From Suction Curet or
for Correction of
Resection by Loop
Procedure (LEEP) for
Correction of a Double
Richardson Composite Operation
and Without Bilateral
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
In cases of perforation by the radium tandem, once the tandem has been
replaced back into the uterus, the radium application can be preceed,
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.
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
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.