Saturday, October 3, 2009

Escaping the Inevitable

Any OB/GYN will tell you it’s inevitable. Sometime, no, multiple times during your career, you will perforate the uterus. They all have a story in which an instrument they so gently insert into the uterine cavity goes a little too far… and into the abdomen. But it could never happen to me, right?

It was the last case of the week and I scrubbed in to do a D&C Hysteroscopy with an attending I had never worked with. I sit down to do the procedure while Dr. M supervises. I examine the patient and note the position of her uterus. I place the speculum and visualize the cervix. I place the tenaculum, a grasping instrument which allows the surgeon to manipulate cervix. I sound, or measure, the length of the uterus and then dilate the cervix. I look inside the uterine cavity with the hysteroscope (an intrauterine camera). Everything is going super smoothly and I am proud of my independence in the case. Then it came time for the curettage. I introduce the curett, a long instrument with a sharp metal loop at the end used to shave off the endometrial lining. It is entirely done by feel. Once I feel as though I am done, we re-introduce the hysteroscope to make sure the uterine cavity looks clean and intact.

This time, I am having a difficult time getting oriented in the uterus. I move the camera past what I believe is the cervix, but the uterine cavity just looks more lumpy than usual. I rotate the camera to try and get my bearings when I see something that makes my heart drop. My camera focuses in on two round bulging structures that look frighteningly familiar. “Dr. M, do you want to take a look and tell me what this is?” She takes control of the hysteroscope and is quiet as she examines these structures. Finally, I say it. “Is it BOWEL???” Everyone in the OR, the circulating nurse, the scrub tech, the anesthesiologist, rush over to the camera screen. To get bowel, aka intestine, into the uterus would not only require a perforation of the uterus, it would require a huge tear. How clumsy could I have been to do that without feeling it?

Then again, it really does look like bowel. Dr. M and the surgical staff don’t know what to say. They have never seen anything like this. We remove the hysteroscope and two other GYN surgeons are called in for a second opinion. The wait for them to appear was painful - you could taste the tension in the room. Meanwhile, thoughts race back and forth in my head. Will we have to cut her abdomen open? What if I perforated her bowel too? Will we have to do a bowel resection? How are we going to explain this to her and her family? I thought about my own fate as well. What will the program say? What if I get sued? No attending is ever going to want to work with me again. Maybe I picked the wrong field after all. I am just going to quit before I hurt anyone else. I even start seeking help from a higher power. Please God, please don’t let me have perfed the uterus. Please…

Finally the other surgeons show up. They replace the hysteroscope. Although it’s a bit bloody and messy inside the uterus, we can’t seem to find those structures again. The consult surgeons suggest using a resectoscope, which is bigger and can dilate the uterus much more to increase our visibility. What we find is shocking. We see a perfectly normal and intact uterus. Dr. M and I can’t believe it. We examine every wall of the uterus 5 times. One ostia, another ostia, anterior wall, posterior wall. All smooth. All intact. No perforation, no bowel. Nothing but normal uterus.

The consult surgeons laugh. “See! We told you everything would be fine! There’s nothing!” The rest of the OR and Dr. M. breathe a huge sigh of relief. As for me, it takes me a good ten minutes before I trust that everything is going to be okay. What. A. Scare.

We never did find out what it was that we originally laid our eyes on. On theory was that we saw clots. My theory is that it was a miracle. God really must not have wanted me to quit my residency program.


  1. You made me scared reading this post! I'm happy that it all worked out. It's definitely a horrible feeling when you think you have had a complication. I haven't perf'd the uterus yet... but I'm sure my day will come!

  2. It never stops. 6 months ago (as a second year resident) one of my staff perforated the uterus on a lap BTL with the uterine manipulator. It took us over an hour, three attempts to suture, five attempts to pack it and a pack and a half of floseal to get it to stop.

    But hey, all bleeding stops eventually, right?