Perforation of a uterus
Contents:
Description:
Perforation of a uterus - the most frequent complication both at diagnostic, and at operational hysteroscopy. Perforation can happen at expansion of the cervical channel or carrying out any surgical manipulations in a cavity of the uterus.
Reason of perforation of a uterus:
The reasons can become:
1. The expressed retroversion of a uterus.
2. Introduction of the hysteroscope without good visibility.
3. Widespread carcinoma of an endometria.
4. The advanced age of the patient causing age changes of fabrics (an atrophy of a neck of uterus, loss of elasticity of fabrics).
The endoscopist has to reveal the happened perforation of a uterus at once.
Symptoms of perforation of a uterus:
Signs of perforation of a uterus at hysteroscopy:
1. The dilator enters on depth exceeding the expected length of a cavity of the uterus.
2. There is no outflow of the entered liquid or it is not possible to support pressure in a cavity of the uterus.
3. Loops of intestines or a peritoneum of a small pelvis can be visible.
4. If the hysteroscope is in parametriums (not getting perforation of leaves of wide uterine sheaves), the endoscopist sees very interesting picture: thin threads similar to a gentle veil.
5. At not getting perforation of a wall of a uterus it is difficult correct to interpret a visible picture.
At perforation of a uterus (or suspicion on perforation) operation is immediately stopped. Tactics of maintaining the patient at perforation of a uterus depends on the size of a perforation opening, its localization, the mechanism of perforation, probability of injury of abdominal organs.
Treatment of perforation of a uterus:
Conservative treatment of perforation of a uterus is shown at the small sizes of a perforation opening and confidence in lack of injury of abdominal organs, lack of symptoms of intra belly bleeding or hematomas in parametriums.
Appoint cold to a stomach bottom, the drugs reducing a uterus, antibiotics. Make dynamic observation.
Perforation of a sidewall of a uterus happens seldom, but can lead to formation of a hematoma in a wide sheaf. At increase in a hematoma the laparotomy is shown.
Serious perforation arise during the work with a rezektor, the resectoscope and the laser. The endoscopic scissors entered via the operational channel of the hysteroscope it is seldom possible to damage the next bodies, more often it occurs during the work with the resectoscope or the laser. The risk of perforation of a uterus is maximum at a section of intrauterine synechias of the III degree and more. At such pathology it is difficult to distinguish anatomic reference points therefore recommend to carry out a control laparoscopy. Frequency of perforation of a uterus at a section of intrauterine synechias even with laparoscopic control makes 2-3 on 100 operations.
During operational hysteroscopy it is easy to distinguish perforation as intrauterine pressure sharply falls due to leaving of liquid in an abdominal cavity, visibility sharply worsens. If at this moment the electrode was not activated, operation is immediately stopped and in the absence of symptoms of intra belly bleeding appoint conservative treatment. If the surgeon is not sure whether the electrode was activated at the time of perforation, and there is a probability of injury of abdominal organs, the laparoscopy with sewing up of a perforation opening and audit of abdominal organs, and if necessary - a laparotomy is shown.
Prevention:
- Careful expansion of a neck of uterus, possible use of laminarias.
- Introduction of the hysteroscope to a cavity of the uterus under direct vision.
- Correct technical performance of operation.
- The accounting of probable thickness of a wall of a uterus on its different sites.
- Laparoscopic control at difficult operations with risk of perforation of a wall of a uterus.
