Management of Major Uterine Perforations From Suction Curet or Radium Tandem

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Management of Major Uterine
Perforations From Suction Curet
or Radium Tandem

Perforation of the uterus by the suction curettage cannula or by the tandem during radium application can cause serious complications of the small and large intestine if it is managed improperly. There is a distinct difference between the effects of these two kinds of perforation. If perforation occurs during suction curettage, the small bowel may be sucked into the eyes of the curet and pulled through the opening into the endometrial cavity and out through the cervix. Laceration of the small bowel can occur during this procedure. Although the large bowel is difficult to pull through the uterine perforation and out the cervix, the suction curet can attach itself to the wall of the large bowel and evulse a segment of it.

A different problem exists with the intracavity radiation therapy radium tandem. If the tandem perforates the uterine wall and the perforation is not recognized, it may cause severe radiation damage to the small bowel on which it comes to rest.

In both of the above situations, the surgeon should immediately insert a laparoscope through the umbilicus under direct vision withdraw the suction curet or the tandem back into the uterus. In the case of the suction curet, the suction should be reapplied, and the pregnancy should be completely terminated to avoid further complicating the situation by adding the sequelae of incomplete abortion.

In cases of perforation by the radium tandem, once the tandem has been replaced back into the uterus, the radium application can be preceed, as indicated.

Points of Caution. If perforation occurs during suction curettage, the suction should be turned off immediately to reduce the degree of injury to the intestine.

Technique

In this sagittal section of the pelvis, the suction curet has perforated the fundus of the uterus. Note that the small intestine is immediately adjacent to the suction curet. B identifies the bladder; R, the rectum; and V, the vagina.

If suction is continued, the small intestine can be suctioned into the eye of the curet and pulled through the fundus down into the endometrial cavity. Frequently, the surgeon mistakes the resistance of the bowel for the adherence of fetal parts and continues to pull.

If sufficient force is used, the intestine is pulled out through the cervix; occasionally, evulsion of the intestinal wall results.

This sagittal section shows the laparoscope being introduced in the routine manner through the umbilicus. The suction cannula is visualized.

With one surgeon viewing through the laparoscope and a second surgeon operating from below and with the suction cannula disconnected from its vacuum pump, the curet is gently withdrawn back into the endometrial cavity.

With the suction cannula safely in the endometrial cavity, vacuum is reapplied and termination of the pregnancy is completed under laparoscopic control.

This sagittal section shows the intracavitary radiation therapy tandem perforating the fundus. At this point, the laparoscope is introduced through the umbilicus, and the tandem is visualized and withdrawn back into the endometrial cavity.

When the tandem is safely withdrawn into the endometrial cavity, the ovoids are applied to the tandem in the routine fashion, and the intracavitary radiation therapy procedure is completed. Rarely does perforation by radium tandem result in hemorrhage severe enough to require surgical closing of the defect.