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3/1/2018

Hysteroscopic Bowel Injury

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 would help to prevent 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   The procedure should be aborted and the operative instruments withdrawn using hysteroscopic guidance.  If only blunt instruments such as cervical dilators have been used prior to recognition of a fundal perforation, and only minimal bleeding is seen by hysteroscopy, observation is appropriate.  Perforations occurring elsewhere and those caused by sharp, electrosurgical or suction instruments require urgent surgical evaluation. 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 laparoscopic inspection. If an injury is detected, depending on their skill and experience 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 of symptoms of peritonitis such as nausea, vomiting, fever, or pain, which 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 the hysteroscope while operating active surgical instruments in the endometrial or myometrial spaces
• Avoid resecting deeply into the myometrium

Routine cervical ripening for these procedures does reduce false passage formation, but not shown to reduce uterine perforation.  However, misoprostol, osmotic dilators, or ultrasound guidance may be helpful in difficult cases to guide dilation of a stenotic cervix and monitor the position of the instruments used in the operation. 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 intrauterine adhesive disease, or who will need deep myometrial resection.

Further Reading:

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 2017, Published March 2018, Revised May 2019, Minor Revision January 2021; Revised May 2022; Minor revision March 2024.

 

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