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Hysteroscopic Bowel Injury

3/1/2018 - Makeba Williams, MD, FACOG. NCMP

Mentor: Lisa Keder, MD, MPH

Editor:  Dan Breitkopf, MD

Although hysteroscopic complications are rare, uterine perforation can cause serious injury to adjacent structures. Compared to diagnostic procedures, operative hysteroscopy elevates the risk of uterine corpus perforation 16-fold, and increases the risk of electrical, mechanical, or thermal injury to the bowel or viscera. Hysteroscopic morcellators used for myoma resection can breach the myometrium and injure the bowel. Monopolar or bipolar resectoscopes may result in thermal injury if an activated electrode perforates the myometrium.  Early recognition of injuries prevents severe morbidity or mortality.

Visualizing bowel or suspected bowel contents through the hysteroscope raises the concern for bowel injury.  The procedure should be aborted and the operative instruments withdrawn using hysteroscopic guidance. Laparoscopy, with the hysteroscope left in the uterus, aids in identifying the perforation site. The surrounding bowel and viscera should be methodically evaluated for injury. Laparotomy may be required to evaluate for thermal damage since this type of injury may be difficult to see on simple visual inspection. If an injury is detected, depending on their skill and comfort level with bowel surgery, the gynecologist should consider general surgery consultation. If no bowel damage is visualized or expectant management is selected due to low likelihood of injury, patients should be advised that peritonitis symptoms such as nausea, vomiting, fever, or pain, may not occur immediately and can develop up to 2 weeks later. Patients should be given strict precautions for follow-up since delays in diagnosis can lead to serious morbidity and mortality.

To reduce the risk of perforation and subsequent bowel injury, the surgeon should:

  • Visualize active electrodes and oscillating blades at all times
  • Refrain from advancing surgical instruments while operating in the endometrial or myometrial spaces
  • Avoid resecting into the myometrium

Ultrasound guidance may be helpful in difficult cases. Alternatively, concomitant laparoscopy provides direct visualization of nearby viscera, and displaces bowel.   Laparoscopy may be considered in patients who have had prior uterine surgeries, have extensive adhesive disease, or who will need deep myometrial resection.

 

Further Reading:

American College of Obstetricians and Gynecologists.  Technology Assessment No. 7: Hysteroscopy. Obstet Gynecol, 2011 Jun;117(6):1486-91, doi: 10.1097/AOG.0b013e3182238c7d.

Munro MG, Christianson LA. Complications of Hysteroscopic and Uterine Resectoscopic Surgery. Clin Obstet Gynecol. 2015 Dec;58(4):765-97.  doi: 10.1097/GRF.0000000000000146.

Initial approval November 7, 2017. Published 3/1/2018.

 

Copyright 2017 - The Foundation for Exxcellence in Women's Health, Inc. All rights reserved. No publication, reuse or dissemination allowed without written permission.

 

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