Complications in hysteroscopy

Introduction

Most complications occur in operative hysteroscopy. Here we have to introduce a large barrel hysteroscope unlike in diagnostic hysteroscopy where we use the small barrel hysteroscope of less than 5 mm diameter.

Dilatation of the cervix

The use of rigid instruments is potentially harmful if we do not take the necessary care. Lacerations of the cervix can occur when excessive traction force is used ( Siegler 1983). A contained force is often necessary to dilate the cervical canal up to Hegar 10.5, this manoeuvre always provokes some bleeding. This is a delicate step and the direction of the force applied should be considered. Patience is mandatory. The use of Hegar dilators increasing by halve a size at the time is less traumatic. Some especially designed instruments, as there is the Pratt dilator seems to cause less harm.
 
Pharmacological cervical dilatation can be considered when the cervix is very rigid at a first evaluation, f.e. in menopause. Prostaglandin’s can be used. Sulprostone and its derivates applied in a gel form are very effective and their maximum effect is reached within one hour. We advise one application the night before and one application one and a half hour before the intervention. Their action softens the cervical stroma resulting in the dilatation of the canal. Doses of 125-250 mg produce the desired effect in 80% of the patients. Side effects include nausea, vomiting hyper- and hypotension and occasionally a skin rash. Mechanical dilatation provoked by Laminaria stents are less useful. The stents are hygroscopic and distend because of the absorption of the vaginal and cervical fluids over a few hours. The problem is that these stents, because of their length, tend to swell beyond the confines of the cervical canal and therefore sometimes are difficult to remove and are a potential hazard for infection. Synthetic laminaria such as Lamicel® ( CaBOT medical Corporation, Langhorne, PA, USA) are a better choice as the dilator, with its polyvinyl core impregnated with less than 500 mg of sodium phosphate, has a memory and therefore does maintain the same diameter over the device at all times. This makes it easier to remove.

Hazards of distension media

CO2 is the least messy distension medium used. The breaking index of this medium equals the breaking index of the light and thus the images seen are equal to the images we are used to see in daily live. Its application however needs the use of an adapted “hysteroflator” and the learning curve is much longer than the curve for the use of liquid distension media.
 
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