Columbus: complications of laparoscopy and hysteroscopy Flashcards
What is the rate of uterine perforation at hysteroscopy?
When does this typically occur?
1%
During sounding, dilation or initial insertion of the scope
What is the single greatest factor leading to injury and liability?
Ignoring contraindications
When does uterine perforation require surgical exploration?
Lateral perforation or perforation with an active electrode
What factors increase the risk of CO2 embolism at laparoscopy?
Length of surgery Obesity Cardiopulmonary disease Patient position Amount of dissection
When does air embolism usually occur during laparoscopy?
At insufflation
What steps should be taken when trocar injury to the large bowel is recognized?
- Leave the laparoscope in place to prevent spread of bacteria
- Begin broad-spectrum antibiotics
- Anesthesiologist to place an NG/OG tube
- consuly general surgery.
What complications can occur during laparoscopy during insufflation?
Failed pneumoperitoneum Pneumoperitonium-Induced Pneumothorax Subcutaneous emphysema Extra peritoneal insufflation Pneumo-Mediastinum CO2 embolism
What are some strategies for failed pneumoperitoneum?
Left upper quadrant insertion
Open laparoscopic port placement
Ninth intercostal space insertion
Laparotomy
How does CO2 embolism present?
Decreased oxygen saturation and expired CO2 Bradycardia, arrhythmia, and widened QRS Bilateral mydriasis Pulmonary interstitial edema Cyanosis Hypotension Acidosis Cardiovascular collapse and death
How is CO2 embolism treated?
Immediate release of pneumoperitoneum
Left side down in Trendelenburg forces gas into base of right ventricle
100% oxygen and anticholinergics
Place central line
Consult cardiologist to aspirate air bubble from right heart
How is CO2 embolism prevented?
Continuous end-tidal CO2 monitoring
Maintenance of intra-abdominal pressure within predetermined limits
Rarely invasive cardiac monitoring
What steps are done prior to surgery to reduce stomach perforation?
Bladder perforation?
Minimal bagging and NG/OG tube.
Indwelling Foley catheter or preoperative emptying.
What patients require consideration of alternative entry site for laparoscopy?
Large pelvic mass, pregnancy, or previous surgery.
How is ureteral injury best diagnosed?
What is the most common clinical finding in patients with ureteral transaction?
Intravenous pyelogram
Elevated WBC
How is left upper quadrant insertion performed? What needs to be considered?
Palmers point
Entry at midclavicular line or lateral
Empty the stomach with NG or OG tube
Evaluate for hepatosplenomegaly
When do patients usually present with ureteral injury?
What are the most common signs of ureteral injury?
48 to 72 hours
Elevated WBC, fever, peritonitis. Hematuria and flank pain are present infrequently.
How is major vascular injury managed laparoscopy?
Leave the Veress or trocar in place to help mark the site of injury
Perform immediate laparotomy with midline incision
Stabilize hemodynamic parameters
Consult vascular surgery
How is ureteral injury repaired?
Reimplantation into the bladder
Anastomosis of the damage ureter
Transureteral ureterostomy
How is inferior epigastric vessel perforation managed?
Pressure, vasopressin, Foley balloon, or suture
How should brisk intraoperative bleeding be managed?
Hydrolavage Mechanically coapt the bleeder Revisit anatomy Mobilize vasculature if necessary Desiccate Hydro lavage and reassess
What are risk factors for adhesion formation?
Ischemia Infection Necrosis Hemorrhage Foreign body Abrasion Surgery
What steps can be performed to improve the safety of hysteroscopy?
Void prior to surgery or Foley catheter
Examination under anesthesia or preoperative imaging
Careful dilation and uterine sounding
How can adhesions be prevented?
Incise rather than excise
Avoid crushing and desiccation
What are contraindications to hysteroscopy?
PID or acute vaginitis
Profuse uterine bleeding
Pregnancy
What is the number one cause of postmenopausal bleeding?
In what other clinical settings may this be seen?
Endometrial atrophy
OCP or progestin use
What are complications of endometrial ablation?
Urine perforation Hemorrhage Fluid overload Infection Thermal injury to viscera Anesthesia related
What are signs of uterine perforation?
Depth of passage of uterine sound or dilator is greater than apparent uterine size
Very rapid flow of liquid distention media
Direct visualization
Any hemorrhage before the beginning of the surgical procedure is suggestive
What are risk factors for uterine perforation?
Postpartum Postmenopausal Retroverted uterus Prior LEEP or cone biopsy Uterine cancer Marked cervical stenosis
How should uterine perforation be managed?
Perforation usually does not require repair.
Stop the surgery
Give antibiotics
Observe patient
Lateral perforation or with active electrode must have laparoscopic evaluation
What steps can be taken to avoid uterine perforation?
Pretreat with misoprostol for patients at high risk
Careful EUA
Laparoscopic or ultrasound guidance
What electrical system is used with glycine and sorbitol distention medias?
What complications are associated with its use?
Monopolar
Fluid overload, hyponatremia, hypo-osmolality leading to pulmonary and cerebral edema
How can intraoperative hemorrhage during hysteroscopy be managed?
What should be considered postoperatively?
Electrocautery
Uterine balloon with 15 to 30 mL for three hours
Consider coagulopathy evaluation
What is the risk of using CO2 as the distention media for diagnostic hysteroscopy?
CO2 venous embolism
Why is dextran 70 high viscosity fluid no longer used?
Associated with anaphylaxis, clotting disturbances, ARDS
What is the advantage of mannitol 5% over glycine or sorbitol?
Mannitol acts as its own diuretic and may cause hyponatremia but not hypo-osmolality.
How much would sodium be expected to drop if 1000 milliliters of glycine were absorbed?
2300?
2700?
8 mEq
16
25
How can fluid overload be prevented?
Strict I/O’s
Stop case at 1.5 L of nonelectrolyte fluid or 2.5 L of saline
For nonelectrolyte fluids check electrolytes at 750 mL deficit
How does fluid overload and hyponatremia present?
How is it treated?
Headache, nausea and vomiting, confusion, and lethargy. If severe can cause seizure, coma, cardiovascular collapse and death
Symptoms usually start at 130 to 125 mEq of sodium
Treated with water restriction, loop diuretic, and close observation.
What is the risk of rapid correction of hyponatremia?
Central Pontine mylinolysis
How is correction of hyponatremia calculated?
And how is the 3% saline administered?
Volume of TBW x (125 - current sodium) = total sodium needed
TBW = 0.6 x weight in kg
3% saline has 513 mEq per liter
Replace at 1 to 2 mEq per hour
What laboratory value is used to diagnose severe hyponatremia?
How does it present?
What is the major risk of the delayed diagnosis and treatment?
How is this treated?
Sodium less than or equal 125 mEq
CNS symptoms such as muscle twitching or weakness convulsions or altered mental status
Risk of brainstem herniation from cerebral edema
Treated with 3% saline
What other steps could be considered for anticipated difficult hysteroscopic resections such as large or multiple fibroids?
Pretreatment with GnRH agonist
Two-stage procedure
Intraoperative use of vasopressin or oxytocin
