteroscopy. The weighted speculum's presence, often
the only reason for the Trendelenburg positioning, is unnecessary once
the hysteroscope is in place. If needed, it can be secured to the labia with
sutures or replaced by a lighter speculum.
• Minimize cervical trauma. Consider the preoperative use of laminaria for
the difficult cervix. Hank-Bradley dilators, with a central canal that ex-
tends the length of the dilator, do not force air into the uterus during
dilation as Hegar dilators may.
• Keep the as occluded. Do not leave it open to room air for any period of
time. The time between removal of the last dilator and insertion of the
hysteroscope is likely to be the longest. Consider leaving the largest dilator
in the cervix or placing a wet sponge in the vagina until the hysteroscope
is completely ready.
• Communicate with the anesthesiologist. Possibly this element is most
important. Be sure that monitoring of end tidal CO2 and pulse oximetry
is standard protocol.

Management

Early detection of air embolism and appropriate intervention can save lives
in some cases. The classic diagnostic findings in air embolism include altered
echocardiography (either by precordial Doppler or transesophageal probe), an
acute rise in pulmonary artery pressure, and aspiration of air from a central
venous line. Infrequent occurrence of air embolism despite the frequency of
362 COOPER & BRADY

hysteroscopic surgery makes central venous or pulmonary artery catheteriza-

tions irrational as standard protocol. Neither Doppler nor transesophageal echo-
cardiography is standard for all hysteroscopy because of the high false-positive
readings obtained." Fortunately, air emboli can be detected rapidly with the
more commonly monitored parameters of end-tidal C02J oxygen saturation,
heart rate, respiratory rate, and blood pressure." The first clinically recognizable
change in a patient with an air embolism is a decrease in the end-tidal CO2.2.
This likely is followed by hypoxia, tachycardia, tachypnea, hypotension, and
then cardiovascular collapse with bradycardia, hypotension, and subsequent
asystole. The diagnosis can be confirmed by auscultation of the machine-like
murmur over the precordium. On suspicion or confirmation of an air embolism,
the surgical team should pursue the following steps:
1. Remove hysteroscope to discontinue insufflation, make sure vagina is
closed or occluded with a wet sponge.
2. Turn patient to left side to elevate and keep gas in the right side of the
heart, decreasing the chance of paradoxic embolus.
3. Consider precordial thumps to break up air pocket.
4. Administer intravenous bolus of normal saline.
5. Consider echocardiography to identify and possibly aspirate gas from
the right side of the heart.
Cardiopulmonary resuscitation likely will be needed. Transfer to an intensive
care unit is mandatory because pulmonary edema and adult respiratory distress
syndrome are likely sequelae of air embolism." Transfer to a center with the
capacity for hyperbaric oxygen therapy should be considered.

SUMMARY

With preoperative evaluation, meticulous technique, and vigilance for im-

pending problems, intraoperative and early postoperative complications of oper-
ative hysteroscopy are largely preventable. Fluid overload is the most common
serious complication. The hysteroscopist must understand the significant differ-
ences between hypotonic, electrolyte-free distention media and isotonic, electro-
lyte-containing media and their respective sequelae. As new operative tools
become available, hypotonic and electrolyte-free distention media may become
obsolete.
The physiology and management of air embolism, the most grave intraoper-
ative complication, are essential to the knowledge base of any active hysteros-
copist, Mechanical accidents, anesthetic complications, laser and electrical injury,
and infections can be reduced by knowledge and preparation. Technologic
advances, ongoing research, and postgraduate training in hysteroscopic tech-
nique continue to expand the safe and beneficial applications of hysteroscopy
into the next century.

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Jay M. Cooper, MD
University of Arizona, School of Medicine
Phoenix Baptist Hospital
6036 N 19th Avenue
Suite 401
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