The lowest intrauterine pressure necessary for adequate distention should be used to complete the operation, preferably at a level that is below the mean arterial pressure. A good range for operative procedures is 70 to 80 mm Hg, which can be achieved with a specially designed pump or by maintaining the meniscus of the infusion bag 1 m above the level of the patient’s uterus. If greater intrauterine pressure is needed for adequate distention, the anesthesiologist may temporarily raise the mean arterial pressure by administration of a vasoactive agent such as phenylephrine.
4. Deficits of more than 1 L require repeat measurement of serum electrolyte levels and consideration of intravenous furosemide in a dose appropriate to the patient’s renal function. When such a deficit exists, the procedure should be completed expeditiously. If the deficit reaches a preset limit (1.5 to 2 L), the procedure should be terminated, and a diuretic such as mannitol or furosemide should be used as needed. Patients with cardiovascular compromise will typically have a lower tolerance for ﬂuid deficits, a circumstance that mandates setting a lower limit for systemic absorption and consequent termination of the procedure (230).
Perforation Perforation may occur during dilation of the cervix, positioning of the hysteroscope, or as a consequence of the intrauterine procedure. With complete perforation, the endometrial cavity typically does not distend, and the visual field is generally lost. When perforation occurs during dilation of the cervix, the procedure must be terminated, but, because of the blunt nature of the dilators, usually there are no other injuries. If the uterus is perforated by the activated tip of a laser, or electrode, there is a risk for bleeding or injury to the adjacent viscera. Therefore, the operation must be stopped and laparoscopy or laparotomy should be performed. Injury to the uterus is relatively easy to detect with a laparoscope. However, mechanical or thermal injury to the bowel, ureter, or bladder is more difficult to detect and laparoscopy is frequently inadequate to make a complete evaluation. If the patient’s condition is managed expectantly, she should be advised of the situation and asked to report any symptoms of bleeding or visceral trauma such as fever, increasing pain, nausea, and vomiting.
Bleeding Bleeding that occurs during or after hysteroscopy generally results from trauma to the vessels in the myometrium or injury to other vessels in the pelvis. Myometrial vessels are more susceptible to laceration with resectoscopic techniques that require myometrial dissection for procedures such as endometrial resection or type II myomectomy.
In planning operations that involve deep resection, autologous blood can be obtained before surgery. The risk for bleeding may be reduced by the preoperative injection of diluted vasopressin into the cervical stroma (229). The risk of injury to branches of the uterine artery can be lowered by limiting the depth of resection in the lateral endometrial cavity near the uterine isthmus, where ablative techniques should be considered. When bleeding is encountered during resectoscopic procedures, the ball electrode can be used to desiccate the vessel electrosurgically. Intractable bleeding may respond to the injection of diluted vasopressin or to the inﬂation of a 30-mL Foley catheter balloon or similar device in the endometrial cavity (177).
Thermal Trauma Thermal injury to the intestine or ureter may be difficult to diagnose, and symptoms may not occur for several days to 2 weeks. Therefore, the patient should be advised of the symptoms that could indicate peritonitis.
1.
Nezhat C, Hood J, Winer W, et al. Video laseroscopy and laser laparoscopy in gynaecology. Br J Hosp Med 1987;38:219–224.
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