Presented by:
Nicole Delaloye
Affiliations:
University of Calgary
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What Is Uterine Peforation: When Hysteroscopic Morcellation of Products of Concpetion Goes Wrong?
Hysteroscopic morcellation is a minimally invasive technique used to remove retained products of conception (RPOC) from the uterine cavity under direct visualization. Unlike blind dilation and curettage, hysteroscopy allows the surgeon to identify and selectively remove retained tissue while attempting to preserve the surrounding endometrium. Here’s what it involves:
- Preoperative Assessment: Ultrasound, clinical history, and symptoms are used to determine the location and extent of retained tissue and assess for complications such as bleeding or infection.
- Hysteroscopic Visualization: A hysteroscope is introduced through the cervix, allowing direct examination of the uterine cavity and identification of retained products.
- Tissue Morcellation: A hysteroscopic tissue removal device is used to mechanically cut and remove retained tissue under continuous visualization.
- Endometrial Preservation: Targeted removal helps limit unnecessary disruption of healthy surrounding endometrium compared with blind instrumentation.
- Cavity Assessment: The surgeon periodically reassesses the uterine cavity to confirm tissue removal and monitor the integrity of the uterine wall.
- Final Inspection: The cavity is inspected for residual tissue, bleeding, or evidence of uterine injury before completing the procedure.
Hysteroscopic removal can provide precise, targeted treatment of RPOC, but patient selection is important, particularly when infection or other factors may compromise the integrity of the uterine wall.
What are the risks of Uterine Peforation: When Hysteroscopic Morcellation of Products of Concpetion Goes Wrong?
Although direct visualization offers important advantages, hysteroscopic morcellation can cause serious complications, particularly when normal anatomy is distorted or the uterine tissue is weakened by infection or recent pregnancy.
- Uterine Perforation: The hysteroscope or morcellation device can pass through the uterine wall, potentially causing significant injury.
- Injury to Surrounding Organs: If perforation occurs while the morcellator is active, nearby structures such as the bowel, bladder, or pelvic blood vessels may be injured.
- Hemorrhage: RPOC can be highly vascular, and tissue removal or uterine perforation may result in significant bleeding.
- Infection or Worsening Infection: Performing hysteroscopic surgery in the setting of active pelvic infection may increase the risk of spreading or worsening infection.
- Incomplete Tissue Removal: Residual products may cause continued bleeding, infection, or the need for additional treatment.
- Intrauterine Adhesions: Trauma to the endometrium can result in scar tissue formation, potentially affecting menstruation or future fertility.
- Fluid-Related Complications: Hysteroscopic distension fluid can be absorbed into the circulation, potentially causing fluid overload or electrolyte abnormalities.
- Need for Additional Surgery: Significant perforation, hemorrhage, or injury to surrounding structures may require laparoscopy, laparotomy, or other surgical intervention.
Careful patient selection, assessment for active infection, continuous visualization, and awareness of uterine wall integrity are important for reducing complications during hysteroscopic removal of retained products of conception.