Uterine perforation is a surgical complication that can occur with any intrauterine procedure. While most perforations can be managed without additional interventions and are not related to important morbidity, uterine perforations can be serious, leading to sepsis, hemorrhage, poor reproductive and obstetric outcomes, and even death.
Preventive strategies for uterine perforation include careful preoperative evaluation, use of appropriate instrumentation and techniques intraoperatively, and adequate training and experience of the surgeon. Preoperatively, preparation includes imaging to assess uterine anatomy and identifying any potential risk factors; consideration for cervical preparation with prostaglandins or osmotic dilators1; and consideration for treatment of any existing vaginal atrophy. However, complications are inevitable for surgeons with high surgical volume and the expertise lies in prompt evaluation, recognition, and management of complications.2 The presurgical consent process should include the possibility of uterine perforation and any additional procedures including laparoscopy or laparotomy. Most perforations occur at the beginning of the procedure with the insertion of cervical dilators, hysteroscope, or sharp instruments with excessive force in a suboptimal axis. Techniques to reduce the incidence of perforation include a bimanual examination prior to dilation, placement of a tenaculum on the cervix to straighten the cervical canal, use of specialized instruments to identify and dilate the cervical canal (eg, os finder, lacrimal duct dilators), use of ultrasound to aid with difficult endometrial access, and proper use of energized instruments (eg, resectoscopic loop movements toward the operator and not the uterine wall).