Hysteroscopic surgery - avoid the complication of hyponatraemic encephalopathy

Abstract

Summary. Hysteroscopic surgery presents risks of four major complications (1) hyponatraemic encephalopathy; (2) uterine perforation (either with or without bowel injury); (3) haemorrhage; (4) infection. To perform this procedure safely, the surgeon must be fully aware of the principles of: (1) fluid management; (2) electrosurgery; (3) bleeding control. The most severe complication which confronts the surgeon in hysteroscopic surgery is neurological sequelae from hyponatraemic encephalopathy. Premenopausal women are 26 times more likely to suffer neurologic sequelae from hyponatraemia as post-menopausal women or men. These women suffer permanent brain damage, paralysis and even death. To prevent this complication, premenopausal women should be transformed into post-menopausal women prior to the performance of a hysteroscopic operation using hyponatraemic fluids as distension media. This can be accomplished by giving GnRH agonists in sufficient quantity and for sufficient length of time to induce menopause. This paper presents a case reviewed by the author of a young women in whom this was not done and who suffered irreversible neurological consequences from hyponatraemia during a hysteroscopic resection of a small submucous myoma. In addition to the severe irreversible damage suffered by this previously healthy young woman, a jury awarded 24 million dollars in a judgement against the physician and the surgery centre involved in her care. The medical and legal consequences of complications of what should be a simple and safe procedure may in fact be unacceptable if precautions are not taken to protect patients from the consequences of hyponatraemic encephalopathy.