Risk of Hysteroscopy

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Paul Indman, MD: “Hello, this is Dr. Paul Indman at the 3rd International Congress of Endoscopy in Veracruz, Mexico, and I’m fortunate to have with me Dr. George Vilos from London, Ontario. George, you’ve been interested in complications of hysteroscopy for a long time, what do you feel the major risks of hysteroscopy are?”

George Vilos, MD: “Any one of them can become a major risk but basically there are three types. One is the mechanical type of complications, the second is complications from the energy source that one uses during the hysteroscopic surgery, and the third is leaking fluids and absorption of the fluids during the procedure itself.”

Paul Indman, MD: “Now you were talking about mechanical complications, what do you think is the largest risk and the most dangerous mechanical complication and how can that be avoided?”

George Vilos, MD: “The commonest is uterine perforation and bleeding but the most major one is an air embolism. This is the one that kills people which can occur during the dilatation process.”

Paul Indman, MD: “Is there something that gynecologists can do to decrease the risk of air embolisms?”

George Vilos, MD: “The most major thing is to be aware of it and then maintain the patient in a flat position. In other words, not in a Trendelenburg position where the uterus is higher than the level of the heart; that is where the mechanism of the air embolism is.”

Paul Indman, MD: “Yes, I think that’s an important point because anesthesiologists want to help us and give us lots of Trendelenburg and certainly if the patient is in a reverse Trendelenburg the weighted speculum will fall out but I think keeping the patient as flat as possible is helpful. Now if someone has a perforation what should the doctor do?”

George Vilos, MD: “Probably nothing other than just watch the patient for possible bleeding. If there’s no bleeding, I don’t think anybody should do anything about it, just observe the patient over the next twenty-four hours.”

Paul Indman, MD: “What about perforation with a resectoscope; is that any different?”

George Vilos, MD: “It’s very different. With a resectoscope if there is a perforation during the procedure and if one is not sure whether the electrical was activated at the time of the perforation then you must do a laparotomy around the bowel and make sure that an intraabdominal injury has not occurred. If it occurred with the resectoscope and the surgeon is absolutely certain that the electrical was not activated at the time, then it can be treated just like a professional dilator where you can watch the patient.”

Paul Indman, MD: “Do you think an experienced laparoscopist can run the bowel through a laparoscope?”

George Vilos, MD: “Absolutely not, you must do a laparotomy. I don’t know of anybody who can run the bowel through the laparoscope.”

Paul Indman, MD: “I’m going to ask you one more question. The whole question of fluids is a topic in itself but you’ve done some work on electrical leakage through resectoscopes, could you talk about that for a minute?”

George Vilos, MD: “All the resectoscopes by design allow about 25%-30% of the electrical current going through the electrode itself to be induced through a mechanism core capacitator unto the sheath of the resectoscope. Potentially, if the resectoscope touches less than two square centimeters of the surface area of the vagina or the vulva then there is enough electrical power there to cause an electrical burn. I think the most important, perhaps, mechanism of burns in the vagina and the vulva are not due to this capacitator leakage but I think it’s probably the fact that the electrodes of the resectoscope allow more current to leak through into the field of the resectoscope.”

Paul Indman, MD: “So then what do we do?”

George Vilos, MD: “Either alternative methods of endometrial ablation but if one has to use a resectoscope we now have the bipolar system which would deliver the energy. The capacitative effect cancels each other out and it’s perhaps a safer resectoscope than the monopolar.”

Paul Indman, MD: “Even the bipolar is prone to equipment malfunction.”

George Vilos, MD: “Oh, absolutely.”

Paul Indman, MD: “So nothing is 100% safe; we have to be careful where our resectoscope is at all times.”

George Vilos, MD: “Correct, I think every surgeon should be fully aware of the equipment he uses and the potential inherent risks and complications for all equipment used in the operating room.”

Paul Indman, MD: “Thank you very much. That was Dr. George Vilos, and I’m Dr. Paul Indman from Puerto Vallarta, Mexico.”