Hysteroscopy is an advanced device for diagnosis and treatment of diseases in the uterine cavity. It allows clear observation of various changes in the uterine cavity and makes a clear diagnosis. Hysteroscopy has some surgical complications, and while every effort is made to avoid them, timely management is also crucial.
Intraoperative detection of hysteroscopy
1. Vital signs: including respiration, pulse, blood pressure, oxygen saturation and cardiac monitoring.
2. Perfusion media: Calculate the difference between the inflow and outflow of perfusion fluid (the amount of perfusion fluid entering the patient’s body). If the difference is ≥ 1000 ml, the change of vital signs should be closely observed and the overabsorption syndrome of perfusion fluid should be alerted; when the difference between the inflow and outflow of perfusion fluid reaches 2000 ml, the change of vital signs should be noted and the operation should be ended as soon as possible.
3.Serum electrolytes: If the difference between the inflow and outflow of perfusate is ≥ 1000 ml, measure the change of serum electrolytes as appropriate.
4.B-ultrasound monitoring: it can indicate the extent and depth of uterine surgical excision to prevent uterine perforation.
5. Combined laparoscopic surgery: choose as appropriate for complex intrauterine surgery, uterine malformation, high risk of uterine perforation and intra-abdominal lesions requiring simultaneous diagnosis and treatment.
Prevention and control of complications of hysteroscopic surgery
1. Bleeding
The main cause of intraoperative bleeding in hysteroscopic surgery is the deeper destruction of the myometrial tissue below the endometrium. High-risk factors for bleeding include uterine perforation, arteriovenous fistula, placental implantation, cervical pregnancy, cesarean scar pregnancy, and coagulation disorders.
Countermeasures to reduce hemorrhage include preoperative pharmacological pretreatment (indocin and hemostatic drugs), uterine balloon compression, combined laparoscopic monitoring and prophylactic uterine artery blockade. The management plan is determined by the amount of bleeding, the site and extent of bleeding and the type of surgery.
2. Uterine perforation
High-risk factors for uterine perforation include cervical stenosis, history of cervical surgery, hyperflexion of the uterus, small uterine cavity, and inexperience of the surgeon.
(1) Clinical presentation.
Collapsed uterine cavity with poor visualization.
free fluid around the uterus on B sonogram, or a large amount of perfused fluid into the abdominal cavity.
Hysteroscopic visualization of the peritoneum, intestinal canal or greater omentum.
translucent, blistered, bleeding, hematoma or perforated trauma on the plasma surface of the uterus if laparoscopic monitoring is available
The acting electrode enters and damages the pelvic and abdominal organs causing symptoms of corresponding complications, etc.
(2) Treatment: Firstly, find the site of perforation, determine whether there is any damage to the adjacent organs, use contraction and antibiotics, and observe; if the scope of perforation is large, may injure the blood vessels or have organ damage, laparoscopy or open exploration should be performed immediately and treat accordingly.
(3) Prevention.
Enhance cervical pretreatment and avoid violent dilation.
Combined B-ultrasound or laparoscopic surgery, as appropriate.
Training and improvement of surgical skills of the operator.
Use GnRH-α drugs as appropriate to reduce the size of the myoma or uterus and thin the endometrium.
3. Over-absorption of irrigated fluid syndrome
Hysteroscopic surgery in dilated uterus pressure and the use of non-electrolyte perfusion media can cause liquid media to enter the patient’s body, which can cause fluid overload and dilutional hyponatremia when the absorption threshold of the body is exceeded, and cause corresponding changes in the heart, brain, lungs and other important organs, with a series of clinical manifestations, including slow heart rate, increased or decreased blood pressure, nausea, vomiting, headache, blurred vision, restlessness, mental disorders and If the diagnosis and treatment are not timely, convulsions, cardiopulmonary failure and even death will occur.
(1) Causes: intrauterine hypertension, massive absorption of perfusion media, etc.
(2) Treatment principles: oxygenation, diuresis, treatment of hyponatremia, correction of electrolyte disorders and water intoxication, management of acute left heart failure, prevention of pulmonary edema and cerebral edema. Pay special attention to the correction of dilutional hyponatremia, which should be calculated and supplemented according to the formula for sodium supplementation: required sodium supplementation = (normal blood sodium value – measured blood sodium value) 52% × body mass (kg).
The initial repletion should be 1/3 or 1/2 of the total calculated amount, and subsequent repletion should be determined according to the patient’s mental status, blood pressure, heart rate, pulmonary signs and changes in serum Na+1, K+1 and Cl-1 levels. Rapid, high concentration intravenous sodium repletion should not be used to avoid temporary intracerebral hypoosmotic state, which may cause fluid transfer between brain tissues into the blood vessels and cause brain tissue dehydration, resulting in brain damage. The risk of hyponatremia is reduced with the hysteroscopic bipolar electric system using saline as the intrauterine perfusion medium, but there is still a risk of fluid overload.
(3) Prevention:
Cervical and endometrial preconditioning helps to reduce the absorption of perfusate.
Maintaining uterine cavity pressure ≤ 100 mmHg or < mean arterial pressure.
controlling the differential perfusion fluid between 1000 and 2000 ml.
Avoid too deep disruption of the myometrium.
4.Gas embolization
Gas embolism may occur as a result of tissue vaporization and room air entering the venous circulation through the open vessels of the uterine cavity. The onset of gas embolism is sudden and fast, and the early symptoms are such as decreased end-expiratory PCO2, bradycardia, decreased PO2, and large water wheel sound in the precordial area; then the blood flow resistance increases, cardiac output decreases, cyanosis, hypotension, shortness of breath, cardiopulmonary failure and death.
(1) Treatment: Immediately stop the operation, positive pressure oxygenation, and correct cardiopulmonary failure; at the same time, input saline to promote blood circulation, place central venous catheter, and monitor cardiopulmonary artery pressure.
(2) Prevention.
Avoid head-low hip-high position.
Evacuate the gas in the water injection tube before surgery.
Perform cervical pre-treatment to avoid cervical laceration due to rough dilation.
Strengthen intraoperative monitoring and emergency treatment.
5. Infection
Strictly grasp the indications for surgery and contraindicate surgery in the acute stage of reproductive tract infection.
6.Treatment failure and recurrence
Treatment failure or recurrence of symptoms can be followed up with secondary hysteroscopic surgery, drugs or hysterectomy as appropriate. Special emphasis is placed on hysteroscopic surgery as a conservative surgery for uterine diseases, and informed consent should be fully fulfilled before surgery, and forced surgery against the patient’s will should be avoided.