Uterine perforation is the most common complication, occurring in 0.25-25% of cases abroad, with an average incidence of 1.3% and 2.25% complicating intestinal injuries; the incidence in China is 0.03% for hysteroscopy and 0.4% for surgery. Factors contributing to the occurrence of uterine perforation are related to the experience of the operator, anatomical site, acting electrode, type of surgery, and history of previous uterine trauma. In uterine perforation a large amount of perfusate enters the abdominal cavity and conventional instruments or instruments with energy sources pass through the perforated uterus and injure neighboring organs. Complicated fluid overload, injury to the digestive and urinary tracts and rupture of large vessels cause fatal complications such as peritonitis, fistulae, hemorrhage and air embolism. Recognition of uterine perforation: subplasma hematoma seen on ultrasound, perfusate overflowing into the peritoneal cavity; hysteroscopy becoming laparoscopy; laparoscopy showing translucency and blistering of the plasma membrane, hemorrhage, hematoma, or perforated trauma, or a sudden increase in the peritoneal fluid; progressive distension of the peritoneal cavity; chemical peritonitis. Management of uterine perforation: Perforation of the uterine fundus: uterotonics, antibiotics, close observation Perforation of the lateral wall and isthmus of the uterus: immediate open exploration Perforation unknown: laparoscopy Hemorrhage: laparoscopic electrocoagulation for hemostasis Perforation: sutures are required for larger cases One should be alert to the pain for 24 hours after the operation Prevention of perforation of the uterus: choose the most appropriate method of monitoring according to the different procedures. Surgical technique must not use any energy source when the field of vision is unclear, TCRE in principle only makes one cut per site, the roller ball or pneumatization electrode must be rolled, TCRM avoids damage to the adjacent and contralateral muscular wall, and TCRS uterine fundus is prone to perforation. Uterine perforation complicates injury to adjacent organs: bowel injuries are most common and can be sutured laparoscopically; thorough irrigation and placement of a drain are required for colonic perforation; bladder injuries have a good prognosis if sutured in time; injury to the great vessels can lead to hemoperitoneum, hematoma, and sudden death; laparoscopy is insufficient to assess the possible consequences of uterine perforation! The long-term prognosis of uterine perforation includes infection, adhesions, and uterine rupture after pregnancy. TURP syndrome TURP —- Fluid overload (defined as the absorption of >1500 ml of tumescent fluid) is a complication specific to hysteroscopy with an incidence of 0.2%, which occurs in relation to hydrostatic pressure, duration of the procedure, and the nature of the tumescent fluid. Excessive absorption of tumescent fluid leads to dilutional hyponatremia, lysis of erythrocytes in non-isotonic fluids, neurological disturbances such as convulsions and coma, cerebral edema, cerebral herniation, and death. Clinical manifestations of TURP syndrome Dilutional hyponatremia, acute hypervolemia. Increased heart rate, increased blood pressure; decreased blood pressure, nausea, vomiting, headache, blurred vision, agitation; dyspnea, pulmonary edema; arrhythmia, slowed heart rate, increased CVP, heart failure; hemolysis; more difficult breathing, excessive lactic acid production by the tissues, metabolic acidosis; worsening of the heart failure: shock, severe ventricular arrhythmias, death; confusion, lethargy, death. Treatment of TURP syndrome The main points of TURP treatment include: monitoring of vital signs; treatment of hyponatremia; anticardiac failure treatment; treatment of pulmonary edema; treatment of cerebral edema; and correction of electrolyte and acid-base balance disorders. Give strong diuresis and sodium supplementation in case of hyponatremia. When strong diuresis, pay attention to the dose, overdose easily lead to blood volume insufficiency. Measurement of hemoglobin content and urine specific gravity can be measured, but also to determine the central venous pressure to determine the amount of diuretics used, at the same time to pay attention to serum electrolytes, to prevent hypokalemia, the amount of sodium supplementation required = (normal value of blood sodium – the measured value of blood sodium) x 52% × kilograms of body weight (52% refers to the total body fluids of the person’s body weight ratio). 3% NaCl preparation: 10% NaCl30ml (containing). Na: 1g/10ml) add 0.9% NaCl100ml100ml (containing Na: 0.9g/100ml) after mixing the configuration of 3% NaCl composition: containing Na3.9g/bag, 130ml/bag. Points for sodium supplementation (1) Avoid rapid, high-concentration intravenous sodium supplementation (2) In the acute phase of hyponatremia, supplementation of sodium ions at a rate of 1-2 mEq/L per hour can alleviate the symptoms (3) Increase in plasma osmolality should not be more than 12 mOsm/L within 24 hours (4) Dynamic monitoring of blood electrolytes and urinary output. Usually it is not necessary to use high salt solution to correct hyponatremia, supplemental saline is extremely effective (5) Generally give 1/3 or 1/2 of the amount first, so that the osmolality of the extracellular fluid increases, the intracellular water is transferred to the extracellular, the cellular function is restored, and the observation is made for half an hour, and the remaining hypertonic saline is inputted at the discretion of the person according to the state of mind, the mental status, the blood pressure, the cardiorespiratory function, and the level of the blood sodium (6) Sodium replenishment is able to maintain the level of the blood sodium At 130mEq/L (mild low sodium) Treatment of acute heart failure: semi-sitting position, in addition to the use of diuretics, the use of digitalis preparations in order to enhance myocardial contractility, increase cardiac output, slow down the heart rate, give peripheral vasoconstriction and hepatic venoconstriction, reduce venous return. Dosage: Sildenafil: 0.4mg IV push slowly; digitalisated preparation: 1.0-1.2mg IV push slowly. Pulmonary edema treatment: treatment of hypoxemia, nasal catheter oxygen, flow rate of 6L/min, confusion, face mask oxygen, the above treatment is invalid, PO2 below 50mmHg, tracheal intubation, start the time intermittent positive pressure respiration, still ineffective, the use of end-of-breath positive pressure respiration, in order to improve the functional residual volume of air, effectively preventing the alveolar atrophy during expiration. Application of defoamers, nasal cannula oxygen, 75-95% alcohol in a filtered bottle, inhaled with oxygen, 20-30% alcohol for mask oxygen administration. Application of morphine, morphine can be used in heart failure and other causes of pulmonary edema, but should not be used in pulmonary edema caused by TURP, morphine prompts the release of antidiuretic hormone, which reduces urination and exacerbates water intoxication Treatment of cerebral edema: the use of a high concentration of urea-osmotropic diuretics, corticosteroids – dexamethasone stabilizes cell membranes and reduces capillary permeability, reduce cerebral edema. Correct electrolyte balance: hypokalemia, heavy use of diuretics, resulting in hypokalemia, cardiac rhythm disturbances therefore need to measure potassium, cardiac monitoring; measure PH in metabolic acidosis, sedation 4% NAHCO3 TURP syndrome prophylaxis Surgical time is best <30 minutes, apply diuretics, use isotonic fluids, low-pressure perfusion ≤100mmHg or ≤mean arterial pressure, measure the negative arrears to avoid resection of too much muscle tissue ≤3 to 4 mm, and connect the outlet tube of the perfusion system to negative pressure suction. Venous air embolism Venous air embolism is a medical complication of air entering the veins after trauma. It is usually caused by expansion of the uterine media CO2, air entering the plumbing, and air from tissue vaporization entering the body through the exposed veins and venous sinuses of the uterine incision margins. Asymptomatic, symptomatic, and lethal VAEs may occur when intrauterine pressure is higher than vascular pressure.Negative pressures generated by cardiac diastole, the height difference between the uterus and the heart in the modified cystotomy position, and pressure gradients between the uterus and the corpusculum can lead to absorption of air into the circulation. Clinical Symptoms Clinical manifestations are related to the amount of air, and the important early symptoms are breath-holding, choking and coughing, cyanosis, sudden decrease in end-expiratory CO2 pressure, bradycardia,decrease in blood pressure, decrease in SPO2, and water-wheel sounds-large machine-like gurgling sounds in the precordial area. It leads to cardiopulmonary failure and cardiac arrest, rapidly developing circulatory shock and sudden death. VAE is sudden in onset, rapid in progression, and difficult to treat, often leading to severe injury or death. Continuous precordial Doppler ultrasound monitoring, monitoring of end-expiratory CO2 pressure and CO2 level, measurement of SpO2, echocardiography, central venous cannulation and gas suctioning are required during the operation. Emergency treatment Once diagnosed immediately stop the operation to prevent further absorption of air, inverted head-low-hip-high position, left lateral recumbency, open the veins, push dexamethasone, positive pressure oxygen administration, obvious dyspnea or intractable hypoxemia patients endotracheal intubation, air pooling central venous catheterization to monitor the intracardiac pressure and pulmonary artery pressure, and then pumping the air and giving hyperbaric oxygen therapy. Prevention Discontinue the use of gas injection methods, reduce exposure to vascular injury margins, reduce intrauterine pressure, increase monitoring, avoid head-down-butt-high position, carefully dilate the cervical canal, apply osmotic dilator in the non-pregnant woman or in those with a history of previous cervical surgery, evacuate air from the intake tube preoperatively, close the vagina after cervical dilatation or block the cervix with wet gauze-don't expose the cervix to air, use the lowest effective dilatation pressure intraoperatively, and monitor blood pressure, heart rate, SPO2 and end-expiratory CO2 partial pressure, controversial: central venous cannulation, ultrasonography. When expanding the uterus using an intravenous infusion device, if the expansion fluid is in glassware, the needle should be inserted into the fluid through the cap. If the two needles are too close together (≤5 mm), there may be enough gas in the tube to flow into the uterine cavity and become a source of gas for VAE. Deep Vein Thrombosis (DVT) Risk factors for DVT include: age, duration of surgery, previous history of DVT, history of radiation exposure, knee edema, severe phlebitis, and change in position. The criteria for diagnosing DVT by ultrasound Doppler are seeing a thrombus image, intermittent vein wall, and failure of the venous lumen to be compressed DVT treatment Once the diagnosis of DVT is confirmed, braking, pharmacologic thrombolysis: antithrombotic medications such as heparin, Favarine, urokinase, low molecular dextrose, and aspirin, surgical incision to remove the embolus, and placement of a mesh in the large vein to dissolve it, so that the dislodged small embolus doesn't follow the blood flow and cause a pulmonary embolism.