Pocket ObGyn – Complications of Laparoscopy & Hysteroscopy

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Pocket ObGyn – Complications of Laparoscopy & Hysteroscopy
See Abbreviations

Incidence (Clin Obstet Gynecol 2002;45(2):469)

  • Occur in 0.2–10.3% of all laparoscopic cases
  • Over 50% during entry into the abdominal cavity

Complications of Laparoscopy (J Minimally Invasive Gynecol 2006;13:352)

  • Extraperitoneal insufflation: Misplacement of Veress needle ® peritoneal tenting

Signs: Immediate insufflation pres >15 mm Hg, abdominal wall fullness/crepitus, hypercarbia, respiratory compromise

Prevention: Monit of insufflation pres, reposition Veress needle as appropriate.

Mgmt: Alert anesthesiologist, should resolve w/ expectant mgmt.

  • Nerve injury: See table with summary
  • Vascular injury: During entry (Veress needle or port placement) or intraop

Common vessels injured: Inferior/superior epigastric artery, aorta, vena cava, iliac vessels

Signs: Port site bleeding, intra-abdominal bleeding on entry, tachy, HoTN

Prevention: Correct needle placement & direct visualization of trocar sites

Open (Hasson) entry may minimize vascular injury risk (Aust N Z J Obstet Gynecol 2002;42:246)

Manage: Small vessels ® tamponade or ligation, large vessels ® laparotomy, abdominal packing & fluids if vascular surgeon not immediately available (J Min Invas Gynecol 2010;17:692)

  • GI injury: Incid 13/1000, occurs during entry or intraop (Br J Surg 2004;91:1253)

Signs: If not recognized intraop, worsening abdominal pain, tachy, fever Intraperitoneal air not reliable sign, occurs in 38.5% laparoscopy (J Reprod Med

1976;16(3):119)

RFs: Prior Surg, intra-abdominal pathology (endometriosis, PID, adhesions)

Prevention: NG or OG tube decomp of stomach. In high-risk pts consider nonumbilical entry point (Palmer’s point –3 cm below costal margin in left midclavicular line).

Mgmt: Surgical repair (oversewing or resxn), Abx

•   Postop bleeding:

Signs: Tachy, > expected Hgb/Hct drop, HoTN, oliguria, AMS, increased abdominal pain, bleeding from incision or vagina

Abd compartment syn: Bleeding/ascites ® ­ intra-abdominal pres ® ¯ lung compliance, ¯ venous return, ¯ kidney fxn ® hypoxemia, oliguria, renal failure

Manage: Fluid resusc, monit UOP, NPO, trend CBC, poss surgical exploration

  • Urinary tract injury: Incid in TLH up to 4% (JSLS 2007;11:422; AJOG 2003;188(5):1273)

Only 30% recognized during operation

Signs: Abdominal/flank pain, peritonitis, hematuria, oliguria/anuria, fever, leakage of urine from incision or vagina, elevated Cr. Consider CT ± urogram, sampling free fluid in abd if suspect urinoma; send fluid for BUN/Cr. If close to serum, then transudate (ascites); if higher, suspect urine leak.

Prevention: Decomp of bladder w/ foley, direct visualization during trocar place- ment, dissection & visualization of ureters (peristalsis), routine stenting not rec- ommended

Mgmt: Closure for large cystotomy, postop bladder decomp, ureter repair

  • Trocar site hernia: Incid 0.5% (Br J Surg 2012;99:315)

Signs: Bulging, small-bowel obst

RFs: Pyramidal trocars, size ³12-mm trocars (3% vs. <1%) (AJOG 1993;168:1493)

Prevention: Close port defects >10 mm (Arch Surg 2004;139:1246)

Mgmt: Surgical vs. expectant depending on severity

  • Shoulder pain: Common, referred pain from diaphragmatic irritation (CO2, bld, fluid)
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Complications of Hysteroscopy

Complications and management (Obstet Gynecol 2011;117:1486; Best Pract Res Clin Obstet Gynaecol 2009;23:619)

  • Fluid overload (5–6%): Excessive intrauterine Absorp of distending media
Main types of distending fluid:

Nonelectrolyte (glycine, mannitol, sorbitol): For use w/ monopolar instruments

Electrolyte (saline, LR): For diagnostic hysteroscopy & w/ bipolar or mechanical instruments

Pathophysiology: Vol overload: CHF, pulm edema; metabolic imbalance: HypoNa, ¯ serum osm, ­ ammonemia, hyperglycemia, acidosis; ¯serum Na by

~10 mmol/L/1000 mL glycine deficit (Lancet 1994:344:1187); neurologic sequelae: Cerebral edema, nausea, visual changes, sz, coma. Prevent overload: Select distending media that minimizes risk of overload (isotonic, electrolyte- containing solutions), monit fluid deficit frequently, use automated fluid monitoring system.

Manage: D/c infusion for (J Am Assoc Gynecol Laparosc 2000;7:167)

Nonelectrolyte solution >1000–1500 mL Electrolyte solution >2500 mL

OR serum Na <130 mmol/L

If severely hyponatremic ® hypertonic saline. Loop diuretics are not indicated unless there is clinical evid for vol overload; may exacerb electrolyte abnor- malities. Low threshold for xfer to ICU for intensive monitoring.

  • Hemorrhage (2–3%): From resection, cervical lacerations, tenaculum site, perforation

Manage: Electrocautery, inject vasopressin, suturing tenaculum site, balloon tam- ponade (AJOG 1983;147:869), laparoscopic suturing, hysterectomy, UAE

  • Uterine perforation (1–1.5%) ® retroperitoneal hematoma, bowel/bladder injury, or signs of acute bld loss

Prevention: Careful sounding, adequate cervical dilation, operate resectoscope toward user (not toward uterine wall)

Mgmt:

Hemodynamically stable ® monit for bleeding, pain, infxn

Large perforation, unstable or perforation w/ electrocautery ® surgical explora- tion w/ repair

  • Infxn: Rare complication of hysteroscopy (<1%)
  • Air/CO2 embolization (gas rarely used as distention medium) ®circulatory collapse (sudden ¯ O2 sat, ¯ BP, dysrhythmia). Place pt in left lateral decubitus w/ head tilted down, cardiopulmonary

See Abbreviations

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