Management of Lateral Uterine Perforation at the Time of Hysteroscopy
7/1/2012 - Jeffrey M. Rothenberg, MD
Editor: Eduardo Lara-Torre, MD
Hysteroscopy is a standard tool in the armamentarium of gynecologists. Therefore, it is important to know how to deal with uterine perforation of the lateral wall at the time of the procedure, a rare, but potentially dangerous complication. The overall rate of hysteroscopic complications is low; diagnostic cases have a lower rate than operative cases. Most perforations occur during insertion of the hysteroscope, tend to be located in the fundus, and are usually self-limited and less serious. Certain procedures are inherently riskier (adhesiolysis) than others (polypectomy). To prevent hysteroscopic complications, one needs to be aware of the risks and precautions. It is also important to know how to manage rare but life threatening complications.
The uterine artery is the main source of blood to the uterus, along with anastomoses from the vaginal artery. Severe bleeding from lateral uterine perforations, albeit rare, can have catastrophic consequences. These perforations may be managed by laparoscopy or laparotomy, and may require emergent hysterectomy. The risks are related to the underlying cause of the damage to the lateral wall. If there is any concern for damage to surrounding organs, the threshold for directly visualizing the pelvis should be low. Lateral wall uterine perforations can lead to the development of a retroperitoneal hematoma, and cervical perforations can result in significant immediate or delayed bleeding. Laparoscopy or laparotomy may be needed to determine the extent of damage, including the existence of bowel or bladder injury. Laparoscopic suturing of a perforation, placement of sutures during laparotomy, hysterectomy, or uterine artery embolization may be necessary. Keeping an open line of communication with the anesthesia team is also critical, especially as fluid overload or embolism may accompany the perforation. Any damage to the uterine vasculature may increase the chance of fluid overload as there is now an easier portal of entry for the distention media.
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Initial Approval July 2012, Revised July 2015, Reaffirmed January 2017
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