The risks of diagnostic hysteroscopy are few, and those complications that occur rarely have severe consequences (199). The uncommon adverse events that should be discussed with the patient include perforation, bleeding, and those related to anesthesia and the distention media. After diagnostic hysteroscopy, most patients have slight vaginal bleeding and occasionally, lower abdominal cramps. Severe cramps, dyspnea, and upper abdominal and right shoulder pain can develop if CO2 is used as the distension media and it passes through the fallopian tubes into the peritoneal cavity. Consequently, even in an office environment, the patient should be encouraged to have a friend or relative escort her home.
Operative Hysteroscopy: Risks
Counseling before operative hysteroscopy varies depending on the planned procedure, the type of anesthesia, and the procedure location—office or operating room. Overall, the risks of operative hysteroscopy are higher than those of diagnostic hysteroscopy, but these increased risks are largely confined to procedures such as adhesiolysis of severe intrauterine synechiae or resection of leiomyomas that are either large or that extend deeply into the myometrium.
These risks include those associated with anesthesia, which are intrinsic to all hysteroscopic procedures, and are related to the specific surgical procedure to be performed. With any hysteroscopic procedure, air embolus is a possibility, as are complications associated with the gaseous or ﬂuid distention media used. Hypotonic distension media may not be tolerated in some patients if there is significant intravascular absorption, especially in patients with underlying cardiovascular disease. The patient must be aware of the risks associated with uterine perforation, which range from failure to complete the procedure, to hemorrhage, or damage to the intestines or the urinary tract. If such complications occur, laparotomy may be necessary to repair the injury.
The equipment required for hysteroscopy depends on the reason for the procedure. The surgeon must be knowledgeable about the equipment, its mechanisms, and the technical specifications to facilitate efficiency, optimal clinical outcome, and a decreased probability of complications. A typical hysteroscopy setup for diagnostic and minor operative procedures is shown in Figures 23.24 and 23.25. Core competencies required for hysteroscopy are as follows: 1.
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Patient Positioning and Hysteroscopy is performed in a modified dorsal lithotomy position; the patient is supine, and the Cervical Exposure legs are held in stirrups. For hysteroscopic procedures performed while the patient is conscious, comfort must be considered in conjunction with the need to gain good exposure of the perineum.
Figure 23.24 Office hysteroscopy setup. Hysteroscopic procedures are facilitated with an electric examination table. Distension media may be positioned on an intravenous pole, but wide, cystoscopy tubing allows maintenance of higher intrauterine pressures suitable for viewing and performing simple procedures such as polypectomy or transcervical sterilization. A light source is necessary and a camera desirable. The camera is attached to the monitor and may be connected to a printer and/or video recorder. The camera head is attached to a ﬂexible hysteroscope.
Stirrups that hold and support the knees, calves, and ankles permit prolonged procedures. “Candy cane” stirrups are inappropriate for hysteroscopic surgery and for conscious patients.
The smallest speculum possible should be used to expose the cervix. A bivalve speculum hinged on only one side allows its removal without disturbing the position of the tenaculum and hysteroscope. The use of weighted specula should be avoided in conscious patients because of the discomfort involved.