Best Practice & Research Clinical Anaesthesiology Vol. 16, No. 1, pp.

3551, 2002
doi:10.1053/bean.2002.0206, available online at http://www.idealibrary.com on

3 Anaesthetic considerations for hysteroscopic surgery

Mary C. Mushambi
MBChB, FRCA

Consultant Anaesthetist Department of Anaesthesia, Leicester Royal Inrmary, Leicester, LE1 5WW, UK

Karin Williamson

MRCOG, FRCS (Ed)

Consultant Gynaecologist Nottingham City General Hospital, Hucknall Road, Nottingham, NG5 1PB, UK

Use of the hysteroscope in modern gynaecological practice continues to develop as a diagnostic and management tool for intrauterine disease. Operative hysteroscopy (OH) is now an accepted alternative to hysterectomy for women with menorrhagia. The advantages of OH are associated with its short operating time, rapid post-operative recovery and low morbidity. However, there are concerns about the potential serious complications which can occur during and following OH, and it is important that both surgeons and anaesthetists are aware of theseespecially as many procedures take place as day-cases. Much has been written in the urological literature concerning complications of endoscopic surgery. Information gathered from patients with post-transurethral resection of the prostate (TURP) syndrome has been useful in the treatment of gynaecology patients. However, the techniques used in TURP are not entirely comparable to hysteroscopic surgery as the uterus has a very thick wall, which requires higher distension pressures. The main complications of OH are uid overload, hyponatraemia, hypo-osmolality, haemorrhage, uterine perforation and, rarely, gas or air embolism. Fluid overload with hyponatraemia and hypo-osmolality occurs in up to 6% of cases and it can be fatal. Therefore, all possible measures should be taken to prevent it or to detect it and treat it early. There are no controlled studies comparing dierent anaesthetic techniques for OH. Regional anaesthesia may oer an advantage over general anaesthesia because it enables early detection of uid overload. Great care should be taken when positioning the patient to prevent peripheral neuropathy. Key words: anaesthesia; gynaecology; equipment; hysteroscope; distending media; surgery.

HISTORY AND DEVELOPMENT OF THE HYSTEROSCOPE The potential value of methods for inspecting the inner cavities of the human body was recognized by physicians as early as the turn of the eighteenth century.1 In 1807 Philipp Bozzini, a practising physician and obstetrician in Frankfurt am Main, published the results of his successful experiments with an illumination invention which made possible the visualization of the rectum and uterus.2 He was able to diagnose
1521-6896/02/010035 17 $35.00/00 c 2002 Elsevier Science Ltd. *

36 M. C. Mushambi and K. Williamson

intrauterine pathology and had the foresight to see that, with further invention, eective treatments would be possible under direct vision. Unfortunately, Bozzini died at the age of 35, and further development of the technique was hampered by conservative opinion in the medical profession. Thus, it was not until the turn of the nineteenth century that the technical development of hysteroscopic equipment accelerated. Candlelight was the original source of light, but the invention of electrical sources allowed substantial improvements to the illumination provided. Sophisticated bre-optic systems are used today. The addition of uid-rinsing systems to clear and distend the uterine cavity greatly improved the view obtained, particularly for operative hysteroscopy. Since the 1950s, hysteroscopes have become shorter and smaller. Television monitors have been added for viewing, and pumps developed to ensure the safe instillation of distension uids; accessory instruments have allowed improved safety in intrauterine operative procedures. TECHNIQUES OF OPERATIVE HYSTEROSCOPY Operative hysteroscopic techniques involve the transcervical removal or desiccation of intrauterine tissue with either electrodiathermy or laser used under direct vision. These operations are performed in the dorsal lithotomy position. Although it is standard practice to use prophylactic antibiotics, post-operative infection occurs in up to 2% of patients undergoing operative hysteroscopy (OH) and this rate is substantially less than that in women undergoing hysterectomy.3 Three techniques have gained popularity, all using a hysteroscope in conjunction with uid infused into the uterine cavity under pressure to distend it and give the operator a clear view within the uterus. Electrodiathermy is used in two of the methods, with the endometrium being resected with a wire loop (resection) or ablated with a `rollerball' (coagulation). Diathermy resection uses a modied urological resectoscope with a cutting loop to cut through the tissues. It is important that there is smooth and easy cutting of the tissues; this requires the electrosurgical generator to deliver typically 100 to 120 watts of cutting current. In the rollerball diathermy technique the operative hysteroscope is tted with a ball electrode which is moved across the surface of the tissue causing coagulation and destruction. For the third technique, a laser is used to ablate the endometrium. While the diathermy equipment is relatively simple and easy to maintain, the laser needs to be used under strict safety guidelines and requires regular maintenance. The laser most suited to intrauterine surgery is neodymium: yttriumaluminiumgarnet (Nd:YAG). When using this equipment, a quartz laser bre is carried down a multichannel operative hysteroscope. The power output used is usually between 30 and 80 watts. Although the three techniques destroy the endometrium in dierent ways, they are known, collectively, as transcervical endometrial ablation (TCEA). The intrauterine use of diathermy either to resect or to destroy tissue requires the uterine irrigation uid to be non-conductive. The most commonly used uids are of low viscosityfor example, sterile 1.5% glycine, sorbitol or sorbitol/mannitol mixtures. Laser surgery allows normal saline to be used as the irrigation uid, and this is more physiological. Recently, three newly developed instruments allow the use of physiological distension media with electrodiathermy.4,5 The ERA sleeve (Conceptus, INC., San Carlos, CA) is a single-use disposable sheath that ts over any standard resectoscope. It is a monopolar system which uses the hysteroscopy sheath as the return electrode instead of the

Anaesthesia for hysteroscopic surgery 37

diathermy plate on the patient's thigh and hence create a short return path for the current. The OPERA Star (FemRx, Inc., Sunnyvale, CA) is another modication of the monopolar system. The design of the system forces current to disperse through tissue and not the physiological media, and the dispersing electrode travels through a morcellator which is contained within the non-conducting sheath of the resectoscope. The third system, Versapoint (Gynecare, Inc., Somerville, NJ) is a bipolar operating system that conducts electric current between two electrodes that are in close proximity within the isotonic media. An active electrode is connected to a larger return electrode, all contained within a narrow sheath. The Versapoint is useful for excision of small polyps and septa and for intrauterine adhesiolysis. Pre-operative preparation of the endometrium with drugs that render the endometrium atrophic is widely practised. These drugs are administered 6 weeks prior to the procedure. Commonly used agents are gonadotrophin-releasing hormone agonists, danazol and the combined oral contraceptive pill.69 Alternatively, the surgery can be timed in the immediate post-menstrual phase when the endometrium is thin. INDICATIONS FOR HYSTEROSCOPIC SURGERY The indications for hysteroscopic surgery are shown in Table 1. Menorrhagia (excessive menstruation) is the most frequent indication. The condition aects 2030% of women and has signicant eects on their quality of life.10 Hysterectomy is a major surgical procedure with signicant morbidity, and hysteroscopic techniques oer an alternative which is safe and eective.1012 Over 90% of women can avoid hysterectomy over a 5-year period with transcervical resection of the endometrium.13 Intrauterine causes of infertility such as submucosal broids, intrauterine adhesions and septae can be successfully treated, with satisfactory live birth rates following hysteroscopic procedures.14 The techniques also have a role in identifying and retrieving misplaced intrauterine devices. DISTENSION MEDIA The uterus has a thick wall and it is therefore necessary to distend it to give good operative views. The ideal distension media should be physiological, i.e. non-toxic,
Table 1. Indications for operative hysteroscopic (OH) surgery. Indications 1. Abnormal vaginal bleeding Menorrhagia Post-menopausal bleeding Intermenstrual bleeding 2. Infertility 3. Displaced intrauterine devices Possible intrauterine pathology amenable to OH surgery 1. Submucosal broids 2. Endometrial polyps 3. Intrauterine adhesions 4. Uterine septal defects

38 M. C. Mushambi and K. Williamson

non-haemolytic, isotonic, not metabolized, allow good visibility and be rapidly excreted. Saline and Ringer's lactate meet these requirements but are not suitable for use with most electrodiathermy machines. Currently available distension media are carbon dioxide (CO2), high-viscosity uid and low-viscosity uid (Table 2). Carbon dioxide Carbon dioxide is suitable only for diagnostic hysteroscopy. This is because operative procedures have open blood vessels through which CO2 can gain access to the circulation and produce pulmonary embolus,1518 and CO2 gives poor intrauterine visibility because it does not allow clearance of debris and blood from the intrauterine environment. Production of smoke during resection can also impair visibility. Carbon dioxide is very soluble and its absorption produces acidosis, hypercarbia, arrhythmias and hypertension. The hypercarbia in the presence of certain inhalational agents increases their arrhythmogenicity. Hysteroscopic examination is usually performed using a ow rate of 5100 ml/min.15 A constant volume, variable pressure system should be used to maintain this ow rate and to maintain the intrauterine pressure of 5100120 mmHg to avoid CO2 embolism.19,20

Table 2. Types of distension media and related complications. Type of distension medium Gas 1. Carbon dioxide High-viscosity uid 1. 32% Dextran-70 Related complications CO2 embolism Poor visibility Anaphylaxis Pulmonary oedema Coagulopathy Fluid overload Renal failure

Low-viscosity electrolyte-free uid 1. Glycine 1.5% Fluid overload Hyponatraemia Hypo-osmolality Hyperammonaemia Hyperglycinaemia 2. Sorbitol 5% Fluid overload Hyponatraemia Hyperglycaemia Crystalline deposit on instruments 3. Mannitol 5% Fluid overload Hyponatraemia Crystalline deposit on instruments Low-viscosity electrolyte-containing uid 1. Normal saline Fluid overload 2. Ringer's lactate Fluid overload

Anaesthesia for hysteroscopic surgery 39

High-viscosity uids Dextran-70 Current use of high-viscosity uid is limited to dextran-70. This is a clear, viscous solution of 32% dextran-70 in 5% dextrose in water. It is electrolyte free, nonconductive, non-toxic, imiscible with blood and it is biodegradable. Dextran allows excellent intrauterine visualization. The molecular weight of dextran-70 ranges from 25 000 to 125 000, with an average of 70 000. Dextrans with molecular weight less than 50 000 are excreted by the kidney, and the larger ones are metabolized by the liver and reticuloendothelial systems to carbon dioxide and water. Unfortunately, dextran is antigenic, and on rare occasions (1:1500 to 1:300 000) anaphylactic reactions can occur.2123 Anaphylactic reactions can occur without prior exposure to dextran-70 because of IgG antibodies formed on prior exposure to naturally occurring dextrans.5 Pulmonary oedema can occur after the use of dextran-70. This may be as a result of simple uid overload. However, there are reports of pulmonary oedema after dextran70 being due to direct toxic eects on pulmonary circulation.24 Dextrans have been associated with coagulation abnormality.2527 Dextran-70 has an anticoagulation eect which is thought to be secondary to reduced platelet adhesiveness to the endothelium and alteration of brin clot making it more prone to lysis. It causes a reduction in brinogen, clotting factors V, VIII and IX to an extent not explained by haemodilution.5,28 Intravascular absorption of dextran has been associated with oliguria and acute renal failure. Dextrans are toxic to kidneys, inducing vacuolization of the tubular cells.5 Therefore, dextran should be avoided or used with extreme care. Its use should be avoided in patients with compromised renal function and in elderly patients. Low-viscosity uids Low-viscosity uids are the most commonly used distension media because of their safety. They can be divided into two types of uids (i) electrolyte free distension media, (ii) isotonic, electrolyte-containing media. Electrolyte-free uids These include glycine 1.5%, sorbitol 5%, mannitol 5% and sorbitol 2.5% with mannitol 0.54%. Because these solutions are electrolyte free, they are non-conducting. This feature has made them the preferred media for use with conventional electrosurgical instrumentation. The major complications of these uids result from excessive uid absorption and associated hyponatraemia. Hypo-osmolality is an added risk of a hypotonic uid such as glycine 1.5%. Glycine. Glycine 1.5% is the most widely used medium. It has good optical qualities but it is hypotonic, with an osmolality of 188 mOsm/kg (serum osmolality is 290 mOsm/kg). Glycine is a non-essential amino acid, which is metabolized in the liver to ammonia and oxalate. About 10% is excreted unchanged in urine and this results in an osmotic diuresis. Its half-life is 85 minutes. Hyperglycinaemia and hyperammonaemia may occur with its use. Hyperglycinaemia has been reported to cause transient blindness in patients undergoing TURP.29,30 Hyperammonaemia may produce deterioration of cerebral function, visual disturbance and muscle weakness when the blood concentration of ammonia exceeds 155 mmol/l (normal 1135 mmol/l).31,32 Oxalate may form

40 M. C. Mushambi and K. Williamson

crystals and precipitate in urine. Absorption of large volumes of glycine into the circulation can cause uid overload, hyponatraemia, pulmonary oedema and cerebral oedema. Sorbitol. Sorbitol 5% is not used widely for endometrial resection. It is isotonic, with a short half-life of 35 minutes. Sorbitol is rapidly converted to fructose and glucose in the liver. Unfortunately it causes a toee-like deposit on the electrode and this may make resection technically dicult. The use of sorbitol as an irrigation uid can result in uid overload and hyponatraemia. Hyperglycaemia may result from its metabolism. The use of a more dilute mixture of sorbitol 2.5% and mannitol 0.54% is available for use as a distension medium.33,34 Its use has been associated with hypo-osmolality but not hyponatraemia.34 Mannitol. Mannitol is a hexitol sugar. Mannitol 5% is isotonic (osmolality 280 mOsm/kg) but it is seldom used as a distension medium. It is not metabolized and therefore is excreted unchanged by the kidney. As a result, diuresis may occur. The half-life of mannitol is 15 minutes. Mannitol, like sorbitol, can cause crystallization on instruments. Hypervolaemia with haemodilution and hyponatraemia are known complications of its use. A study by Phillips and colleagues reported a series of 122 women who underwent OH using either 1.5% glycine or 5% mannitol as the distension medium;35 women in the mannitol group had greater post-operative hyponatraemia but no hypo-osmolality. Isotonic, electrolyte-containing distension media These include normal saline and Ringer's lactate. Because they are isotonic and contain sodium, they do not cause hyponatraemia or hypo-osmolality. Fluid overload from normal saline or Ringer's lactate is less dangerous and easier to treat. Unfortunately, they cannot be used with most conventional electrosurgical resection but may be used in mechanical resection. COMPLICATIONS OF OPERATIVE HYSTEROSCOPY Hysteroscopic surgical techniques have some advantages over conventional open surgical techniques, they are associated with shorter operating times, fewer complications, reduced analgesic requirements and a faster return to normal activities. However, the procedures are not without risk. Moreover, although mortality rates following hysteroscopic surgery are low, a small number of deaths directly related to such operations have been recorded. This type of surgery is often conducted as a daycase procedure so that meticulous pre-operative counselling regarding the nature of possible complications, and the signs and symptoms that might herald them, is necessary. The three most common intra-operative complications are uid absorption, uterine perforation and haemorrhage3638 (Table 3). Gas or air embolism is an uncommon complication which will be discussed because of its catastrophic consequences. There is little published information on the predictors of complications of hysteroscopic surgery. However, recent reports have identied that some hysteroscopic procedures carry more risk of complications than others.38,39 Hysteroscopic adhesiolysis, myomectomies and resection of uterine septa have signicantly higher rates of complications, particularly of excessive uid absorption.

Anaesthesia for hysteroscopic surgery 41 Table 3. Reported complications of operative hysteroscopy. Author Scottish Hysteroscopy Audit Group 199536 MISTLETOE 199737 Jansen et al 200038 n 978 10 868 2515 Perforation (%) 1.1 1.5 1.3 Bleeding (%) 3.6 2.4 0.16 Fluid overload (%) 6.0 1.9 0.2

Early post-operative complications (within the rst 24 hours) and post-discharge complications (within 6 weeks) were uncommon in a large UK national survey of the complications of endometrial destruction (MISTLETOE study), occurring in up to 2.9 and 4.6% of cases respectively.37 These include infection, secondary haemorrhage and thromboembolism. Fluid overload and hyponatraemia Incidence Fluid overload is a common and potentially serious complication of operative hysteroscopic procedures. It is dened as uid decit exceeding 2000 ml and it occurs in about 0.2 to 6% of procedures.38,4042 Pathophysiology Absorption of large volumes of hypotonic, electrolyte-free uid can cause uid overload and electrolyte disturbances, which may lead to the syndrome familiar to urologists and anaesthetists as transurethral resection of the prostate (TURP) syndrome. Most uid absorption occurs during the operation through blood vessels opened up by the resection. Some uid may enter the peritoneal cavity through patent Fallopian tubes, and may also be absorbed into the circulation, but the magnitude or signicance of this uid is unclear. One study has shown a 20% reduction in uid absorption in women with occluded Fallopian tubes caused by prior sterilization.43 The development and clinical presentation of uid overload is inuenced by several factors, including type of irrigation uid, infusion pressure, vascularity of the uterus, duration of surgery and surgical technique. Hyponatraemia occurs when there is absorption of electrolyte-free uids such as glycine, sorbitol and mannitol. Hypo-osmolality arises from absorption of hypotonic uid such as glycine 1.5%. Pre-menopausal women are 25 times more likely than men to die or have permanent brain damage from hyponatraemic encephalopathy.44 There is some evidence to show that the absence of hypo-osmolality following the use of mannitol may protect the patient from hyponatraemic encephalopathy. Excess absorption of hypotonic uid may also lead to haemolysis, haemoglobinuria and anaemia. Clinical The signs and symptoms of uid overload (Table 4) will depend on whether the patient is conscious or unconscious and whether hyponatraemia is present or not. In the conscious patient, uid overload presents as nausea, vomiting, headache, dyspnoea, chest pain, confusion and, nally, seizures. Hypertension, hypothermia, dilated pupils

42 M. C. Mushambi and K. Williamson Table 4. Signs and symptoms of uid overload. Cardiovascular system Hypertension Bradycardia Respiratory system Chest pain Pulmonary oedema Oxygen desaturation Dyspnoea Central nervous system Nausea and vomiting Headache Restlessness Reduced conscious level Blurred vision Dilated pupils Hypothermia Seizures Coma

Table 5. Signs and symptoms and ECG changes in acute hyponatraemia. Serum sodium 120 mmol/l # # 100 mmol/1 ECG changes Widening of the QRS Bradycardia Elevated ST segment Ventricular tachycardia Ventricular brillation Clinical ndings Restlessness Confusion Nausea Semiconscious Seizures Coma

and a reduction in oxygen saturation are common signs in both conscious and unconscious patients. If it is not recognized or treated early, it may lead to hypotension, bradycardia, pulmonary oedema, cerebral oedema and cardiopulmonary collapse and can prove fatal.33,45 Symptoms and signs of hyponatraemia are related to the speed of its development. Acute changes which occur in the situation of hysteroscopic surgery produce more symptoms than chronic hyponatraemia46 (Table 5). Most clinical signs occur when the sodium decreases by 15 to 20 mmol/1. A plasma concentration of less than 120 mmol/1 is regarded as severe hyponatraemia.47 ECG changes are characterized by widening of the QRS complex, ST elevation followed by ventricular tachycardia or brillation if the sodium levels fall to below 100 mmol/1.

Prevention of uid overload Awareness of the risk of uid overload, early recognition and treatment are important in preventing fatal outcome. Measures should be taken to reduce excessive uid absorption. These include monitoring of uid decit, control of irrigation pressures, good surgical technique and pre-surgery preparation of the endometrium (Table 6).

Anaesthesia for hysteroscopic surgery 43

Monitoring of central venous pressure should be considered in patients with cardiac or renal disease. Monitoring of uid decit. The amount of uid absorbed by the patient equals the volume of uid infused into the uterine cavity minus the volume which passes out through the cervix into the collection system and onto drapes and swabs. This is dened as the uid decit. It is important to monitor ongoing uid decit in order to provide an early estimation of the rate of uid absorption. Unfortunately there is no simple, accurate method of measuring uid decit. Volumetric or gravimetric methods are commonly used. The simple volumetric method measures the dierence between the volume of irrigation uid used and the volume recovered. However, this method is inaccurate. A more complex but accurate volumetric method has been described by Hahn and colleagues.48 This method uses 3-litre bags, which are accurately weighed before and after use and placed 60 cm above the centre of the patient's surgical eld. The rst bag is used to ll the irrigation system before the operation is started. A volumetric irrigating uid balance is obtained every 10 minutes during the operation: the irrigation uid inlet is closed, the uterus emptied and the irrigating uid bag as well as the collecting bag replaced. Because this method is complex, it is less applicable for routine use and is more useful for research. The gravimetric method involves weighing the patient either on the operating table or the bed.49 Hulten and colleagues described a simple, non-invasive and continuous method of monitoring irrigation uid absorption during TURP using ethanol.50 Irrigation uid is tagged with ethanol, and expired breath ethanol concentration is estimated using an alcohol analyser. Glycine 1.5% with 12% ethanol is available for use as an irrigation uid. The principle of the breathalyser is that ethanol concentrations in the exhaled gas should reect the concentrations in the blood. Blood ethanol concentrations reect the balance between the rate of entry into the circulation and its rate of removal and redistribution and elimination. Nomograms have been developed which relate the ethanol concentration in the exhaled breath to the volumes of irrigant uid absorbed and to the resulting fall in serum sodium concentration during TURP surgery. The same evaluations of the correlations between exhaled ethanol concentration, serum sodium and the volume of irrigant absorbed have been made based on a few patients having transcervical endometrial ablation (TCEA).49,51 Using these nomograms, the volume of irrigant absorbed during TCEA gives about a 10% greater rise in breath ethanol concentration and a 40% greater fall in sodium concentration than does TURP. This dierence may be explained by the dierence in weight and extracellular water between men and women.52 More work using larger numbers is required in order to

Table 6. Prevention of uid overload. 1. 2. 3. 4. 5. 6. 7. Monitoring of uid decit Control of irrigation pressure Good surgical technique Preparation of the endometrium Limit duration of surgery Monitor serum electrolytes and osmolality Use of CVP measurement in patients with cardiac or renal disease

44 M. C. Mushambi and K. Williamson

develop accurate nomograms for women undergoing endometrial ablation. A study by Molnar and colleagues found that measurement of expired ethanol was insucient to assess overall uid balance during OH and that continuous volumetric analysis is still required.53 Fluid decit estimation may also be done by automated uid inow/outow devices (Flo-Sta, Gynecare, Somerville, NJ, and AquaSens, Davol Inc, Rhode Island, USA) that provide accurate, non-invasive and continuous monitoring of uid decit.5,54 Fluid decit is the best indicator of uid overload. It is recommended that surgery be stopped as soon as possible when the decit is 10002000 ml and to stop immediately if the decit is 2000 ml or more.55 Some suggest than when a 500 ml decit is noted, serum electrolyte concentrations should be measured to check the sodium concentration, and if a 1000 ml decit be noted, frusemide 20 mg should be administered intravenously.15 Control of irrigation pressures. The uterine cavity has a low compliance, and high irrigation pressures are required during OH procedures. Although views of the uterine cavity are possible with irrigation pressures of 40 mmHg, it has been shown that pressures of 100110 mmHg may be required to see the tubal orices.56 The intrauterine pressure (IUP) attained during endometrial laser ablation may inuence the amount of uid absorbed, and it has been suggested that this should be limited to 60 mmHg.6 Various methods are employed to introduce uid into the uterine cavity under some form of pressure control. The simplest method uses a gravity-fed system. This consists of a 3-litre bag containing uid and held one metre above the uterus. It provides sucient pressure for uterine distension. The infusion pressure can be altered by varying the height of the bag. Pressurizing the infusion bag is an alternative, and is a relatively cheap method of controlling uterine pressure. Peristaltic pumps, although considerably more expensive, have been widely used to provide constant ow. These give excellent visual conditions but may be associated with a progressive rise in IUP. With such constant-ow variable-pressure pumps, excess uid absorption is a particular problem. This problem can be reduced by using pressure-controlled pumps.7 In a study by Hasham and colleagues,8 a hysterogram was taken during endometrial laser ablation; it showed no absorption of irrigation uid into the venous system at an IUP of 70 mmHg, while at 150 mmHg contrast medium was seen entering the uterine venous system. Pre-surgery preparation of the endometrium. Less absorption of uid may occur if resection takes place when the endometrium is relatively avascular; hence it is preferable to carry out this procedure during the mid-proliferative phase of the menstrual cycle (i.e. immediately after menstruation). Alternatively, drugs are administered to make the endometrium atrophic.6,9 Duration of surgery. Absorption of uid may be inuenced by the duration of the resection. It has been suggested that reduction of operating time to 1 hour or less may minimize the development of TURP syndrome. However, as with TURP syndrome, the risk of developing uid overload in OH is not always related to the duration of surgery: the syndrome may develop in as little as 1015 minutes.57,58 Surgical technique. Surgical technique also inuences the development of uid overload. Traumatic cervical dilatation should be avoided as it creates open vessels through which uid is absorbed. Every precaution should be taken to ensure that

Anaesthesia for hysteroscopic surgery 45

uterine perforation does not occur and, if it occurs, that it does not go un-noticed. Slowly advancing the hysteroscope with direct visualization of the endocervical canal during each entry should be standard practice. Of the three methods used, endometrial rollerball coagulation carries least risk.59 In this technique, there is no cutting of blood vessels or tissue and this is associated with reduced uid absorption and haemorrhage compared with the other two techniques. Treatment Treatment of uid overload depends on the nature of the uid absorbed. Fluid overload following the use of sodium chloride or Ringer's lactate causes pulmonary oedema but not hyponatraemia, hypo-osmolality or cerebral oedema. Therefore, the treatment required may be only diuretics and supplemental oxygen therapy. Absorption of mannitol is associated with hyponatraemia and pulmonary oedema but not hypo-osmolality. Treatment should include supplemental oxygen and monitoring of electrolytes, urine output and oxygen saturation. Fluid overload secondary to the use of hypotonic agents, such as glycine, produces the most dangerous situation of hypervolaemia, hyponatraemia and hypo-osmolality. Plasma sodium concentration and osmolality should be monitored closely. As a guide to the management of hyponatraemia, it has been suggested that a serum sodium of 120 mmol/l is the borderline between mild and severe hyponatraemia.47 Mild hyponatraemia should be treated with uid restriction and diuretics (frusemide 20 mg) while hypertonic saline 35%, 200500 ml over 4 hours60 may be used to treat severe hyponatraemia. There is, however, concern about the use of hypertonic saline. If hyponatraemia is corrected too rapidly, it may lead to abrupt decrease in cerebral blood volume and cause intracranial haemorrhage.61 Another concern is that cerebral demyelination lesions (central pontine myelinolysis) may be produced by excessively rapid correction of chronic hyponatraemia62 although the pathophysiology of chronic hyponatraemia diers from that of acute hyponatraemia, and demyelinating lesions have not yet been described in either TURP63 or following OH procedures. Initially, the serum sodium may be increased by 1 mmol/l per hour.5 The aim should be to correct the sodium serum level to mildly hyponatraemic levels rather than striving for normal sodium concentrations. Two ampoules of sodium bicarbonate (50 mmol each) may be used for initial replacement if hypertonic saline is not immediately available.5 Fluid overload requires the use of diuretics but it may be severe enough to require admission to the intensive care unit for endotracheal intubation, intermittent positive pressure ventilation (IPPV) or positive end-expiratory pressure (PEEP) and arterial and central venous pressure monitoring.57 Hypertension and chest pain can occur as a result of uid overload and may require treatment with vasodilators, oxygen, morphine and sublingual glyceryl trinitrate (GTN). In all cases of uid overload, monitoring should include urine output using an indwelling urinary catheter, serum electrolytes and osmolality, oxygen saturation using a pulse oximeter and arterial blood gases. Serum electrolytes should be monitored frequently until the patient's condition stabilizes. A full blood count and blood lm should be considered if haemolysis is suspected. Uterine perforation A rapid absorption of uid, sudden losses of distension pressure and a loss of visibility in the uterine cavity accompany perforation of the uterus. If an energy source is being

46 M. C. Mushambi and K. Williamson

used this must be stopped and the cavity inspected for possible perforation sites. If a perforation is conrmed it is essential to exclude damage to surrounding pelvic organs and vessels. This is particularly important if an energy source was being used at the time of perforation. Laparoscopy can be used to check the pelvis but missing bowel trauma can have such serious consequences that laparotomy should always be considered. Uterine perforation occurs more commonly with diathermy resection than the other methods; however, the incidence of such injury is less than 2%.37 Haemorrhage Bleeding during surgery may be dicult to quantify due to the dilution of blood with irrigation uid, and the usual signs of tachycardia and hypotension may be masked by the bradycardia and hypertension of distending uid absorption. Various methods have been used to estimate blood loss. They include radioactive labelling of RBC or measuring the haemoglobin concentration of the irrigation uid, but these are not routinely used. Haemorrhage after hysteroscopic surgery may be vaginal or intraperitoneal. Vaginal bleeding that occurs as a result of injury to a large blood vessel in the uterine wall may occasionally necessitate emergency hysterectomy. The bleeding may be apparent at the time of surgery, but continued post-operative bleeding may become problematic. Uterine tamponade with a Foley catheter can be successful in controlling both operative and post-operative bleeding. The balloon can be inated with 3050 ml saline and left in place for 24 hours. Intraperitoneal haemorrhage will occur if there has been perforation of the uterus. In a small atrophic post-menopausal uterus the bleeding may be minimal, but in younger women, where the uterus is more vascular, bleeding may be considerable. Post-operative abdomino-pelvic pain, tachycardia and hypotension should raise the suspicion of intra-peritoneal haemorrhage, and laparoscopy or laparotomy should be considered at an early stage. Gas or air embolism Gas embolism is a rare but devastating complication of hysteroscopy. The gas can arise from either pressurized gas (CO2 used as a distension medium), or ambient air, and it enters the circulation through venous channels in the cervix and endometrium. Other causes of gas embolism are from the use of either air, nitrous oxide or carbon dioxide to cool the co-axial bres of the Nd-YAG laser.64 The Food and Drug Administration (USA) reviewed incidences of gas/air embolism and recommended that gas/air should not be used for cooling the laser tip or for insuation of the uterus when a laser is in use.65 Carbon dioxide should be used only as a distension medium in diagnostic and not operative hysteroscopy. Steep Trendelenburg position places the uterus above the heart and can create a venous vacuum which can potentially suck air through the open venous sinuses. Gas embolism can be diagnosed by a decrease in end-tidal CO2 (ETCO2), hypoxia, tachycardia, tachypnoea, hypotension followed by bradycardia, and nally electromechanical dissociation or asystole. Diagnosis may be conrmed by the classic millwheel murmur which can be heard on auscultation of the precordium. Doppler echocardiography may be used to diagnose air embolism but this is seldom readily available during OH and its use is associated with high false-positive readings. In the event of suspected gas embolism, the following should be carried out:

Anaesthesia for hysteroscopic surgery 47

. Discontinue nitrous oxide, administer 100% oxygen and institute appropriate cardiovascular resuscitation; . Stop insuation of the uterus; . The operative site should be ooded with saline; . Ensure that the vagina is closed or occluded with a wet swab; . If practical, turn the patient to the left lateral position to aim to keep the air on the right side of the heart. However, if the patient requires external cardiac massage, this may not be practical as the patient needs to be supine; . If the patient has a CVP line in situ, try to aspirate air; . Echo or trans-oesophageal echo should be considered to help identify and possibly aspirate gas from the right side of the heart through a CVP line. . The operation should be abandoned and the patient should be admitted to the intensive care unit for further management.

ANAESTHESIA FOR HYSTEROSCOPIC SURGERY Types of anaesthesia The ideal anaesthesia for operative and diagnostic hysteroscopy should provide good operative conditions, no discomfort to the patient and minimize complications. It should allow early detection of uid overload and hyponatraemia. The choices of anaesthesia are: 1. 2. 3. 4. Local anaesthesia inltration with or without sedation; Paracervical block with or without sedation; Regional anaesthesia, i.e. spinal, epidural or combined spinal-epidural anaesthesia; General anaesthesia.

There are no studies comparing dierent types of anaesthesia for operative hysteroscopy. Diagnostic hysteroscopy can be carried out using local anaesthetic inltration66 and paracervical block but these may not be adequate for operative hysteroscopy. Local anaesthesia may also be used in patients undergoing a new technique of uterine thermal balloon therapy.67,68 Local anaesthetic inltration and paracervical blocks are useful for patients who are unt to undergo either general or regional anaesthesia. Regional anaesthesia may be a more appropriate form of anaesthesia because it allows early detection of signs and symptoms of dilutional hyponatraemia and uid overload. Spinal, epidural and combined spinal-epidural anaesthesia are acceptable alternatives to general anaesthesia in day-case surgery.69 Combinations of short-acting local anaesthetics, short-acting opioids and non-opioids may be used to provide early post-operative ambulation and discharge. Patients should be warned about the risk of post-dural puncture headache should it occur after a spinal or an epidural. The use of small atraumatic needles reduces the incidence of post-spinal headache signicantly. The uterus and cervix are supplied by nociceptive aerents that pass to the spinal cord by accompanying sympathetic nerves in the inferior, middle and superior hypogastric plexus. They pass through the lumbar and lower thoracic sympathetic chain and enter the spinal cord through the posterior nerve roots of T10, T11, T12, L1. Parasympathetic innervation is not thought to be important in the mediation of uterine and cervical pain. The pudendal nerve (S2, 3, 4) supplies the vagina and the perineum. General anaesthesia is commonly used for these procedures. It is usual to induce anaesthesia with propofol or sodium thiopentone and to maintain anaesthesia with oxygen, N2O and an inhalational agent. The patient may breath spontaneously through

48 M. C. Mushambi and K. Williamson

a laryngeal mask airway (LMA). However, the use of steep Trendelenburg may necessitate endotracheal intubation and controlled positive pressure ventilation. Endotracheal intubation is required if the patient is obese or has a risk of regurgitation. Full monitoring should include ECG, pulse oximeter, blood pressure, capnometry and temperature. There should be strict monitoring of uid decit and measurement of serum electrolytes and osmolality if indicated. Hysteroscopic surgery may proceed to a laparoscopy or laparotomy if complications occur. The anaesthetist should therefore be aware and be prepared for these procedures. Position of the patient The operation takes place with the patient in the lithotomy and Trendeleburg position. Care must be taken in the positioning of the arms and legs so that they are properly padded in order to avoid neuropathies, particularly common peroneal nerve, tibial nerve and brachial plexus neuropathy.70 Hypothermia Body temperature falls during anaesthesia, and elderly patients have been shown to have a lower thermoregulatory capacity. The use of cold irrigation uids, cold intravenous uids, exposure of the lower trunk and limbs and a cold theatre environment all predispose to heat loss during OH. Appropriate measures should be taken to reduce heat loss, and body temperature should be monitored. Fortunately, the risk of hypothermia during OH is minimized because these procedures are of reasonably short duration. Post-operative pain Post-operative pain following hysteroscopy is minimal, and non-steroidal antiinammatory drugs, paracetamol and dihydro-codeine are often adequate analgesia drugs. Occasionally, administration of parenteral opiates may be required. SUMMARY The hysteroscope is now an established diagnostic and therapeutic tool in gynaecology. The distension media used during operative hysteroscopy may cause uid overload, hyponatraemia and hypo-osmolality, and it is essential that measures be taken to minimize these complications. Should these complications occur, treatment must be instituted early in order to avoid fatal outcome. Monitoring of uid decit is the key factor in determining uid overload, and serum electrolyte concentrations should be measured early to detect hyponatraemia. The use of ethanol-tagged distension media to measure uid decit may be useful, but further research is needed in patients undergoing OH surgery. There are no studies to compare regional anaesthesia and general anaesthesia during OH. Both types of anaesthesia are widely used, but regional anaesthesia may be more appropriate as it allows early detection of uid overload and hyponatraemia. The technology involved in OH is still developing, and it is important that the operators be trained in the use of new equipment in order to minimize technical complications particularly those associated with the use of laser and electrodiathermy. The ability to use isotonic electrolyte-containing distension uid with new

Anaesthesia for hysteroscopic surgery 49

Practice points
. operative hysteroscopy is now an established gynaecological procedure but it can be associated with serious complications . absorption of irrigation uid can lead to uid overload, hypo-osmolality and hyponatraemia; this can be fatal if it is not recognized and treated early . monitoring of uid balance is the key factor in preventing uid overload . during anaesthesia for OH, patients should be kept warm and care should be taken to prevent peripheral neuropathy . both regional and general anaesthesia are widely used for OH but regional anaesthesia may oer more advantages

Research agenda Further research is needed in the following: . investigation of an easy, non-invasive, accurate and continuous method of measuring uid decit . the use of ethanol-tagged irrigation uid during OH . comparison of general and regional anaesthesia for OH equipment is welcome. It will invariably reduce some of the complications associated with hyponatraemia.

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