Complications of Hysteroscopic and Uterine Resectoscopic Surgery

Effect of esketamine on haemodynamic fluctuations in patients undergoing hysteroscopic surgery: A prospective, double-blind randomized clinical trial

AIMS

We explored whether esketamine anesthesia during hysteroscopic surgery can reduce intraoperative hemodynamic fluctuations and improve patient benefit.

METHODS

A total of 170 patients undergoing hysteroscopic surgery were enrolled, and 151 patients were finally included in the analysis, among which 19 used vasoactive drugs during surgery. Patients were randomly assigned to either the esketamine anesthesia group (E group) or the sufentanil anesthesia group (S group). The primary outcomes were blood pressure and heart rate during the surgery. Secondary outcomes included resistance to laryngeal mask insertion, demand for propofol and remifentanil, nausea and vomiting, Richmond Agitation and Sedation Scale (RASS), dizziness and pain intensity after resuscitation, vasoactive medication treatment, hospitalization time and expenses.

RESULTS

E group had a more stable heart rate, systolic blood pressure, diastolic blood pressure and mean blood pressure than the S group (p < 0.001). Patients in E group had a higher demand for propofol (p < 0.001) but better RASS scores (p < 0.001) after resuscitation. The incidence of intraoperative vasoactive medication use was higher in the S group (18.4% vs. 6.7%, p = 0.029). There were no statistically significant differences in terms of resistance to laryngeal mask insertion, remifentanil demand, time required for resuscitation, postoperative pain, dizziness, nausea or vomiting.

CONCLUSIONS

Compared with sufentanil, esketamine-induced anesthesia during hysteroscopic surgery can reduce intraoperative hemodynamic fluctuations and the incidence of intraoperative vasoactive medication. Although esketamine-induced anesthesia may increase the demand for propofol during surgery, it does not affect the anesthesia recovery time and the quality of patient recovery is better.

Coincidental spontaneous perforation of the small intestine following operative hysteroscopy: A case report

OBJECTIVE

Operative hysteroscopy is a common gynecologic procedure, but it carries the risk of complications. Spontaneous small intestine perforation is rare and fatal, especially in young adults. We present a spontaneous small intestine perforation after operative hysteroscopy with mimicking sign of uterine perforation after operation hysteroscopy.

CASE REPORT

A 30-year-old nulligravida woman underwent Truclear® hysteroscopic polypectomy in the morning in LMD. She suffered from upper abdominal pain in the afternoon. Subsequently, progressive abdominal distention and imminent shock occurred the next morning. Initially, it was supposed to be a case of uterine rupture with internal bleeding. She was transferred to the emergency department of our hospital. Complete biochemistry data and abdominal CT were performed. The CT revealed pneumoperitoneum and ascites. Emergent laparoscopy was arranged. The abdominal cavity was full of intestinal fluid and the myomatous uterus was intact. The surgeon performed a laparotomy, two sites of spontaneous perforation of the small intestine were detected. The patient underwent laparotomic segmental resection and anastomosis and was discharged 14 days after surgery without incident.

CONCLUSIONS

The risk of uterine perforation during hysteroscopy is up to 1.6%. The use of non-thermal intrauterine morcellator device (Truclear®) has been shown to significantly reduce the risk of perforation and thermal injury. As this case highlights, we suspected the possibility of uterine perforation immediately after hysteroscopic surgery. However, it happened to be rare spontaneous perforation of small bowel. The patient recovered well after timely transfer and management. Hysteroscopy is a very common procedure in gynecologic clinics, but even relatively safe intrauterine morcellator devices carry risk of complications. As a healthcare provider, we should beware of any comorbidity, for sometimes it would be catastrophic.

The use of intrauterine balloon therapy in reproductive medicine and surgery: a guidance for practice

The use of balloon therapy in obstetric practice especially in postpartum haemorrhage (PPH) is well established and has recently been reviewed. However, little attention has been drawn regarding the use of intrauterine balloon (IUB) in gynaecological practice. This study focuses on the various usage of IUB in gynaecological practice. An electronic literature search through Medline, EMBASE and Clinicaltrial.gov from inception to August 2022 was conducted. The study focuses on the three following areas: (1) Indications: prevention and removal of intrauterine adhesions, management of ectopic pregnancy, facilitation of endoscopic surgery and other clinical usages; (2) Practical aspects of balloon therapy including ultrasound guidance, choice of balloon, inflation volume, duration of balloon therapy; and (3) Potential complications including pain, infection, uterine rupture and how they can be avoided. IUB therapy is a simple, inexpensive and effective method that can be applied in various gynaecological conditions ranging from IUA to intrauterine haemorrhage. Complications are rare, but in most cases can be avoided with correct use.

Management of Early Pregnancy Loss

This JAMA Insights Clinical Update discusses the management of early pregnancy loss, including expectant, medical, and surgical management regimens.

Clinical observation of different dosages of dexmedetomidine combined with a target-controlled infusion of propofol in hysteroscopic submucosal myomectomy

Objective

This study aimed to explore the clinical effects of different dosages of dexmedetomidine (Dex) combined with a target-controlled infusion of propofol in hysteroscopic submucosal myomectomy.

Methods

Ninety patients who underwent hysteroscopic submucosal myomectomy between September 2021 and March 2022 were enrolled and randomly divided into three groups, with 30 patients in each group. Patients in Groups A, B, and C received injections of 0.25, 0.5, or 0.75 µg/kg of Dex, respectively, by intravenous pump over 10 min. After this time, a maintenance dosage of 0.5 µg/kg/h was administered by intravenous infusion until the end of the surgery. Anesthesia was induced using 1.5 mg/kg of propofol and 0.3 µg/kg of sufentanil that were introduced through a laryngeal mask. The plasma concentration of propofol was maintained at 3 µg/ml by target-controlled infusion until the end of the surgery. The mean arterial pressure (MAP), heart rate (HR), and electroencephalographic bispectral index (BIS) were observed when the patient entered the operating room (T0), after catheter indwelling for anesthesia (T1), at the time of cervical dilation (T2), at the time of hysteroscopic surgery (T3), and at the end of the surgery (T4) in all three groups. The total dosage of propofol for induction and maintenance, anesthesia awakening time, orientation recovery time, Visual Analog Scale (VAS) score of the post-awakening uterine contraction pain, and adverse reactions were recorded.

Results

The intraoperative reductions of MAP and HR in patients were significant in Group C when compared with those in Groups A and B (P < 0.05), and BIS was significantly lower in Group C at T2 and T3 when compared with the baseline measurement at T0 (P < 0.05). The dosage of propofol was significantly higher for Group A than for Groups B and C (P < 0.05). The anesthesia awakening time and orientation recovery time were significantly longer for patients in Group C when compared with patients in Groups A and B (P < 0.05). Within 5-30 min after awakening, the VAS scores in Groups B and C were significantly lower than those for Group A (P < 0.05). The incidence of adverse reactions in Group B was significantly less than that for Groups A and C (P < 0.05).

Conclusion

The continuous pumping of 0.5 µg/kg of Dex combined with a target-controlled infusion of propofol in hysteroscopic submucosal myomectomy resulted in positive anesthetic and analgesia effects and fewer adverse reactions. It therefore has high clinical significance.

Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology

Hysteroscopy provides a minimally invasive strategy to evaluate intrauterine pathology and manage conditions such as abnormal uterine bleeding, infertility, intrauterine adhesions, müllerian anomalies, and intrauterine foreign bodies. Increasing access to hysteroscopy procedures in the office has the potential to improve patient care by minimizing financial and logistical barriers, aiding in streamlined diagnosis and treatment planning, and potentially averting unnecessary operative procedures and anesthesia. Office hysteroscopy refers to procedures performed in outpatient settings where pain management involves no medications, oral nonsedating medications, local anesthetic agents, or oral or inhaled conscious sedation. We present best practices for the implementation of hysteroscopy in an office setting. These include appropriate patient selection, optimal procedural timing, cervical preparation for patients at highest risk of cervical stenosis or pain with dilation, individualized pain-management strategies, use of distension media, and video monitoring to engage patients in the procedure. We describe miniaturized equipment for use in the office setting and "no-touch" vaginoscopic approaches to limit patient discomfort. With appropriate training and experience, office hysteroscopy presents a simple and cost-effective modality for optimizing gynecologic care for our patients.

Hysteroscopic myomectomy: The guidelines of the International Society for Gynecologic Endoscopy (ISGE)

OBJECTIVE

With this publication, the International Society for Gynecologic Endoscopy (ISGE) aims to provide the clinicians with the recommendations arising from the best evidence currently available on hysteroscopic myomectomy (HM).

STUDY DESIGN

The ISGE Task Force for HM defined key clinical questions, which led the search of Medline/PubMed and the Cochrane Database. We selected and analyzed relevant English-language articles, published from January 2005 to June 2021, including original works, reviews and the guidelines previously published by the European Society for Gynecological Endoscopy (ESGE) and the American Association of Gynecologic Laparoscopists (AAGL), in which bibliographies were also checked in order to identify additional references, using the medical subject heading (MeSH) term "Uterine Myomectomy" (MeSH Unique ID: D063186) in combination with ''Myoma" (MeSH Unique ID: D009214) and ''Hysteroscopy" (MeSH Unique ID: D015907). We developed the recommendations through multiple cycles of literature analysis and expert discussion.

RESULTS

The ISGE Task Force did develop 10 grade 1A-C and 4 grade 2A-C recommendations. For planning HM, evaluation of the uterus with saline infusion sonohysterography (SIS) or combined assessment by transvaginal ultrasound (TVUS) and diagnostic hysteroscopy is recommended (Grade 1A). The use of STEPW (Size, Topography, Extension of the base, Penetration and lateral Wall position) classification system of submucosal leiomyoma (LM) is recommended to predict the complex surgeries, incomplete removal of the LM, long operative time, fluid overload and other major complications (grade 1B). For type 0 LMs, in addition to resectoscopy (slicing technique), morcellation is recommended, being faster and having a shorter learning curve with respect to resectoscopy (grade 1C). For type 1-2 LMs, slicing technique is currently recommended (grade 1C). A fluid deficit of 1000 mL also in case of bipolar myomectomy with saline solution, in healthy women of reproductive age, contains low risk for major complications. Lower thresholds (750 mL) for fluid deficit should be considered in the elderly and in women with cardiovascular, renal or other co-morbidities (Grade 1B).

CONCLUSION

HM is the most effective conservative minimally invasive gynecologic intervention for submucous LM. The set of 14 ISGE recommendations can significantly contribute to the success of HM and the safety of patients for whom the choice of appropriate surgical technique, as well as the surgeon's awareness and measures to prevent complications are of the utmost importance.

Complication Rates after Endometrial Ablation in Ontario: A Cohort Analysis of 76 446 Patients

STUDY OBJECTIVES

Endometrial ablation (EA) is an alternative to hysterectomy for the management of heavy menstrual bleeding; however, EA is not without risk. Our objective was to determine complication rates in women undergoing EA in the province of Ontario over a 15-year time period. The primary outcome was a composite of multiple complications within 30 to 180 days of surgery. The secondary outcomes included mortality, length of hospital stay, hospital readmission, and emergency department visit within 30 days of discharge.

DESIGN

Retrospective cohort study using Cochran-Armitage test for trend.

SETTING

Administrative data from the Canadian province of Ontario, assessing patients undergoing surgery in a publicly funded healthcare system.

PATIENTS

Women in Ontario undergoing a primary EA over a 15-year time period.

INTERVENTIONS

The intervention was a primary EA.

MEASUREMENTS AND MAIN RESULTS

We assessed for genitourinary complication, fistula, gastrointestinal complication, pain, control of bleeding, blood transfusion, infectious complication, venous thromboembolism, fluid overload, thermal injury, and other injuries related to surgery. The secondary outcomes included 1-month and 6-month mortality, length of hospital stay, hospital readmission, and emergency department visit within 30 days of discharge. A total of 76 446 primary EAs were evaluated from 2002 to 2017, with the number of EAs per year increasing over the study period by 47%. Complications were seen in 4.8% of the cohort, with the complication rate being relatively stable over time. Although 6.2% of the cohort re-presented to the emergency department, <1% required readmission, and <0.05% died within 180 days. On multivariable analysis, the risk of complications increased with a preoperative diagnosis of other than bleeding (odds ratio [OR] 2.89; 95% confidence interval [CI], 2.61-3.21; p <.001), previous abdominal surgery (OR 1.42; 95% CI, 1.28-1.56; p <.001), and American Society of Anesthesiologists score 3+ (OR 1.37; 95% CI, 1.27-1.48; p <.001).

CONCLUSION

Primary EA is associated with complications in <5% of the patients, with serious complications infrequent.

Successful treatment of cardiac arrest following hysteroscopic surgery using extracorporeal membrane oxygenation: A case report

RATIONALE

Cardiac arrest caused by water intoxication syndrome following hysteroscopic surgery is a rare but life-threatening occurrence. Extracorporeal membrane oxygenation (ECMO) is rarely used to treat water intoxication syndrome in hysteroscopic surgery. Here, we successfully treated a patient with water intoxication syndrome following hysteroscopic surgery with ECMO.

PATIENT CONCERNS

We report a rare case of cardiac arrest during hysteroscopic surgery treated with veno-venous (VV) ECMO.

DIAGNOSIS

Water poisoning syndrome was diagnosed by electrolyte examination, the lowest value of serum sodium was 110.7 mmol/L.

INTERVENTIONS

VV-ECMO was prescribed as a measure after traditional cardiopulmonary resuscitation.

RESULTS

ECMO was successfully evacuated on day 5 and the patient was discharged on day 45.

CONCLUSION

Mastering the hysteroscopic operative techniques and using a bipolar hysteroscopic generator, isotonic fluid, perfusion pressures less than 100 mm Hg, and local anesthesia may reduce the risk of hysteroscopic water intoxication syndrome. During hysteroscopic surgery, patients may experience cardiac arrest and fatal water intoxication syndrome. Even when traditional cardiopulmonary resuscitation is successful, VV ECMO may contribute to the recovery of brain function if oxygenation is not maintained.

Hysteroscopy and the risk of gas embolism: A review

Hysteroscopy is one of the most frequent procedures that a gynecologist will perform over their career. It is also one of the safest procedures. Operative hysteroscopy has an increased risk profile due to the nature of the surgery. The following review will address the issue of gas embolism in hysteroscopy. This review will look at the evidence regarding the likely causation, rates, and potential methods of minimizing risk to patients as well as treatment options available should this complication arise.

CLINICAL VALUE OF TRANSVAGINAL ULTRASONOGRAPHY IN COMPARISON TO HYSTEROSCOPY WITH HISTOPATHOLOGIC EXAMINATION IN DIAGNOSING ENDOMETRIAL ABNORMALITIES

The aim of our retrospective study was to compare the performance of transvaginal sonography in relation to histologic diagnosis of samples obtained by hysteroscopy through analysis of data collected over 16 years. Data on suspected formation of endometrial polyp or submucosal fibroid found on ultrasound examination were extracted. The study included a total of 3679 women examined during the 2000-2015 period. All women underwent ultrasound examination preoperatively for better planning the type and scope of operation to be performed. The study included only women with samples for histopathologic analysis collected during the operation. Ultrasound diagnosis of polyps compared with histology showed 89.6% sensitivity and 39.1% specificity. For submucosal myomas, sensitivity was 69.2% and specificity 91.3%. In conclusion, ultrasound is not reliable method for definitive diagnosis but it is an excellent orientation method.

Overcoming the Challenging Cervix: Identification and Techniques to Access the Uterine Cavity

Importance

Cervical stenosis is a challenging clinical entity that requires prompt identification and management in order to avoid iatrogenic injury at the time of endocervical canal cannulation.

Objective

The aim of this study was to identify cervical stenosis and discuss associated etiologies, risk factors, and review medical and surgical approaches for overcoming cervical stenosis.

Evidence Acquisition

Computerized searches of MEDLINE and PubMed were conducted using the key words "cervix", "cervical stenosis," "embryo transfer," "hysteroscopy complications," "misoprostol," and "ultrasound." References from identified sources were manually searched to allow for a thorough review. Data from relevant sources were compiled to create this review.

Results

Transcervical access to the uterine cavity is frequently required for procedures such as hysteroscopy, dilation and curettage, endometrial biopsy, sonohysterogram, hysterosalpingogram, intrauterine insemination, embryo transfer in those undergoing in vitro fertilization, and insertion of intrauterine devices. These procedures can become complicated when difficult cannulation of the endocervical canal is encountered. Management strategies include preprocedural use of cervical-ripening agents or osmotic dilators, ultrasound guidance, no-touch vaginoscopy, manual dilatation, and hysteroscopic resection of the obstructed endocervical canal.

Conclusions and Relevance

Cervical stenosis is associated with iatrogenic complications that can result in significant patient morbidity. In patients undergoing in vitro fertilization, difficult embryo transfer is associated with lower pregnancy rates. The clinician should carefully consider the patient's menopausal status, risk factors, and symptoms in order to anticipate difficult navigation of the endocervical canal. Various medical and surgical management strategies, including hysteroscopic resection, can be used to overcome the stenotic cervix.

Identifying the superior surgical procedure for endometrial polypectomy: A network meta-analysis

OBJECTIVE

To identify the superior surgical procedure for endometrial polypectomy based on network meta-analysis.

METHOD

Literature retrieval was conducted in globally recognized databases, namely, MEDLINE, EMBASE and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating the clinical effects of respective surgical procedure for endometrial polypectomy. Surgical parametric data, including operative time, success rates and complications, were quantitatively pooled and estimated based on the Bayesian theorem. The values of surface under the cumulative ranking (SUCRA) probabilities regarding each parameter were calculated and ranked by various procedures. Node-splitting analysis was performed to test the inconsistency of the main results and publication bias was assessed by examining funnel-plot symmetry.

RESULTS

After a detailed review, 8 RCTs containing 5 different procedures were finally included for network meta-analysis. The results indicated that hysteroscopic morcellation possessed the highest possibility of revealing best clinical effects on operative time (SUCRA, 0.49), success rate (SUCRA, 0.90) and complications (SUCRA, 0.50). Moreover, node-splitting analysis and funnel-plot symmetries illustrated no inconsistency or obvious publication bias in the current study.

CONCLUSIONS

Current evidence demonstrated that hysteroscopic morcellation showed optimal potential superior clinical effects for endometrial polypectomy compared to other procedures. However, high-quality large sample trials are still expected, and new investigations on other relative procedures in this field should be included in the future.

Is there a survival advantage in diagnosing endometrial cancer in asymptomatic postmenopausal patients? An Israeli Gynecology Oncology Group study

BACKGROUND

Incidental ultrasonographic findings in asymptomatic postmenopausal women, such as thickened endometrium or polyps, often lead to invasive procedures and to the occasional diagnosis of endometrial cancer. Data supporting a survival advantage of endometrial cancer diagnosed prior to the onset of postmenopausal bleeding are lacking.

OBJECTIVE

To compare the survival of asymptomatic and bleeding postmenopausal patients diagnosed with endometrial cancer.

STUDY DESIGN

This was an Israeli Gynecology Oncology Group retrospective multicenter study of 1607 postmenopausal patients with endometrial cancer: 233 asymptomatic patients and 1374 presenting with postmenopausal bleeding. Clinical, pathological, and survival measures were compared.

RESULTS

There was no significant difference between the asymptomatic and the postmenopausal bleeding groups in the proportion of patients in stage II-IV (23.5% vs 23.8%; P = .9) or in high-grade histology (41.0% vs 38.4%; P = .12). Among patients with stage-I tumors, asymptomatic patients had a greater proportion than postmenopausal bleeding patients of stage IA (82.1% vs 66.2%; P < .01) and a smaller proportion received adjuvant postoperative radiotherapy (30.5% vs 40.6%; P = .02). There was no difference between asymptomatic and postmenopausal bleeding patients in the 5-year recurrence-free survival (79.1% vs 79.4%; P = .85), disease-specific survival (83.2% vs 82.2%; P = .57), or overall survival (79.7% vs 76.8%; P = .37).

CONCLUSION

Endometrial cancer diagnosed in asymptomatic postmenopausal women is not associated with higher survival rates. Operative hysteroscopy/curettage procedures in asymptomatic patients with ultrasonographically diagnosed endometrial polyps or thick endometrium are rarely indicated. It is reasonable to reserve these procedures for patients whose ultrasonographic findings demonstrate significant change over time.

The effect of antibiotic prophylaxis for acute pelvic inflammatory disease after hysterosalpingography: a retrospective cohort study

AIMS

Concerns about acute pelvic inflammatory disease (PID) after hysterosalpingography (HSG) have been raised since 1980. However, the effectiveness of prophylactic antibiotics remains unclear. This study investigated the effect of antibiotic prophylaxis in women undergoing HSG.

METHODS

Women undergoing HSG between 2000 and 2012 were screened from the Taiwan National Health Insurance Research Database for eligibility. The prophylactic cohort included patients using any antibiotics of 1st-generation cephalosporins, doxycycline, clindamycin, and metronidazole, within 7 days before HSG (n = 3257). Patients not using any antibiotics were registered as the non-prophylactic cohort (n = 4662). An unconditional logistic regression model was applied to calculate the odds ratio (OR) and 95% confidence interval (CI) of acute PID after HSG associated with prophylactic antibiotics.

RESULTS

The cumulative incidences of acute PID after HSG were 0.46% and 1.42% in the prophylactic and non-prophylactic cohorts, respectively. Prophylactic patients had a significantly reduced estimated relative risk of acute PID compared with non-prophylactic patients (adjusted OR = 0.33, 95% CI = 0.19-0.58; p = .001). Doxycycline users had the lowest adjusted OR of 0.20 (95% CI = 0.04-0.81; p = .02), followed by users of 1st-generation cephalosporins (adjusted OR = 0.35, 95% CI = 0.18-0.68; p = .002). Multivariate sub-group analysis verified this protective effect for almost all sub-groups of prophylactic patients.

CONCLUSIONS

Antibiotic prophylaxis is associated with a decreased estimated relative risk of acute PID in HSG patients. Doxycycline and 1st-generation cephalosporins may be effective prophylactic regimens for HSG.

Cesarean Delivery Changes the Natural Position of the Uterus on Transvaginal Ultrasonography

OBJECTIVES

To assess whether cesarean delivery changes the natural position of the uterus.

METHODS

In this retrospective Institutional Review Board-approved cohort study, we conducted a search of our university gynecologic ultrasonography (US) database. Patients with transvaginal US images before and after either vaginal or cesarean delivery between 2012 and 2015 were included. Women with prior cesarean delivery were excluded. Two readers independently measured antepartum and postpartum flexion angles between the longitudinal axis of the uterine body and the cervix. We calculated intraclass correlation coefficients to measure inter-reader agreement. Antepartum and postpartum uterine flexion angles were compared between patients with vaginal and cesarean delivery.

RESULTS

We included 173 patients (107 vaginal and 66 cesarean delivery). The mean interval between scans ± SD was 18 ± 10 months. Inter-reader agreement for flexion angles was almost perfect (intraclass correlation coefficients: antepartum, 0.939; postpartum, 0.969; both P < .001). There was no difference in mean antepartum flexion angles for cesarean delivery (154.8° ± 45.7°) versus vaginal delivery (145.8° ± 43.7°; P = .216). Mean postpartum flexion angles were higher after cesarean delivery (180.4° ± 51.2°) versus vaginal delivery (152.8° ± 47.7°; P = .001. Differences in antepartum and postpartum flexion angles between cesarean and vaginal delivery were statistically significant (25.6° versus 7.0°; P = .027).

CONCLUSIONS

Cesarean delivery can change the uterine flexion angle to a more retroflexed position. Therefore, all women with a history of cesarean delivery should undergo a transvaginal US examination before any gynecologic surgery or intrauterine device placement to reduce the possibility of surgical complications.

Simulation for Training and Assessment in Hysteroscopy: A Systematic Review

Hysteroscopy simulation complements conventional training on patients, yet evidence-based recommendations about its implementation and use are lacking. This systematic review analyzes and critically discusses hysteroscopy simulation literature published over the last 30 years. Systematic searches on PubMed, Embase, PsychINFO, ERIC, and the Cochrane Library produced 27 original articles published through 2017. Strategies based on different simulation models (e.g., animal organs, vegetables, synthetic uteri, virtual reality) were evaluated by users and appeared to facilitate learning. Observational studies have suggested a large impact on the knowledge and technical skills of novices for a wide range of hysteroscopic procedures, including for diagnosis, resection, and sterilization. Pretest/posttest studies show large improvements in performance time (6 studies; pooled effect size, 1.45; 95% confidence interval, 1.06-1.85) and overall performance scores (4 studies; pooled effect size, 3.19; 95% confidence interval, 1.45-4.94). Additionally, performance assessment on simulated models distinguishes novices from experts. Caution should be exercised because the available evidence largely originates from heterogeneous studies with weak designs, conducted in experimental settings with nonclinical participants (i.e., medical students). Moreover, neither clinical outcomes nor the clinical value of simulation-based assessment has been addressed. Hysteroscopy simulation may be supported ethically and pedagogically, but its role should be evaluated in pragmatic contexts, with robust interventional studies and broader competence-defining outcomes that include nontechnical skills.

Safety aspects of hysteroscopy, specifically in relation to entry and specimen retrieval: a UK survey of practice

Background

The purpose of this study is to evaluate current practice amongst gynaecologists across the UK, regarding safety aspects of inpatient hysteroscopy under anaesthesia, specifically in relation to entry and specimen retrieval.

A survey was created using survey monkey. The first round was circulated to all registrar trainees and consultant gynaecologists across Wales. Following a good response, the survey was then circulated to all members of the British Society of Gynaecological Endoscopy (BSGE).

Results

There were 212 responses including, 140 consultants, 36 senior registrars, 17 junior registrars and 18 clinical nurse specialists. In total, 136 out of 212 (64.7%) always perform a vaginal examination prior to hysteroscopy. 10.4% always sound the uterus, and 5.2% always dilate the uterus prior to insertion of the hysteroscope. Twenty-three consultants, six senior registrars, three junior registrars and one clinical nurse specialist knew how to position the internal cervical os as visualised through the scope when using a 30° hysteroscope. 35.8% of candidates always perform a post-procedure cavity check, and 9% use suction to flush the cavity to aid vision during the post-procedure cavity check. The majority (76%) predicted dilatation as the stage most likely to cause uterine perforation and predicted the most likely site for perforation as the posterior uterine wall in the anteverted uterus and the anterior uterine wall in the retroverted uterus.

Conclusion

This study highlights varied practice across the UK regarding safety aspects of hysteroscopy, in relation to entry and specimen retrieval. There is a need for increased awareness of the risks of hysteroscopy and paramount precautions that should be performed routinely as part of their practice. Standardised guidelines may be a beneficial tool to help bring about this change in practice, leading to a reduction in uterine perforation rates.

Gas Embolism During Hysteroscopic Surgery?: Three Cases and a Literature Review

During a period of 1 month, 3 episodes of probable or actual venous air embolism occurred during hysteroscopic surgery. All patients developed the same symptoms of ventilatory and hemodynamic decompensation, beginning with a reduction in end-tidal carbon dioxide, arterial desaturation, and cyanosis on the upper trunk, and rapidly progressed to hypotension and 2 cardiac arrests. While entrainment of some air is common during hysteroscopy, life-threatening embolism is a rare but serious complication for which an anesthetist needs to be vigilant and prepared. If even a small drop in end-tidal carbon dioxide occurs, venous air embolism should be suspected and the operation should be discontinued.

Advanced Hysteroscopic Surgery: Quality Assurance in Teaching Hospitals

Advanced hysteroscopic surgery (AHS) is a vitally important technique in the armamentarium for the management of many day-to-day clinical problems, such as menorrhagia, surgical excision of uterine myomata and septa in the management of female infertility, hysteroscopic excision of chronically retained products of conception (placenta accreta), and surgical removal of intramural ectopic pregnancy. In today's climate of accountability, it is necessary that gynecologists take a more active role in assuring the quality of their work. In this article, we discuss the quality assurance system from the point of view of the surgical audit meetings in some of the major teaching hospitals affiliated with the University of Queensland (Brisbane, Queensland, Australia).

Uterine perforation following a fractional curettage successfully treated with the modified polysaccharide 4DryField® PH: a case report

Background

Uterine perforation is the most common complication of curettage and may result in bleeding. Therefore, urgent control of bleeding from the uterine wall perforation is necessary to avoid an emergency hysterectomy or blood transfusion, to prevent peritoneal adhesion formation, possible chronic pelvic pain, and infertility. In the present case, an active bleeding secondary to a perforation of the uterus during curettage, for diagnosis of endometrial carcinoma, was instantaneously and successfully treated with only the application of a novel modified polysaccharide powder. This is, to the best of our knowledge, the first time that the agent 4DryField® has been used for this purpose.

Case presentation

A 71-year-old German woman with serometra and endometrial hyperplasia suffered a perforation of the anterior wall of the uterus during the hysteroscopic resection of submucosal polyps and a fractional curettage. Subsequently, an immediate laparoscopy showed an active bleeding from the wound, which was promptly stopped with only the application of the hemostatic and anti-adhesion polysaccharide powder, 4DryField®. There were no postoperative complications. Nine weeks later, a laparoscopic hysterectomy with bilateral salpingoophorectomy for endometrial carcinoma (histology: stage IA, pT1a, cN0, L0 V0 M0/G2) was performed. The former injured area looked slightly prominent, was completely healed, and showed a shiny serosa. All her pelvic organs were free of adhesions, and there was one 0.5-mm calcified granuloma in the Douglas pouch.

Conclusions

The efficient hemostasis combined with the adhesion prevention effect of 4DryField®, allowed a fast control of the uterine wall bleeding, saved operation time, avoided the risks of other procedures for bleeding control and contributed to the normal healing of the uterine wall without any adhesion formation.