1018
CASE REPORTS
British Journal of Obstetrics and Gynaecology December 1992, Vol. 99, p. 1018
Endoscopic management of uterine perforation occurring during endometrial resection J. A. MARK BROADBENT Clinical Research Fellow
remained normal and the patient was discharged from hospital 48 hours later. Antibiotics were continued for one week.
BELA G. MOLNAR Wellcome Research Fellow
Discussion
M I C H A E L J . W. C O O P E R Chenhall Research Fellow A D A M L. M A G O S Consultant Obstetrician and Gynaecologist Minimally Invasive Therapy Unit, University Department of Obstetrics & Gynaecology, The Royal Free Hospital, Pond Street, London NW3 2QG, UK.
Case report A 31-year-old healthy, multiparous woman underwent transcervical resection of the endometrium (TCRE) for dysfunctional uterine bleeding unresponsive to medical therapy. At operation the uterine cavity was noted to be normal but with a thickened endometrium which had not been medically thinned prior to surgery. Endometrial resection was started at the uterine fundus, but within minutes a sudden loss of uterine distension occurred with loss of visibility whilst resecting the right cornual region. It was simultaneously noted that 950 ml of the uterine irrigant, 1.5% glycine solution tagged with 1%ethanol (Baxter Healthcare Ltd, UK), had been absorbed by the patient, and the blood alcohol level was noted to be high at 40 mg/dl as assessed with a breath Alcolmeter (Lion Laboratories, UK). All these findings suggested the possibility of uterine perforation with rapid absorption of the irrigant. Hysteroscopic surgery was stopped immediately and the patient prepared for laparoscopy . Laparoscopy confirmed a uterine perforation, medial to the insertion of the right fallopian tube, which was bleeding slightly. There was no other obvious trauma. Using two atraumatic grasping forceps inserted suprapubically, the rectum, sigmoid colon and ileum were systematically examined for evidence of burns or perforation but no visceral damage was noted. The uterine perforation was stitched laparoscopically using endosutures (Ethicon, Germany). This achieved satisfactory haemostasis but uterine distension was not possible due to continued leakage of irrigant from this site. The perforation was therefore ‘plugged’ hysteroscopically with a chip of resected endometrium to allow sufficient distension to complete the endometrial resection. Total fluid absorption was 1650 mi by the end of surgery. Postoperatively, vital signs Correspondence: 3. A. M. Broadbent.
TCRE is becoming increasingly widely performed in the United Kingdom; a recent audit by the Royal College of Obstetricians found that 47% of acute units are now offering this procedure to patients with menorrhagia (RCOG Audit 1991). In accordance with our own experience (Magos et al. 1991), this survey confirmed that the procedure is safe with serious complications such as uterine perforation and fluid overload being relatively uncommon. However rare uterine perforation during endometrial resection may be, it is an important operative complication; once recognised surgery has either to be abandoned to prevent excessive intraperitoneal loss of uterine irrigant or to be continued only after laparotomy to check for intra-abdominal trauma and allow uterine repair, that is, a choice between incomplete treatment or major open surgery. Here we have described a third option whereby purely endoscopic techniques are utilised: laparoscopic assessment of the perforation and intra-abdominal contents, laparoscopic repair of the uterus, hysteroscopic plugging of the myometrial defect to affect a fluid-tight seal allowing completion of the resection under laparoscopic control whilst avoiding laparotomy. This case demonstrates that in the absence of major intraabdominal trauma endometrial ablation can be continued successfully even after uterine perforation without resort to laparotomy or hysterectomy. It also illustrates the value of using ethanol labelled glycine solution and measuring breath ethanol concentrations during surgery, not only as an aid to the estimation of overall fluid absorption (Molnar et al. 1992) but also as a rapid warning system against possible uterine perforation. References Magos A. L., Baumann R., Lockwood G. M. & Turnbull A. C. (1991) Experience with the first 250 endometrial resections for menorrbagia. Lancet 337,1074-1078. Molnar B. G., Rolfe K. J., Broadbent J. A. M. & Magos A. L. (1992) Prevention of fluid overload during endometrial resection by detection of trace ethanol in expired breath. Proceedings of 5th European Congress on Hysteroscopy and Endoscopic Surgery, June 3-6th, Hamburg, Germany (abstract). Royal College of Obstetrics and Gynaecology Audit Unit (1991) Third Bulletin, November 1991. Received 12 May I992 Accepted 25 June I992
CASE REPORTS
British Journal of Obstetrics and Gynaecology December 1992, Vol. 99, p. 1018
Endoscopic management of uterine perforation occurring during endometrial resection J. A. MARK BROADBENT Clinical Research Fellow
remained normal and the patient was discharged from hospital 48 hours later. Antibiotics were continued for one week.
BELA G. MOLNAR Wellcome Research Fellow
Discussion
M I C H A E L J . W. C O O P E R Chenhall Research Fellow A D A M L. M A G O S Consultant Obstetrician and Gynaecologist Minimally Invasive Therapy Unit, University Department of Obstetrics & Gynaecology, The Royal Free Hospital, Pond Street, London NW3 2QG, UK.
Case report A 31-year-old healthy, multiparous woman underwent transcervical resection of the endometrium (TCRE) for dysfunctional uterine bleeding unresponsive to medical therapy. At operation the uterine cavity was noted to be normal but with a thickened endometrium which had not been medically thinned prior to surgery. Endometrial resection was started at the uterine fundus, but within minutes a sudden loss of uterine distension occurred with loss of visibility whilst resecting the right cornual region. It was simultaneously noted that 950 ml of the uterine irrigant, 1.5% glycine solution tagged with 1%ethanol (Baxter Healthcare Ltd, UK), had been absorbed by the patient, and the blood alcohol level was noted to be high at 40 mg/dl as assessed with a breath Alcolmeter (Lion Laboratories, UK). All these findings suggested the possibility of uterine perforation with rapid absorption of the irrigant. Hysteroscopic surgery was stopped immediately and the patient prepared for laparoscopy . Laparoscopy confirmed a uterine perforation, medial to the insertion of the right fallopian tube, which was bleeding slightly. There was no other obvious trauma. Using two atraumatic grasping forceps inserted suprapubically, the rectum, sigmoid colon and ileum were systematically examined for evidence of burns or perforation but no visceral damage was noted. The uterine perforation was stitched laparoscopically using endosutures (Ethicon, Germany). This achieved satisfactory haemostasis but uterine distension was not possible due to continued leakage of irrigant from this site. The perforation was therefore ‘plugged’ hysteroscopically with a chip of resected endometrium to allow sufficient distension to complete the endometrial resection. Total fluid absorption was 1650 mi by the end of surgery. Postoperatively, vital signs Correspondence: 3. A. M. Broadbent.
TCRE is becoming increasingly widely performed in the United Kingdom; a recent audit by the Royal College of Obstetricians found that 47% of acute units are now offering this procedure to patients with menorrhagia (RCOG Audit 1991). In accordance with our own experience (Magos et al. 1991), this survey confirmed that the procedure is safe with serious complications such as uterine perforation and fluid overload being relatively uncommon. However rare uterine perforation during endometrial resection may be, it is an important operative complication; once recognised surgery has either to be abandoned to prevent excessive intraperitoneal loss of uterine irrigant or to be continued only after laparotomy to check for intra-abdominal trauma and allow uterine repair, that is, a choice between incomplete treatment or major open surgery. Here we have described a third option whereby purely endoscopic techniques are utilised: laparoscopic assessment of the perforation and intra-abdominal contents, laparoscopic repair of the uterus, hysteroscopic plugging of the myometrial defect to affect a fluid-tight seal allowing completion of the resection under laparoscopic control whilst avoiding laparotomy. This case demonstrates that in the absence of major intraabdominal trauma endometrial ablation can be continued successfully even after uterine perforation without resort to laparotomy or hysterectomy. It also illustrates the value of using ethanol labelled glycine solution and measuring breath ethanol concentrations during surgery, not only as an aid to the estimation of overall fluid absorption (Molnar et al. 1992) but also as a rapid warning system against possible uterine perforation. References Magos A. L., Baumann R., Lockwood G. M. & Turnbull A. C. (1991) Experience with the first 250 endometrial resections for menorrbagia. Lancet 337,1074-1078. Molnar B. G., Rolfe K. J., Broadbent J. A. M. & Magos A. L. (1992) Prevention of fluid overload during endometrial resection by detection of trace ethanol in expired breath. Proceedings of 5th European Congress on Hysteroscopy and Endoscopic Surgery, June 3-6th, Hamburg, Germany (abstract). Royal College of Obstetrics and Gynaecology Audit Unit (1991) Third Bulletin, November 1991. Received 12 May I992 Accepted 25 June I992
