Author
Information
(Hon. Endosopic
Surgeon Wadia Hospital & Railway Hospital (Byculla), Anesthesiologist,
Director: Velankar Hospital &Paranjpe Maternity Home, Chembur, Mumbai, India.)
Abstract
The breaking of
the tip of a metal suction cannula while performing a suction evacuation
procedure is a rare and almost unheard of the complications. Usually such a
complication is managed by removing that broken tip, with a ring forceps or an
artery forceps, both of which are blind procedures. Here we present a case of a
22 year old woman while undergoing an MTP, wherein, the tip of the metal
suction cannula was broken during the procedure and was retained inside the
uterus. We removed that broken tip with an innovative method using a
laparoscopic 5 mm tenaculum passed alongside the hysteroscope. Thus
establishing a safe and under vision, method of the removal of any foreign body
from the uterus, under direct vision, as a better option than a blind procedure
and the need for new innovative hysteroscopic instruments, for retrieving
heavier and larger objects.
Introduction
A review of
literature shows very few cases of breaking of the metal tip of a cannula
during suction and evacuation. As such foreign body in uterus is a very rare
condition. The usual foreign bodies that are found are intrauterine devices.
Other foreign bodies found in the uterus are broken laminaria tents, tips of
curettes, and non-absorbable suture materials. Very rarely fetal bones after an
incomplete abortion have also been written about. Hysteroscopy is always a
better option for foreign body removal as direct vision reduces the chances of
complications than that of a blind procedure. It also helps to see whether the
foreign body is removed in whole and completely, as the entire cavity can be
scanned under vision.
Case Report
A 29 year old
female gravida 3 para 2 living 2 with 6 weeks of pregnancy came to us for a
medical termination of pregnancy. All routine blood examinations were sent and
her hemoglobin, platelets and urine routine were within normal range. While
doing a suction and evacuation with a metal vacuum aspiration cannula, the tip
of the cannula broke inside the uterus and did not come out. The suction cannula was checked prior to the
procedure but probably due to the wear and tear it broke inside while
performing the procedure. An
attempt was made to try to remove the tip doing a curettage and also of a blind
procedure by using a ring forceps and an Allis’ forceps, both of which failed
due to improper grasp on the broken tip, probably due to a change in position
of the broken tip.
Figure 1. Metal
tip and tenaculum seen during hysteroscopy.
Figure 2. Position
of tenaculunm to remove tip vertically.
A decision of
hysteroscopic removal of the broken tip was taken. Normal saline was used as a distension media.
The outflow track of the hysteroscpe was intermittently opened due to which the
vision was not hampered. But the hysteroscopic grasper would have been too
small to catch heavy and large broken metal tip. Thinking that the
hysteroscopic grasper would also break while trying to hold a larger and
heavier object like the metal tip, the idea was abandoned.
Hence an
innovative technique was used wherein we used a laparoscopic 5 mm tenaculum.
The tenaculum was
passed along side the hysteroscope. There was minor leakage from alongside the hysteroscope but did not
compromise the distension nor the vision. And due to the direct vision, we were able to
grasp the hollow part of the broken tip with the laparoscopic 5 mm tenaculum
due to which the tip could be removed vertically with the least diameter.
Discussion
Early case reports
in the literature date to the mid 60’s and the management of in-utero foreign
bodies’ cases have previously been blind dilatation and removal with a ring
forceps or a hysterectomy.[1] Verma et al reported their experience with
ultrasound-guided removal of retained IUDs, as safe and cost-effective, and it
could be performed in an office setting.[2] Roy et al. reported removal of an
intrauterine wooden stick retained for 12 years from the uterine fundus, under
ultrasound guidance.[3] Yazicioglu et al. removed the tip of number 6 Karman’s
cannula hysteroscopically from the subvesical space.[4]
But as we can see
from this case that holding the broken tip at a specific site and reducing the
possibility of injuring any surrounding areas was only possible under direct
vision.
Also a larger
instrument like a laparoscopic tenaculum was needed to retrieve a large and
heavy object like the broken metal tip.
Operative
hysteroscopy is an evolving branch as thus we conclude that removing the broken
tip under vision was a better option than a blind or under ultrasonography
guidance. Also there is a need to
develop new larger innovative hysteroscopic instruments for different operative
procedures.
References
- De Brux J, Palmer R, Ayoub-Despois H () Les ossifications de l'endometre. Gynecol Obstet (Paris) 1956;55:494–497.
- Verma U, Astudillo-Davalos FE, Gerkowicz SA. Safe and cost-effective ultrasound guided removal of retained intrauterine device: our experience. Contraception. 2015 Feb 21;12:52-3.
- Roy KK, Mittal S, Verma A. Removal of an intrauterine foreign body retained for 12 years. Int J Obstet Gynecol 1996;54:185-6
- Yazicioglu HF, Yasar L, Dulger O. Hysteroscopic removal of a foreign body from the subvesical space. Int J Obstet Gynecol 2004;86:48-9.