Advanced Operative Hysteroscopy & Laparoscopy

Patient Preference Regarding Incisions

Whenever the surgery that is considered can be performed equally well and equally safely by either laparoscopy or laparotomy, the decision as to the type of incision to be used can (and in my opinion really should) include the patient.

In the hands of an experienced laparoscopic surgeon, virtually any endometriosis associated problem that can be treated by laparotomy can now be handled via laparoscopy. Laparoscopic surgery has benefited women in many ways. Differences in approach include:

(1) laparotomy

• opening the abdomen to perform the surgery directly through a large open incision
• cosmetically considered "disfiguring" by many younger women
• requires a stay (usually several days) in the hospital
• postoperative recovery may be several weeks with significant time out from work

(2) laparoscopy

• minimally invasive same day surgical approach
• a telescope is entered through an incision about 1 cm long near the umbilicus and one to three smaller incisions are also usually made in the lower abdomen for the entry of additional instruments
• postoperative recovery usually only a few days with little time out from work.
• little incision discomfort compared to laparoscopy incisions.

Part 1

Part 2

Part 3

Surgical Techniques

In 1998, several different surgical approaches can be (and are) used for the treatment of infertility. Decisions concerning the techniques and equipment used are guided by many variables, including

• the preoperative diagnosis (the "working reason" for going to the operating room),
• a strong desire to prevent postoperative adhesion (scar) formation,
• the familiarity of "the OR team" with the specific equipment used,
• available equipment to accomplish cutting, coagulation and reapproximation of tissue,
• the surgeon's usual "routine" during similar cases,
• complications associated with the specific surgery performed,
• patient preference (including differences in postoperative recovery period and cosmetic

Preoperative Diagnosis

The preoperative diagnosis is critically important in deciding on the type and extent of surgery to be considered. Therefore, a careful pre-op evaluation is desirable using non-surgical tools (including the woman's history and physical examination, radiologic tests, and blood tests) to gather as much useful information as possible. Ideally, a pre-op consult between the physician and the patient (including appropriate significant others such as the husband) will include a thorough review of surgical and nonsurgical treatment alternatives along with the specific risks and benefits of each.

My preoperative evaluation for infertility couples typically includes documentation of ovulation (and if anovulatory then documentation of an appropriate ovarian reserve), a semen analysis (even with a past history of fertility) and an hysterosalpingogram (HSG). The HSG is very important since it will indicate the presence of any large filling defects (possibly fibroids, polyps, a septum or adhesions) in the uterine cavity and will also determine tubal patency. If the fallopian tubes are blocked then the extent of dilatation (size of the hydrosalpinx) and condition of the inner lining of the tubes can be assessed and the couple can be advised about the prognosis for pregnancy if a repair is performed. In this way, a couple can be appropriately counseled about the treatment options preoperatively and discussions between the couple and the infertility specialist will often allow the specialist to make decisions intraoperatively that best suit the particular couple's goals.

Historically, a basic infertility evaluation included a diagnostic laparoscopy. The goal of the diagnostic laparoscopy was to assess the pelvis for abnormalities (including endometriosis and adhesions) that are not identifiable using the other basic infertility tests. After this assessment was completed, the findings were discussed with the couple and a decision was made about the utility of a laparotomy (open surgery with a large abdominal incision). Advances in operative laparoscopy and hysteroscopy have essentially eliminated the use of the diagnostic laparoscopy in the infertility evaluation because most of the surgery that previously required a laparotomy is now able to be accomplished via the laparoscope. Today, infertility specialists will typically discuss likely findings at laparoscopy at a preoperative visit so that the couple can allow the surgeon to make informed intraoperative decisions about the type and extent of repair desired by the couple. Then, the laparoscopy can easily include operative interventions as needed.

Reduction of Postoperative Adhesions (Scar)

The prevention of adhesion (scar) formation should be a primary goal of all fertility surgery. Efforts can (and should) be undertaken to reduce postoperative adhesion formation partially by using principles collectively referred to as "microsurgical techniques." When the infertility surgeon recreates a pelvic organ, opens a previously blocked fallopian tube, removes abnormal structures from within the uterine cavity, ablates endometriosis, or lyses existing pelvic adhesions the restoration of normal anatomy and function often depends on minimizing scar tissue secondary to the surgery.

The microsurgical techniques that should be employed include

• very gentle tissue handling (pulling, rubbing and poking the delicate reproductive tissues can result in trauma and adhesion formation),
• meticulous control of bleeding = hemostasis (whole blood within the pelvis is highly irritating to the peritoneal lining and the inflammation that results can lead to adhesion formation),
• use of magnification if necessary (for establishing proper tissue planes during dissection and for determining the degree of reapproximation accomplished when tissues are placed together)
• careful avoidance of infection (administration of antibiotics to prevent reactivation of a dormant infection within say the fallopian tubes, sterile technique in handling the operating instruments)
• maintaining tissue moisture (irrigation is generally better than sponging, preventing desiccation or drying is important since either leads to adhesion formation)
• minimal effective coagulation of bleeding sites (over cauterizing results in ischemia and this may enhance adhesion formation)
• reducing foreign material that is placed intraoperatively (use of small caliber suture material reduces overall bulk, rinsing sterile gloves or similar objects placed intraabdominally removes talc)
• reducing lateral thermal damage of tissue (lasers, especially ultrapulse and superpulse CO2 lasers, allow application of very high power densities to tissues to accomplish ablation by vaporization with little lateral thermal damage. This is theoretically of great significance)

In theory (although not proven in the existing literature) laparoscopy has an advantage over laparotomy in terms of adhesion formation. With laparoscopy, small abdominal incisions are made and ports maintain access while occluding the holes when no instruments are actively being used. When compared to laparotomy, this should result in less infection (since the sites are not open for the duration of the case), less tissue drying (especially for longer duration cases when drying can be tremendous for open laparotomies), and less tissue trauma secondary to rubbing or moving intraabdominal structures with surgical gloves. Additionally, the laparoscope is able to be placed immediately adjacent to the operative site to enhance visualization of structures that are buried in the pelvis and the laparoscope can magnify tissues slightly. The magnification achieved with the laparoscope is proportional to the distance of the lens from the tissue viewed, such that at a distance of 1 cm from tissue the laparoscope typically magnifies the tissue about 6 fold, at 2 cm about 4 fold, at 3 cm about 2 fold, at 4 cm there is no magnification and at distances greater than 4 cm there is a reduction in size of the viewed tissue.

Adjuvants are materials that can be used to help prevent adhesion formation. The two primary classes of adjuvants include mechanical barriers and surgical adjuvants.

Mechanical barriers include Gore-Tex surgical membranes (that must be sewn into position), Interceed TC-7 (a material placed over raw surfaces), and 32% Dextran 70 (a highly concentrated sugar like solution made up of high molecular weight glucose polymers that draws in water to act as a mechanical barrier between structures).

Of these barriers, Interceed seems to be the most commonly used. Literature from several clinical reports support a role for Interceed in adhesion prevention.

32% Dextran 70 (Hyskon) has been popular in the past and is still in use in some centers. Mechanical separation of raw surfaces is associated with the water drawn into the concentrated solution (hydroflotation) and a siliconizing effect (the solution is slick). When 200 cc of 32% Dextran is placed intraperitioneally there is usually some ascites for up to a week, and patients occasionally complain of fluid leaking from the incision sites, labial swelling, bloating and weight gain.

Surgical adjuvants include anti-inflammatory drugs, anticoagulants, prophylactic antibiotics, calcium channel blockers and plasminogen activators.

The anti-inflammatory drugs include corticosteroids (intended to decrease vascular permeability and enhance lysosomal stabilization, each of which should limit adhesion formation), antihistamines (intended to decrease vascular permeability and decrease fibroblast proliferation, each of which should limit adhesion formation), and nonsteroidal anti-inflammatory agents like motrin (reduces prostaglandin formation to limit adhesion formation). None of these agents has been shown to be beneficial in terms of adhesion formation in large clinical trials but they are often used by physicians whose personal experience with the medications has been favorable. I do not use these agents at this time.

Anticoagulants include low dose heparin (about 1-5 units/mL) within irrigation solutions. High doses of heparin should not be used because there is an increased chance of hemorrhagic surgical complications. Low dose heparin has not been shown to be of benefit in terms of adhesion formation in clinical trials.

Antibiotics may reduce the incidence of infection when given prophylactically. The goal is to achieve adequate doses at the tissue sites during the surgery. Vibramycin is often used for tubal surgery since it effectively treats Chlamydia. Many of the higher generation cephalosporins also work well for gynecological pelvic surgery. I typically use cefotetan or mefoxin (depending on availability).

Calcium channel blockers have been used in hamsters with good results, but human studies are lacking. In theory, these agents decrease tissue ischemia, limit prostaglandins, reduce platelet aggregation, and limit vasoconstriction. The use of these agents is awaiting appropriate human trials.

Plasminogen activators accelerate fibrinolysis to reduce the bulk of fibrin clots. Use of these agents is also awaiting appropriate human clinical trials.

Next Month:

• Familiarity of "the OR team" with the Specific Equipment
• Equipment Generally Available to Cut and Coagulate Tissue
• The Surgeon's Routine

Familiarity of "the OR team" with the Specific Equipment

A surgeon's choice of equipment is occasionally limited by its availability in a particular hospital's operating room. Many of the advanced operative laparoscopic and hysteroscopic tools used by reproductive endocrinologists are available in operating rooms in which infertility specialists routinely work.

Familiarity with the specific tools (equipment) to be used is of paramount importance. The operating room personnel ("the team") as well as the physician must know how to operate the equipment to facilitate the preparation of the patient and "the room," enhance intraoperative communication between members of the surgical team and guide postoperative care. Troubleshooting is an ongoing and critically important aspect of surgery. As a surgeon changes the approach taken during a case or the tools required for the case in response to specific intraoperative findings the OR team must be prepared to respond in a timely and accurate fashion. Each member of the surgical team must understand their responsibilities so that

• the patient is adequately and accurately monitored prior to, during and after the case
• the equipment is properly cleaned, in good working order and prepared for use by the surgeon
• use of fluids (if any) is adequately and accurately (provided and) monitored during the case
• the instrument and gauze pad counts are accurate at the conclusion of the case
• settings for the equipment (on variables such as power) are accurately provided as requested by the surgeon
• communication between the surgeon and the rest of the team is accurate and meaningful

Miscommunication between members of the surgical team or failure to understand one's responsibilities in the operating room can result in mistakes. These mistakes can have a variable impact, ranging from an annoying delay in the completion of the case to a poorer than expected surgical outcome to even a surgical tragedy (long-term morbidity or death). It is prudent for each surgeon bringing new technology into a hospital's operating room to make sure that the team using the new equipment is adequately prepared and familiar with the equipment prior to the actual case so as to avoid mistakes. If the hospital's operating room is familiar with the equipment to be used, then the surgeon usually lets the OR know his preferences for types of solution, suture material, power settings and the like.

Occasionally, a patient will request a particular tool be used for the performance of her surgery. I have several patients who specifically request that a CO2 laser be used for the treatment of their endometriosis and may even recommend the wave form (ultrapulse or superpulse versus continuous) that I use. Fortunately, I am very familiar with the most modern lasers available for this type of laparoscopic surgery and these lasers are available in the operating rooms in which I work. Therefore, I am able to provide the highest quality of care that I am capable of by applying cutting edge technology and using my extensive experience with these sorts of cases.

On the internet, I am often asked questions like "which is the best tool to treat endometriosis- laser, harmonic scalpel, or cautery."

I am the moderator for the "Endometriosis and Polycystic Ovarian Syndrome" bulletin boards for INCIID ("www.inciid.org"). INCIID is the "InterNational Council on Infertility Information Dissemination" (pronounced "inside") which is a nonprofit organization dedicated to educating infertile couples about the latest methods to diagnose, treat and prevent infertility and pregnancy loss. INCIID is currently (1998) one of the internet's most active bulletin board and chat group sites and couples from all over the world visit it to ask questions about their situation.

In my hands I strongly prefer the ultrapulse type CO2 laser. However, couples asking this question come from anywhere in the world and one must recognize that in another surgeon's hands this type of laser may be much less effective than another tool that the particular surgeon is more familiar with. I always recommend allowing the surgeon who will be performing the surgery to decide on the equipment to be used since (s)he will know which tools are available in the chosen operating room. The most important concern for the patient should be finding a (considerate) surgeon with a good track record at achieving the goal desired (pain relief, fertility, etc.) for the surgery contemplated.

Equipment Available to Cut and Coagulate Tissue

There are several surgical tools designed to remove (ablate) tissue and control any bleeding that results. Each tool has its own set of operating characteristics. The surgical tools that remove, destroy, incise and coagulate tissue include

(1) scalpels and scissors,

• a variety of blade sizes and shapes as well as scissor sizes and shapes are available.
• the knife is ideal for cutting the skin, with research documenting greater tensile strength and faster healing in skin cut with a knife as compared to the carbon dioxide laser, harmonic scalpel or electrosurgical devices.
• scissors are ideal instruments for dissection of tissue and can also be used effectively to cut tissues ranging from tough to filmy. These instruments can be used to remove tissue on which endometriosis has grown. Excised tissue will include some normal tissue and any bleeding created needs to be controlled. This has limited the use of these instruments in the routine treatment of endometriosis.

(2) electrosurgical devices,

• these can be adjusted to provide different amounts of power (20 to 80 watts is usually used) with different blends of cutting and coagulation. The electrical generator has variable power (wattage) settings. Pure cutting is a continuous delivery of undamped electrical energy so that a relatively low voltage is required to achieve a particular chosen power (wattage) usage. Pure coagulation is an interrupted or damped delivery of electrical energy such that current is flowing less than 10% of the time (it flows only 6% of the time) so that a much greater peak voltage is required to achieve the same chosen power (wattage) use (compared to cutting). Blends of cutting and coagulation allow the surgeon to select the relative degree of damping used. In the rare situations in which I use cautery to cut (such as during hysteroscopic surgery) I typically use blend 1 which applies current 80% of the time and gives just a little coagulation as compared to pure cutting.
• a wide range of effects is possible. Pure cutting current has little char (which acts to coagulate). At the other end of the spectrum, fulgaration produces a superficial layer of char by holding the electrode a small distance from the tissue and allowing the current to spark. Lateral thermal damage with these instruments due to heating of surrounding tissue limits their use in the ablation of endometriosis, especially when close to other vital structures.

(3) thermocoagulation devices,

• these differ from electrocoagulation devices in that they do not deliver high frequency electrical current to generate heat in the tissues.
• these devices deliver heat directly via a hot metal tip that is applied to tissue.
• these devices are adjusted to deliver heat at up to 160 degrees centigrade, and tissue generally turns white when desiccation causes coagulation.
• of course it is necessary to avoid inadvertently touching tissues other than those desired while using this tool and during its cool down period.
• this is an ideal coagulating device but extensive lateral thermal damage has limited its use in the treatment of endometriotic lesions that are close to other vital structures.

(4) lasers,

• these devices can deliver fine beams of intense energy to tissue with the power density (watts per square centimeter) at the tissue site determining the effect (vaporization, excision, coagulation).
• there are different laser systems. These include fiber delivery via KTP-532 or Nd:YAG lasers where the energy released from the tip of the fiber diverges to dissipate the energy (highest power density is closest to the tip of the laser fiber). The carbon dioxide (CO2) laser focuses the laser energy with a series of mirrors into differing size spots that help to determine the power density at the tissue.
• the CO2 lasers can deliver power in different wave forms that determine the power density achieved and amount of lateral thermal damage. The most common laser in use for most fertility work during laparoscopy is the CO2 laser and the optimal wave form for fertility work is the ultrapulse wave. There are noticeable differences in the effects produced by

Operative Hysteroscopy Guidelines

INDICATIONS

• abnormal uterine bleeding
• infertility
• recurrent pregnancy loss
• abnormal hysterosalpingogram revealing intrauterine adhesions, polyps, fibroids, septum
• possible intrauterine foreign bodies

CONTRAINDICATIONS

• pregnancy
• heavy uterine bleeding
• pelvic inflammatory disease
• cervical malignancy
• recent uterine perforation

DELIVERY DEVICES

• maximum recommended intrauterine operating pressure is 150 mm Hg
• intrauterine pressure is a function of inflow pressure and outflow pressure
• inflow pressure may be produced by gravity, pressured cuffs with (pressure) gauges, or approved pumps

DISTENDING MEDIA

• Group A: Isotonic Ionic Solutions (Normal Saline, Ringer's Lactate)
• Group B: 5% Dextrose in Water
• Group C: 1.5% Glycine, Sorbitol, Cytal
• Group D: Hyskon (32% Dextran 70)

FLUID MONITORING

• 1) it is the role of the circulating nurse to maintain a flow sheet recording inflow and outflow of hysteroscopic media during the case
• 2) for Groups A, B and C the inflow and outflow must be estimated for every 500 cc of fluid used and measured at the conclusion of each bag of distending media
• 3) for Group D the inflow and outflow must be measured for every 100 cc of fluid used
• 4) the operating surgeon will be informed of fluid balance status as it is recorded on the flow sheet
• 5) spillage should be avoided and quantitated whenever a significant spill occurs
• 6) use of a table drape to collect excess fluid for accurate recording of fluid output is required

EXCESSIVE FLUID ABSORPTION

The recommended volume of input to output discrepancy at which point the surgeon must assess serum electrolytes (especially sodium concentration)* is

• Group A: 1 liter
• Group B: 1 liter
• Group C: 1 liter
• Group D: 250 mL

Once these volumes of discrepancy have been reached, serum electrolytes must be obtained and the operating surgeon has the option of:

a) terminating the case
b) awaiting the results of the electrolyte levels and proceeding accordingly
c) administering Lasix IV and judiciously proceeding with the case until the results are available

* IMPORTANT NOTES:
The volumes that are recommended in this section are not based on established "standards of care" since such standards have not yet been clearly formalized. For example, I use 1 Liter as a cut off for D5W while some of the world's leading hysteroscopic surgeons use 3 Liters. There is no established limit for the volume of D5W that can safely be given as an IV solution being directly infused into the circulation of a healthy person. I have found no reports of major morbidity associated with the use of D5W in the literature.

Additional patient assessment following a large volume discrepancy between input and output may immediately involve determination of serum electrolytes. If a significant time has passed since the (presumed) absorption of fluid, other clinical parameters (if available) may become more informative (evidence of tissue edema, an increase in cardiac output associated with volume overload, change in pulse oximetry or ventilation parameters, change in patient temperature if room temperature fluid is used)

I use a resectoscope with continuous flow and a loop electrode to perform most of my hysteroscopic surgery. I have not found a pumping system for distending media that is sufficiently accurate, rapid in response (so as to maintain a constant pressure), affordable, and easy to use. Many pumps are available and as this technology develops I anticipate that a great pumping system will become available. At present, I use a simple system of placing a blood pressure cuff around each one liter bag of D5W solution to be used and apply 150 mm Hg pressure (as measured on a gauge attached to the cuff) to the pressure cuff. This is connected to the inflow port on the resectoscope and flow is then adjustable using a stop cock on this port. Outflow from the resectoscope is via a tubing that connects directly to a suction canister under full wall suction. The outflow port also has a stopcock that can be used to adjust the outflow.

The circulating nurse's primary responsibility during the operative hysteroscopy is to maintain pressure on the pressure cuff and watch the inflow and outflow balance. The nurse might appropriately report this balance to the surgeon and anesthesiologist every 15 minutes or whenever there is a significant volume of use (say 500cc).

The resectoscope's monopolar electrocautery loop is attached to an electrical generator with variable power (wattage) settings. For any given power setting selected, there are also various blends of cutting or coagulation that can be chosen. I typically use blend 1 which applies current 80% of the time and gives just a little coagulation as compared to pure cutting. For most resectoscopic use, I use 50-80 Watts on blend 1 and coagulate bleeders (if not initially controlled with the blend 1 settings) using 50 Watts at pure coagulation.

Once the hysteroscopic portion of the case is completed, I request a final tabulation of inflow and outflow volumes for the distending media.

I direct my attention to the laparoscopy once the hysteroscopy is complete. A uterine manipulator is placed through the cervix, I typically invert the umbilicus and insert a Verres needle through this site (while holding up the umbilicus). Alternative sites for Verres needle insertion (rarely used) include the left infracostal midclavicular line or the left periumbilical midclavicular line. Insufflation of the abdomen with CO2 gas so as to create a pneumoperitoneum is accomplished after "confirming the proper placement" of the Verres needle. Note that absolute certainty of placement of the Verres needle is not possible given the blind nature of its entry. Many of the laparoscopic injuries that occur do so at the time of Verres needle insertion. Failure to achieve an adequate pneumoperitoneum is the most common reason for procedural failure.

Once the pneumoperitoneum is created, the Verres needle is replaced by a trocar and sleeve. Again, the trocar insertion is blind and the direction of insertion is typically towards the hollow of the sacrum. The diameter of the umbilical (main) trocar is 10-12 mm so that this instrument can cause considerable injury if not placed properly and atraumatically into the abdominal cavity. The presence of adhesions (scar) that elevates the bowel to the anterior abdominal wall is a consistent source of concern for laparoscopic surgeons. I always try to enter the trocar through the abdominal wall (while holding the inverted umbilicus up with clamps) so that the tip of the trocar and its outer sheath are just inside the inner abdominal wall and then confirm an atraumatic entry with the laparoscope before going on.

If abundant adhesions are anticipated such that the surgeon believes that the complication rate with the blind Verres needle and trocar insertion is unacceptably high, then "open laparoscopy" may be chosen. Hasson introduced this technique in 1971, in which the direct insertion of the trocar without the creation of a prior pneumoperitoneum is accomplished by performing a cut down under direct observation of the layers of the abdominal wall. Suture holds the layers of the inner abdominal wall (fascia and peritoneum) to the trocar sleeve to prevent the release of gas through the incision site during the case. Extreme care must be exercised in making the peritoneal incision since bowel injury to adherent bowel may occur under direct observation as well.

Accessory trocar sites are usually required during the laparoscopic case. Typically I use two additional sites for placement of 5 mm (or uncommonly 10 mm) trocars in the suprapubic midline and left lower quadrant. All accessory trocars have the advantage of being able to be inserted under direct observation so injury is less common. One injury associated with placement of the accessory trocars is laceration of the deep inferior epigastric vessels (which may be difficult to see either directly or via transillumination). Injury to the inferior epigastric vessels can be consistently avoided by placement of the additional trocars either lateral to the internal inguinal ring or medial to the umbilical ligaments (two structures that are usually easy to identify under direct laparoscopic observation).

Tools that are selected for the performance of the laparoscopic surgery should allow the surgeon to minimize postoperative adhesion formation. The surgical principles as discussed above are very important in terms of achieving the desired outcome. Gentle tissue handling during laparoscopy takes a great deal of time to develop. Avoidance of bleeding with gentle tissue handling is important and so is careful hemostasis using (selective) bipolar cautery. Continuous irrigation and aspiration of the tissues to remove char and minimize drying should be second nature to the laparoscopic infertility surgeon. Use of cutting instruments that minimize lateral tissue damage is also a primary concern.

Once the case has been completed, the instruments are removed from the abdomen allowing for the efflux of CO2 gas. I usually take an additional 5 or so minutes to move the abdominal wall and contents about with only one remaining trocar sleeve in place to try to allow any trapped gas to escape. Incisions are closed with subcuticular stitches so as to avoid cosmetically unpleasant "railroad" type skin scars. The fascia is closed on any incision in the fascia greater than 5 mm.

In the immediate postoperative recovery time period, common problems include

• nausea and vomiting, most likely related to the CO2 gas or the narcotic pain medications used perioperatively. Zofran is often the most effective anti emetic agent for post laparoscopic vomiting. The nausea and vomiting does not typically persist for more than 12 hours postop.
• shoulder pain due to retained CO2 gas, which if trapped under the diaphragm (at base of the lungs) causes irritation of the phrenic nerve to cause the sensation of shoulder pain. Lying on one's abdomen with a pillow under the hips and lower abdomen (or the knee chest position) may allow the CO2 gas to recollect in the pelvis rather than under the lungs and reduce this discomfort.
• subcutaneous crepitance (crackling) under the skin over the abdomen and extending superiorly to the chest and neck or inferiorly to the buttocks and thighs is typically a minor complication due to escape of the gas into the abdominal wall. A rare patient develop a very low blood pressure (not related to blood loss) and usually responds immediately to a bolus of IV solution.
• incisional pain is usually mild but the internal (visceral) pain after surgery can be intense and may require narcotics or anti inflammatory agents. Reportedly a heating pad applied to the abdomen may also be helpful.
• if a large volume of fluid is left in the abdomen at the conclusion of the case (I rarely leave this fluid here but some surgeons do this as a routine) then leakage through the incision sites is common for up to 2 days.
• the surgeon should be called if there is a fever (greater than 100 degrees) or chills, heavy or prolonged vaginal bleeding, heat or swelling of the incision sites, frequency or burning on urination, severe pelvic pain, persistent nausea or vomiting, faintness or dizziness, inability to spontaneously urinate.
• postoperative urinary retention occurs more often in cases that last longer than 2 hours. If the patient is not able to void within 4-5 hours postop (and after removal of the foley catheter) then she should be straight catheterized for the residual volume of urine and she should try to void spontaneously once again. I do not allow my patients to go home until either they can void spontaneously or they have an indwelling foley catheter placed (for about 1 day).

Complications of Operative Hystoscopy

1) Dilatation of the cervix:
The cervix must be dilated in order to enter the hysteroscope into the uterine cavity. Most resectoscopes have an outer sheath diameter of about 9 mm so that cervical dilatation using mechanical dilators must be at least this amount. It is optimal to avoid overdilatation of the cervix since leakage of the distending media through the cervix and around the hysteroscope (especially under pressures of about 150 mm Hg) then becomes possible.

Some cervical canals are difficult to negotiate with dilators. Different dilators have a variable amount of curvature to chose from. It is possible to perforate the lower uterine segments during dilatation. Clinical situations in which perforation is more common include dilatation of the pregnant uterus, fibroid uterus, uterus of a women exposed to DES in utero, uterus after exposure to prostaglandins for cervical ripening, and infected uterus. Many cases of perforation occur at the onset of dilatation and the subsequent dilators then continue to open the perforation site.

Occasionally, a rent in the lower uterine segment occurs during dilatation. It is thought that rapid dilatation or a difficult dilatation involving a stenotic inflexible cervix may enhance the frequency of these tears. It is possible for a tremendous amount of distending media to become intravasated through these rents and into the large vessels of the lower uterine region if they are transected.

Cervical incompetence following hysteroscopic surgery is rarely reported but theoretically possible. The cervix is composed of a tough fibroconnective tissue and smooth muscle. Closure of the internal os of the cervix is the general rule even following manual dilatation of up to 15 mm.

2) Bleeding:
The pressure maintained in the uterine cavity may (but generally should not) exceed both the venous and the arterial pressures so that active blood flow from transected vessels may not become apparent until the uterus is deflated. At lesser pressures, bleeding can be identified and usually controlled. If there is excessive bleeding following destructive procedures such as endometrial ablation then this is frequently controlled by tamponade using an inflated foley catheter balloon (10-30 mL for up to 16 hours) in the uterus. Sometimes the excessive flow can be controlled with estrogen hormonal therapy (if due to denuding the lining).

3) Excessive intravasation of distending media or CO2 gas:
Whenever vessels are transected during hysteroscopic surgery and either fluid or gas is entered into the uterine cavity under pressure there is a possibility of intravasation (entry of these substances into the circulation). For a more complete discussion of characteristics of the different available distending media and a sample operating room protocol see "The Surgeon's Routine" subsection.

I use D5W (5% Dextrose in Water) almost exclusively for my resectoscopic surgery. Major complications with this solution are very rare. In fact, there are no reports in the world literature of major morbidity or mortality with the use of D5W at hysteroscopy. Possible complications include water intoxication (a reduction in serum osmolality) with a dilutional reduction in sodium concentration, volume overload (when the circulating volume in the vascular system exceeds the ability of the heart to adequately pump this volume and the excess fluid typically begins to collect in the tissues of the lungs), hypothermia (significant reduction in body temperature) if room temperature solutions are used without warming the patient with devices like a "Bair Hugger," and hyperglycemia (significant excess in circulating glucose concentration that may not be rapidly metabolized if the patient has insulin resistance or diabetes mellitus).

The major complication that most hysteroscopic surgeon's focus on avoiding is water intoxication. The risk of water intoxication from D5W in a healthy woman with normal renal function is very low, since the kidneys can typically produce in excess of 1000cc of dilute urine in response to a decrease in serum osmolarity.

4) Adhesions:
Following hysteroscopic surgery, there is a chance of adhesion (scar) formation. When I use significant electrocoagulation within the uterine cavity I provide the infertility patient with intraoperative estrogen IV (25 or 50 mg of Premarin) and at least a 30 day course of higher dose Premarin postoperatively (1.25 mg or preferably 2.5 mg if tolerated).

5) Burn injury to the bowel:
When resectoscopic electrosurgery is performed in the area of the uterine ostia (near the entry site of the fallopian tubes) there is a chance of thermal injury to adjacent tissue outside the uterine cavity. This is because the uterine wall in these regions is very thin and heat from the cautery can travel through the uterine wall and burn adjacent bowel.

6) Infection:
Endometritis is uncommon after operative hysteroscopy and antibiotics are usually not "routinely" given. I however have a very low threshold for the decision to use antibiotics since their potential benefits outweigh their risks when exposure to infection occurs.

Complications of Operative Laparoscopy

1) Verres needle and Trocar injuries:
Most complications from laparoscopic surgery have been reported to occur at the time of Verres needle or Trocar placement.

The primary concern of the surgeon when entering these tools is the possibility of inadvertent laceration of a major blood vessel that may not be recognized immediately since the tools are entered blindly into the abdomen. Several procedural techniques minimize this risk, which actually occurs very rarely in the hands of an experienced laparoscopist. A high index of suspicion also allows for a more rapid identification of injury to a major vessel.

If the Verres needle is placed directly into a major vessel and this is not recognized then insufflation of the vessel with CO2 gas may result in a massive pulmonary (gas) embolism and cardiovascular compromise or collapse.

Trocar injuries may involve the major vessels. More commonly the trocar injures the bowel during the blind insertion. To minimize either of these events, I always invert the umbilicus, hold the abdominal wall up (to maximize distance from the deep structures such as bowel and vessels), and enter the instruments into the abdomen just past the inner lining of the abdominal wall. I have not had any such injuries using this technique.

2) Vascular injury in abdominal wall and great vessels of the pelvis and abdomen:
Vascular injuries appear to account for about 30-50% of laparoscopic trauma, but injury to the major vessels is very uncommon (less than 1 in 1000). Injury to the vessels in the abdominal wall may involve the

• deep epigastric vessels (inferior or superior epigastric vessels). The epigastric artery originates from the external iliac artery near its transition to the femoral artery and the deep inferior epigastric artery then lies adjacent (lateral) to the obliterated umbilical ligaments (usually easy to see on direct laparoscopic inspection of the inner abdominal wall) beneath the lateral margin of the rectus abdominus muscle. Entry of additional trocars lateral to these vessels reduces vascular injury to these vessels within the abdominal wall.
• the superficial epigastric vessels. These vessels course "on top" of the rectus abdominus muscle and are usually able to be visualized with transillumination using the laparoscope as the source of light within the pelvis.
• the deep and superficial circumflex iliac vessels. These vessels course lateral to the epigastric vessels, usually lateral to any typical placement site for a trocar.

If there is an injury to one of these deep abdominal wall vessels with significant bleeding seen from the site of the trocar the exact location of the bleeding site should be identified (if possible) by carefully moving or rotating the trocar so as to identify the precise site of the injury. Then bipolar cautery can be used to try to immediately control the bleeding. The epigastric artery should be coagulated above and below the site of injury. This is not always possible and a second manipulation that can be useful is tamponade (using a Foley catheter that is passed through the 5 mm port, inflation of the balloon, pulling the balloon tightly against the inner abdominal wall and holding it in place with a (Kelly) clamp. After a few minutes (about 10-15 minutes) the balloon may be released and the bipolar used once again if the bleeding has significantly decreased. If this fails to control bleeding, a figure of eight suture may be placed through and through the abdominal wall to control the bleeding (with tying on the outer skin of the abdominal wall). If all of these techniques fail then a cut down for exploration and tying off the vessels may be required.

If there is injury to one of the superficial vessels of the abdominal wall then pressure on the skin usually controls the flow. If external pressure is not successful then ligature is required. At the end of the case the sites should be reevaluated after removal of the trocars since the release of tamponade from the trocar may allow reactivation of bleeding.

Injury to the aorta, inferior vena cava or common iliac vessels can be life threatening. Immediate laparotomy with the assistance of a vascular surgeon is usually indicated.

2) Urinary tract injury:
Injury to the urinary tract (bladder or ureters) is uncommon in laparoscopic surgery involving the pelvis, however, endometriosis or infection can certainly involve these structures intimately and the possibility of injury is important to recognize.

Bladder perforation with a Verres needle or the midline lower abdominal trocar is possible. This risk is dramatically reduced if a foley catheter is placed into the bladder at the onset of the case (with confirmation of urine flow since occasionally the lubricating gel plugs the catheter). Treatment may be a double layer closure (water tight) with a low reactive long half life suture like Vicryl or PDS, placement of a foley catheter for 7 days and antibiotics.

Bladder injury during resection of endometriosis or adhesiolysis (especially if there is a history of prior bladder surgery or cesarean section) is not common and depends on the extent of pathology being resected and the experience of the surgeon.

Ureteral injury is not common, most often involving the ureters as they course near the uterosacral ligaments. The most common cause is the use of cautery (either unipolar or bipolar) in the area and either direct or lateral thermal damage. If not immediately recognized, the diagnosis is suggested by development of flank pain, (unilateral) pelvic pain, fever, leukocytosis and peritonitis. If there is an intraoperative concern about ureteral injury, 5 cc of indigo carmine can be injected IV by the anesthesiologist and this should appear in the Foley bag within about 10 minutes. Postoperative diagnosis is usually guided with intravenous pyelography.

3) Gastrointestinal injury:
Injury to the bowel is most often caused by the Verres needle or Trocar when blindly inserted. A Verres needle injury may be quite small and remain unrecognized. These injuries may involve the small bowel, large bowel or stomach. Electrosurgical or laser injury is relatively uncommon.

Extensive enterolysis for small bowel adhesions may result in injury in as many as 25% of the cases. These injuries often are not recognized. If recognized, the repair of small bowel injuries consists of a surgical consultation, repair with 3-0 or 4-0 silk (or PDS) suture (tapered SH needle), and nasogastric tube.

Large bowel injury is probably most often caused by the Verres needle and may go undiagnosed a large percentage of the time. Foul smelling gas is a characteristic sign. If the hole is small (needle size), expectant management is usually recommended.

Trocar injury to the large bowel usually occurs when there are dense adhesions from the large bowel to the inner anterior abdominal wall. Occasionally, these injuries are only identified when the trocar is removed under direct observation since they may be through and through the walls of the bowel. Laparotomy and repair by a general surgeon is indicated, leaving the trocar in situ for identification of the site of injury.

Most large bowel injuries are due to mechanical trauma as adhesions from the rectosigmoid bowel are freed from the cul de sac in the presence of dense endometriosis or chronic inflammation. Superficial injury may be able to be managed expectantly but deep injury requires surgical repair.

Stomach injuries may be more common following difficult endotracheal intubation since the stomach may be filled with gas. These injuries usually occur with subsequent (blind) entry of the Verres needle or Trocar into the inflated stomach. Placement of a nasogastric tube may reduce this possibility.

4) Infection:
Reactivation of a dormant infection during laparoscopic surgery is possible but uncommon. Whenever surgery is performed in the presence of an active infection or is to repair the pelvis that has been damaged through a chronic infection antibiotics should be used liberally.