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Iatrogenic uterine rupture caused by overinflation of RUMI manipulator balloon
Journal of Minimally Invasive Gynecology (2005) 12, 174-176
Iatrogenic uterine rupture caused by overinflation of RUMI manipulator balloon Hsin-hung Wu, MD, Guang-Perng Yeh, MD, and Tsung-Che Hsieh, MD From the Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua (Drs. Wu, Yeh, and Hsieh); the College of Health Sciences, Institute of Medical Research, Chang Jung Christian University, Tainan (Dr. Wu); and the Department of Obstetrics and Gynecology, Chung Shan Medical University, Taichung (Dr. Yeh), Taiwan. KEYWORDS: RUMI; Uterine rupture; Overinflation
The RUMI uterine manipulator is a useful device for uterine mobilization and chromopertubation during laparoscopic surgery. We report two cases of iatrogenic uterine rupture caused by overinflation of the intrauterine balloon of the RUMI manipulator during chromopertubation. One rupture, which occurred on the uterine fundus, simply was sutured during surgery. The other rupture, which occurred into the uterine lateral wall, caused retroperitoneal hematoma. A second operation was required to treat this complication. Overinflation of the tip balloon of the RUMI manipulator during chromopertubation can cause uterine rupture that can result in massive hematoma. © 2005 AAGL. All rights reserved.
The RUMI manipulator (Cooper Surgical, Shelton, CT) was designed for uterine mobilization and chromopertubation during laparoscopic surgery.1,2 It consists of a reusable handle and a disposable tip. There are two ports with tubes connected to the tip. One port is to the tip balloon for securing the set in the uterus by inflating the balloon with 2 to 3 mL of water. The other port leads to the openings at the tip to allow retrograde chromopertubation with methylene blue. The soft, elastic tip is designed to prevent uterine perforation. However, it is easy to confuse the balloon port with the injection port.
the tubal problem. During the operation, bilateral fimbrial obstruction and peritubal adhesion were noted. The adhesion was lysed, and salpingoneostomy of both tubes was performed. The tubal patency was monitored by chromopertubation with the RUMI uterine manipulator. During chromopertubation, we found that the fundal area of the distended uterus had ruptured (Figure 1). The hole was created by overinflation of the intrauterine balloon due to injection of methylene blue into the balloon instead of into the uterine cavity. We deflated the balloon and sutured the uterine rupture. The patient recovered well and was discharged on the third postoperative day.
Patient no. 1 A 33-year-old woman had an 8-year history of primary infertility. Hysterosalpingography showed bilateral tubal obstruction. She underwent laparoscopic surgery to correct Corresponding author: Hsin-hung Wu, MD, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Changhua Christian Hospital, No. 135 Nan-hsiao Street, Changhua, Taiwan 500. E-mail: [email protected].
1553-4650/$ -see front matter © 2005 AAGL. All rights reserved. doi:10.1016/j.jmig.2005.01.012
Patient no. 2 A 40-year-old patient had reported chronic low abdominal pain since her tubal sterilization surgery 7 years earlier. She decided to undergo surgical intervention for the pelvic pain and tubal reversal. During laparoscopy, endometriosis over both uterine sacral ligaments and adhesion over the scar of the previous tubal ligation were found. We fulgurated the
Wu et al
Uterine rupture by RUMI
Figure 1 The ruptured uterus. The arrow indicates the RUMI intrauterine balloon inflated with methylene blue.
endometriosis, lysed the adhesion, and anastomosed the tubes. Tubal patency was checked by chromopertubation with the RUMI manipulator. None of the dye spilled from either tube during the injection of approximately 25 mL of dye. When checking the procedure of chromopertubation, we found that all of the dye was injected into the intrauterine balloon. The uterine surface was intact under laparoscopy. We deflated the balloon, finished the operation, and withdrew all of the laparoscopic instruments. Severe abdominal distention, tachycardia, and mild fever were noted on the next day. A blood test showed that the patient’s hemoglobin had dropped to 6.2 mg/dL. She was sent to the operating room to rule out internal bleeding. During laparoscopy, we found a large mass protruding from the right broad ligament. Because of severe bowel distention, laparotomy was performed. We opened the retroperitoneum and found a hematoma measuring 18 ⫻ 8 ⫻ 6 cm3. We removed the blood clot and performed right uterine artery ligation. The patient was discharged on the eighth postoperative day.
Discussion Uterine rupture caused by laparoscopic tubal surgery with chromopertubation by uterine manipulator rarely has been reported. As far as we know, this is the first report of uterine rupture caused by overinflation of the intrauterine balloon of the RUMI manipulator during laparoscopic tubal surgery. Chromopertubation is a common procedure to monitor the patency of tubes during laparoscopic surgery. The RUMI manipulator is one of many manipulators with an intrauterine balloon used to perform chromopertubation. The blunt tip was designed to be secured safely in the uterine cavity. During the two procedures described above, surgical personnel who were not acquainted with the RUMI manipulator, probably confused the balloon port and the injection
175 port; this confusion led to the infusion of the methylene blue into the balloon in error. In vitro studies have shown that the intrauterine balloon can be inflated to 30 mL without rupturing, which can lead to uterine rupture. In our opinion, the balloon port should be designed to inject with a needle or should be fixed on the handle without connecting to a free tube. In addition, the balloon should be designed with a 20-mL capacity maximum. To overcome the existing design problems, we now notify our assistants to use the correct port for methylene blue injection in advance of the chromopertubation procedure, and the balloon port will be masked after securing the RUMI in the uterine cavity. Intrauterine pressure is the most important factor that causes uterine rupture. The pressure can increase or decrease depending on the compliance of the uterus and the amount of intrauterine fluid. The natural capacity of the uterus is between 2 and 20 mL, and can tolerate a pressure of 170-180 mm Hg, according to the pressure-volume curves for patients treated by the ThermaChoice system (Gynecare, Inc., Menlo Park, CA).3 Both patients in this report had relatively normal uterine cavity capacities. In both cases, the uterine rupture occurred accidentally when the intrauterine balloon was inflated to approximately 25 mL. Ruptures usually occur in the weakest area of the uterus. If the rupture is on the fundal area, it can be detected easily during the operation and repaired by suturing. However, if the rupture is on the lateral wall of the uterus, within the broad ligament where the branches of uterine arteries are located, it will not be identified easily during surgery. Bleeding may continue, causing blood to accumulate in the retroperitoneal space. The mechanism by which retroperitoneal hematoma forms is similar to that which causes vaginal wall laceration during vaginal birth. Although there was no direct evidence that the hematoma was induced by the rupture of the uterine lateral wall, the uterine overdistension was the only unusual event during the operation and probably caused the lateral wall rupture. Women with a history of uterine scarring or defect due to uterine rupture are at risk of uterine rupture during subsequent pregnancy.4 Although the obstetrical consequences of perforation and rupture cases are not well known, cases of pregnancy complicated by uterine rupture and defect after uterine perforation have been reported.5,6 Those women who had known or suspected uterine rupture must be counseled about the risks of uterine rupture and receive adequate follow-up during pregnancy.
Conclusion Although chromopertubation with the RUMI manipulator is a simple procedure during laparoscopic surgery, accidental overinflation of the intrauterine balloon can result in severe complications, which may increase the risk of uterine rupture during subsequent pregnancies.
176
Journal of Minimally Invasive Gynecology, Vol 12, No 2, March/April 2005
References 1. Koh CH. A new technique and system for simplifying total laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc. 1998;5:187-192. 2. Koh Ch, Janik GM. Laparoscopic microsurgical tubal anastomosis. In: Endoscopic Management of Gynecologic Disease. Adamson GD, Martin DC, eds. Philadelphia, PA: Lippincott-Raven;1996:119-145. 3. Vilos GA, Aletebi FA, Eskandar MA. Endometrial thermal balloon ablation with the ThermaChoice system: effect of intrauterine pressure
and duration of treatment. J Am Assoc Gynecol Laparosc. 2000;7:325329. 4. Ofir K, Sheiner E, Levy A, Katz M, Mazor M. Uterine rupture: risk factors and pregnancy outcome. Am J Obstet Gynecol. 2003;189:1042-1046. 5. Reed WC. Large uterine defect found at cesarean section: a case report. J Reprod Med. 2003;48:60-62. 6. Koutele F, Nicolas K, Riviere MF, Ledoux A. About two cases of uterine rupture outside of labour: consequences of an unnoticed previous perforation [in French]. Gynecol Obstet Fertil. 2003;31: 362-364.
Iatrogenic uterine rupture caused by overinflation of RUMI manipulator balloon Hsin-hung Wu, MD, Guang-Perng Yeh, MD, and Tsung-Che Hsieh, MD From the Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua (Drs. Wu, Yeh, and Hsieh); the College of Health Sciences, Institute of Medical Research, Chang Jung Christian University, Tainan (Dr. Wu); and the Department of Obstetrics and Gynecology, Chung Shan Medical University, Taichung (Dr. Yeh), Taiwan. KEYWORDS: RUMI; Uterine rupture; Overinflation
The RUMI uterine manipulator is a useful device for uterine mobilization and chromopertubation during laparoscopic surgery. We report two cases of iatrogenic uterine rupture caused by overinflation of the intrauterine balloon of the RUMI manipulator during chromopertubation. One rupture, which occurred on the uterine fundus, simply was sutured during surgery. The other rupture, which occurred into the uterine lateral wall, caused retroperitoneal hematoma. A second operation was required to treat this complication. Overinflation of the tip balloon of the RUMI manipulator during chromopertubation can cause uterine rupture that can result in massive hematoma. © 2005 AAGL. All rights reserved.
The RUMI manipulator (Cooper Surgical, Shelton, CT) was designed for uterine mobilization and chromopertubation during laparoscopic surgery.1,2 It consists of a reusable handle and a disposable tip. There are two ports with tubes connected to the tip. One port is to the tip balloon for securing the set in the uterus by inflating the balloon with 2 to 3 mL of water. The other port leads to the openings at the tip to allow retrograde chromopertubation with methylene blue. The soft, elastic tip is designed to prevent uterine perforation. However, it is easy to confuse the balloon port with the injection port.
the tubal problem. During the operation, bilateral fimbrial obstruction and peritubal adhesion were noted. The adhesion was lysed, and salpingoneostomy of both tubes was performed. The tubal patency was monitored by chromopertubation with the RUMI uterine manipulator. During chromopertubation, we found that the fundal area of the distended uterus had ruptured (Figure 1). The hole was created by overinflation of the intrauterine balloon due to injection of methylene blue into the balloon instead of into the uterine cavity. We deflated the balloon and sutured the uterine rupture. The patient recovered well and was discharged on the third postoperative day.
Patient no. 1 A 33-year-old woman had an 8-year history of primary infertility. Hysterosalpingography showed bilateral tubal obstruction. She underwent laparoscopic surgery to correct Corresponding author: Hsin-hung Wu, MD, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Changhua Christian Hospital, No. 135 Nan-hsiao Street, Changhua, Taiwan 500. E-mail: [email protected].
1553-4650/$ -see front matter © 2005 AAGL. All rights reserved. doi:10.1016/j.jmig.2005.01.012
Patient no. 2 A 40-year-old patient had reported chronic low abdominal pain since her tubal sterilization surgery 7 years earlier. She decided to undergo surgical intervention for the pelvic pain and tubal reversal. During laparoscopy, endometriosis over both uterine sacral ligaments and adhesion over the scar of the previous tubal ligation were found. We fulgurated the
Wu et al
Uterine rupture by RUMI
Figure 1 The ruptured uterus. The arrow indicates the RUMI intrauterine balloon inflated with methylene blue.
endometriosis, lysed the adhesion, and anastomosed the tubes. Tubal patency was checked by chromopertubation with the RUMI manipulator. None of the dye spilled from either tube during the injection of approximately 25 mL of dye. When checking the procedure of chromopertubation, we found that all of the dye was injected into the intrauterine balloon. The uterine surface was intact under laparoscopy. We deflated the balloon, finished the operation, and withdrew all of the laparoscopic instruments. Severe abdominal distention, tachycardia, and mild fever were noted on the next day. A blood test showed that the patient’s hemoglobin had dropped to 6.2 mg/dL. She was sent to the operating room to rule out internal bleeding. During laparoscopy, we found a large mass protruding from the right broad ligament. Because of severe bowel distention, laparotomy was performed. We opened the retroperitoneum and found a hematoma measuring 18 ⫻ 8 ⫻ 6 cm3. We removed the blood clot and performed right uterine artery ligation. The patient was discharged on the eighth postoperative day.
Discussion Uterine rupture caused by laparoscopic tubal surgery with chromopertubation by uterine manipulator rarely has been reported. As far as we know, this is the first report of uterine rupture caused by overinflation of the intrauterine balloon of the RUMI manipulator during laparoscopic tubal surgery. Chromopertubation is a common procedure to monitor the patency of tubes during laparoscopic surgery. The RUMI manipulator is one of many manipulators with an intrauterine balloon used to perform chromopertubation. The blunt tip was designed to be secured safely in the uterine cavity. During the two procedures described above, surgical personnel who were not acquainted with the RUMI manipulator, probably confused the balloon port and the injection
175 port; this confusion led to the infusion of the methylene blue into the balloon in error. In vitro studies have shown that the intrauterine balloon can be inflated to 30 mL without rupturing, which can lead to uterine rupture. In our opinion, the balloon port should be designed to inject with a needle or should be fixed on the handle without connecting to a free tube. In addition, the balloon should be designed with a 20-mL capacity maximum. To overcome the existing design problems, we now notify our assistants to use the correct port for methylene blue injection in advance of the chromopertubation procedure, and the balloon port will be masked after securing the RUMI in the uterine cavity. Intrauterine pressure is the most important factor that causes uterine rupture. The pressure can increase or decrease depending on the compliance of the uterus and the amount of intrauterine fluid. The natural capacity of the uterus is between 2 and 20 mL, and can tolerate a pressure of 170-180 mm Hg, according to the pressure-volume curves for patients treated by the ThermaChoice system (Gynecare, Inc., Menlo Park, CA).3 Both patients in this report had relatively normal uterine cavity capacities. In both cases, the uterine rupture occurred accidentally when the intrauterine balloon was inflated to approximately 25 mL. Ruptures usually occur in the weakest area of the uterus. If the rupture is on the fundal area, it can be detected easily during the operation and repaired by suturing. However, if the rupture is on the lateral wall of the uterus, within the broad ligament where the branches of uterine arteries are located, it will not be identified easily during surgery. Bleeding may continue, causing blood to accumulate in the retroperitoneal space. The mechanism by which retroperitoneal hematoma forms is similar to that which causes vaginal wall laceration during vaginal birth. Although there was no direct evidence that the hematoma was induced by the rupture of the uterine lateral wall, the uterine overdistension was the only unusual event during the operation and probably caused the lateral wall rupture. Women with a history of uterine scarring or defect due to uterine rupture are at risk of uterine rupture during subsequent pregnancy.4 Although the obstetrical consequences of perforation and rupture cases are not well known, cases of pregnancy complicated by uterine rupture and defect after uterine perforation have been reported.5,6 Those women who had known or suspected uterine rupture must be counseled about the risks of uterine rupture and receive adequate follow-up during pregnancy.
Conclusion Although chromopertubation with the RUMI manipulator is a simple procedure during laparoscopic surgery, accidental overinflation of the intrauterine balloon can result in severe complications, which may increase the risk of uterine rupture during subsequent pregnancies.
176
Journal of Minimally Invasive Gynecology, Vol 12, No 2, March/April 2005
References 1. Koh CH. A new technique and system for simplifying total laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc. 1998;5:187-192. 2. Koh Ch, Janik GM. Laparoscopic microsurgical tubal anastomosis. In: Endoscopic Management of Gynecologic Disease. Adamson GD, Martin DC, eds. Philadelphia, PA: Lippincott-Raven;1996:119-145. 3. Vilos GA, Aletebi FA, Eskandar MA. Endometrial thermal balloon ablation with the ThermaChoice system: effect of intrauterine pressure
and duration of treatment. J Am Assoc Gynecol Laparosc. 2000;7:325329. 4. Ofir K, Sheiner E, Levy A, Katz M, Mazor M. Uterine rupture: risk factors and pregnancy outcome. Am J Obstet Gynecol. 2003;189:1042-1046. 5. Reed WC. Large uterine defect found at cesarean section: a case report. J Reprod Med. 2003;48:60-62. 6. Koutele F, Nicolas K, Riviere MF, Ledoux A. About two cases of uterine rupture outside of labour: consequences of an unnoticed previous perforation [in French]. Gynecol Obstet Fertil. 2003;31: 362-364.