[Intraoperative complications of 697 consecutive operative hysteroscopies]

Complications due to hysteroscopy are relatively rare events. They occur more frequently with operative hysteroscopy than with diagnostic hysteroscopy. Exact complications rates are difficult to determine owing to the natural tendency to report successes but not complications. Recognition of these situations will lead to prevention; in fact, all the most serious complications of operative hysteroscopy can be avoided when proper precautions are taken and close communication is maintained among gynecologic surgeon, the anesthesiologist and nursing staff. The more clinically significant complications are: uterine perforation, haemorrhage and electrolyte imbalance.

Between January 1993 and December 1998, 697 women underwent operative hysteroscopy in our Department. Operative hysteroscopy was performed with continuous flow, high frequency resectoscope. Under general anesthesia the cervix was dilated to 10 mm and the uterine cavity was distended with 1.5% glycine solution or mannitol under 80 to 120 mmHg pressure. Resection with electrocoagulation was completed. The patients were submitted to the following procedures: 354 endometrial polypectomies (50.7%), 160 myomectomies (23%), 114 endometrial ablations (16.4%) and 69 hysteroscopic metroplasties (9.9%).

In our series complications occurred in 95 out of 697 patients (13.6%). The most important complications were: 12 (1.7%) uterine perforations, 48 (6.9%) intraoperative haemorrhages and 35 (5%) excessive hypotonic fluid absorptions. Four out of 12 perforations occurred during the dilation of the cervical channel. Since the distention of the uterine cavity could not be achieved, the procedures were stopped. No signs of vaginal or intraperitoneal haemorrhage were observed; 8 out of 12 perforations were due to the tip of the electrical source. The operative hysteroscopies were immediately stopped and the consequences were: 6 diagnostic laparoscopies, 1 laparotic hysterectomy (hemorrhage) and 1 laparotomy for thermal bowel injury. In 48 patients intraoperative bleeding could not be controlled with electrocautery. In these cases in the operating room a Foley catheter was inserted into the uterine cavity and the bulb inflated with 10 to 30 mL of liquid to tamponade the bleeding. The catheters were removed 12 to 24 hours later. No patients required blood transfusion. Excessive intravasation of electrolyte-free fluid occurred in 35 patients. Hyponatremia and hypokalemia (hypo-osmolarity result) were never serious. Headaches, nausea and vomiting were the most frequent symptoms of our patients. No cardiac arrhythmia, cerebral edema, brain herniation occurred. In our series, hemorrhage was the most common complication; intravasation and uterine perforation were at the second and the third place. Complications rates decreased progressively du to a better major training and experience of the surgeons. Also the curves of each complication show a significant decrease. Myomectomy in our hands has been the most dangerous procedure. However, serious sequelae were rare mainly for two reasons: we prefer stop the intervention rather than continue when a deficit of 1.000 mL is reached. Consequently, it is very important to discuss the possibility of incomplete resection of the endouterine lesion with the patient preoperatively; a protocol for fluid management in the operating room must be used for all the procedures (also the easiest) by all the surgeons and the nurses.

Our relatively high prevalence of intraoperative complications and distribution of the different types do not differ from the findings of published reports. In personal experience operative hysteroscopy is a safe surgical procedure for the treatment of endouterine abnormalities.