The challenge with any classification system is reproducibility. Even among experienced shoulder arthroscopists, there is a lack of consensus on making a SLAP diagnosis [4]. Gobezie et al. [68] studied the inter and intra-observer reliability in the diagnosis and treatment of SLAP tears with 73 "expert surgeons." Video clips containing 22 vignettes of approximately 15 seconds duration were sent 73 shoulder surgeons and each was asked to classify the superior labral anterior posterior type using Snyder's classification system (types I–IV). The same video clips were sent again 12 months later to obtain data on intraobserver reliability. Several significant trends were noticed regarding the diagnosis and treatment responses. These included the difficulty distinguishing type III lesions from type IV lesions and the difficulty distinguishing normal shoulders from type II SLAP tears. Regarding type II SLAP tears, only 52% of surgeons made the correct diagnosis of distinguishing normal shoulders from type I and from type II SLAP lesions and making the appropriate treatment recommendations. This is a significant study and further, prospective studies need to be performed in this area and possibly better surgical education.

## **4. Clinical evaluation**

#### **4.1 History**

The proper diagnosis of SLAP lesions can be very difficult as the clinical picture may mimic other shoulder pathology. SLAP lesions rarely occur in isolation and are often associated with other shoulder conditions such as impingement, rotator cuff tendinitis, instability, and rotator cuff tears. When occurring in throwing athletes, SLAP lesions present an additional layer of complexity when evaluating the throwing shoulder. Studies of SLAP lesions suggest that most patients have pain, mechanical symptoms, notably, loss of range of motion, or inability to perform at their previous activity level [5, 6]. The diagnosis of isolated SLAP lesions has historically been difficult, and this has been attributed to several reasons including the high incidence of other associated pathology especially in an athlete's shoulder.

It is important first to determine whether there was an acute episode of trauma or a history of repetitive use as in overhead athletes. Many others have described a fall on an outstretched arm [1, 6] as a common mechanism of injury that can cause SLAP tears. This fall can cause impaction of the shoulder with a superiorly directed force driving the humeral head against the superior labrum and the biceps anchor [65]. If the force is severe enough, a "SLAP fracture" can occur, which appears as a divot in the superior dome of the humerus more anterior that the usual posterior lateral Hill-Sachs-type instability lesion [65].

Maffet et al. [6] suggested that the most common etiology was traction on the biceps tendon. The shearing forces on the superior biceps labral complex with the long head of the biceps acting as a decelerator of the arm during the follow through phase of throwing have also been proposed as mechanism for type II SLAP tears [57, 69]. Burkhart et al. described the contracture of the posterior-inferior glenohumeral ligament in throwers causing a shift of the glenohumeral contact point posterior and superiorly, increasing the shear forces on the posterior-superior labrum, generating the "peel-back" effect and a SLAP lesion [57].

The most common complaint of symptom of patients with a SLAP lesion is some type of mechanical catching or locking of the shoulder. This occurs when the unstable labrum is trapped between the humeral head and glenoid. In case of chronic SLAP lesions, there is history of an insidious onset of shoulder pain, especially in overhead athletes. The pain may increase in severity and limit sports performance with mechanical symptoms with forceful overhead movements as in throwing or overhead sports such as volleyball and the spiking maneuver.

The biggest difficulty is differentiating a symptomatic SLAP lesion from degenerative changes of the labrum or even normal variants. Most SLAP lesions occur in the dominant arm of male, high level, overhead athletes who are younger than 40 years old [70]. Patients older than 40 years of age often have degenerative changes of the labrum, which may or not be clinically significant or pathologic [4]. Pfahler and associates [11] described the normal aging pattern of the superior labrum with normal microscopic and macroscopic changes. Significant glenohumeral arthritis or full-thickness rotator cuff tears typically do not accompany a symptomatic type II SLAP tear but rather are just a part of the entire degenerative process of the shoulder joint.

SLAP tears can also occur in the presence of a shoulder dislocation and are found as the anterior labral tear progresses superiorly to the biceps anchor and posteriorly to create a SLAP with an associated Bankart lesion.

#### **4.2 Physical examination**

The symptoms of a SLAP lesion can mimic those of impingement syndrome, pathology of the rotator cuff or the AC joint, or other shoulder disorders. It is important to remember that no single physical examination finding is pathognomonic for SLAP tears [71]. SLAP tears rarely occur in isolation and are often associated with other shoulder pathology [1, 3, 5, 6, 72–74]. Even when seen in isolation, SLAP tears may mimic impingement (52%) or even anterior instability (39%) [71, 75]. Very few studies have examined the clinical signs and symptoms of isolated SLAP lesions. In 1997, we retrospectively examined 2375 patients who underwent shoulder arthroscopy and SLAP lesions were identified in 140 shoulders. Of these 140 SLAP lesions, only 26 had no other pathology. In 23 patients who had adequate postoperative followup, all patients had nonspecific shoulder pain, which increased with overhead activity and mimicked rotator cuff pathology. Nine patients (39%) had a positive apprehension test with only one (4%) positive relocation test. Of the 23 patients, over one half (52%) had a positive Neer test and 35% had a positive Hawkins test. A positive Speed's test (biceps tension test) was seen in 35% and 43% who had mechanical popping and snapping in their shoulder. It is apparent that even with isolated SLAP lesions, the clinical picture can be confused with rotator cuff symptomatology.

Many studies have evaluated the sensitivity, specificity, and positive and negative predictive values as well as inter-observer and intra-observer reliability of various clinical exams with limited success [68]. In a previous study of isolated SLAP lesions of the shoulder, we found no sensitive clinical test for their detection [71]. Snyder and colleagues also determined that no single or combination of tests could conclusively and reliably predict when and what type of lesion would be found at arthroscopy [5]. They determined that the most accurate test was Speed's biceps tension test [65]. Although this test is much more suggestive for damage to the biceps tendon proper than the labrum or anchor, it may be helpful when the anchor is unstable [65].

In 1996, Liu et al. [76] described the crank test and found it to be 91% sensitive in detecting glenoid labral tears, including SLAP lesions. In 1998, O'Brien et al. [77] described the active compression test, the so-called "O'Brien test" to clinically diagnose labral tears and pathologic conditions of the acromioclavicular joint. Of 56 patients who had a positive O'Brien test result and underwent subsequent operation, 53 (95%) were found to have a labral tear.

We conducted a prospective study in 2002 to determine whether the crank or O'Brien tests were reliable tools for detecting superior glenoid labral tears. Results of diagnostic arthroscopy were compared with those of the preoperative tests and determined that the crank test had only had 46% sensitivity and was only 56% specific and the O'Brien test had only a sensitivity of 54% and 31% specificity. We determined that the O'Brien and crank tests were not sensitive clinical indicators for detecting glenoid labral tears [2]. The poor sensitivity and specificity of these clinical examination tests and others combined with difficulties with the interpretation of advanced imagery [12–14] make the clinical diagnosis of SLAP tears extremely challenging.

Cook et al. [12] conducted a prospective study to determine the accuracy of five orthopedic clinical tests for the diagnosis of SLAP lesions. The purpose of the study was to identify the diagnostic utility of the Active Compression (O'Brien's test), the biceps load II test (Kim's test), the dynamic labral shear test (O'Driscoll's test), Speed's test, and the labral tension test when diagnosing isolated SLAP lesions. Physical exam findings were compared to the findings at the time of diagnostic arthroscopy. No tests demonstrated diagnostic utility when diagnosing any SLAP lesion, including those

with concomitant diagnoses. The findings suggested that each of the five stand-alone tests and clusters of tests provide minimal to no value in the diagnosis of a SLAP lesion.

Several investigators have questioned the role of SLAP lesions in shoulder stability [78]. Some have reported that SLAP lesions occur without associated glenohumeral instability [9, 60, 72, 74] while others feel that SLAP lesions are directly related to instability. The relationship between a physical finding of laxity or instability and a superior labral lesion has not been fully elucidated [78].

At the present time, there is no sensitive clinical examination test for SLAP lesions as many other pathologic conditions are associated with SLAP lesions. A high index of suspicion is necessary to accurately diagnose and treat these injuries.

#### **4.3 Imaging**

The first step in evaluating any shoulder pain is proper X-rays of the shoulder joint. This includes an anteroposterior view of the glenohumeral joint (not the shoulder as this will not give a proper view of the joint), an axillary view, and a supraspinatus outlet view. This will help rule out bony abnormalities including glenohumeral osteoarthritis, an os acromiale, or even a rare locked posterior dislocation if there is a history of significant trauma or a seizure disorder. The supraspinatus outlet view will help determine the acromial morphology (types I–III) and the thickness of the acromion, which can be important if an arthroscopic subacromial decompression is ever performed.

An MRI or an MR arthrogram is the next imaging study in evaluating shoulder pain in overhead athletes. Although a routine MRI will show significant rotator cuff pathology and glenohumeral osteoarthritis, it is not highly sensitive for detecting subtle abnormalities of the labrum such as SLAP tears or partial rotator cuff tears. An MRA is recommended as it has shown to increase the sensitivity and specificity for detecting labral tears and also partial articular sided rotator cuff tears, which is important in evaluating the overhead athlete with shoulder pain [79]. An MRI or an MRA that shows a SLAP lesion is not an automatic indication for surgery [16]. In our prospective study of U.S. Olympic Volleyball athletes, 46% of asymptomatic elite volleyball players had MRI evidence of SLAP tears but no history of complaints of shoulder problems [80]. SLAP tears are also identified on MRI in up to 48% of pitchers who are asymptomatic [23, 81]. These studies show that pathologic MRI findings in elite overhead athletes can be present. However, they are often asymptomatic. In competitive overhead athletes such as volleyball players or baseball pitchers, an MRI or MRA evidence of a SLAP lesion may not be the cause of their shoulder pain and can initially treated with nonoperative management.

## **5. Nonoperative treatment**

Frequently, injuries of the superior labrum can be successfully treated with a wellstructured and carefully implemented nonoperative rehabilitation program. The key to successful nonoperative treatment is a thorough history, clinical examination, and accurate diagnosis [42]. Typical nonoperative treatments have centered on posterior capsular stretching while maintaining glenohumeral and periscapular strength and stability [19].

The repetitive micro-traumatic stresses placed on the athlete's shoulder joint complex during the throwing motion challenges the physiologic limits of the surrounding tissues. Athletes often exhibit numerous adaptive changes that develop from the

repetitive micro-traumatic stresses during overhead throwing. Alterations in throwing mechanics, muscle fatigue, muscle weakness or imbalance, and excessive capsular laxity may lead to tissue breakdown and injury [42].

Little information is available on these patients who had a successful result after nonoperative treatment [19] for SLAP lesions. Edwards et al. [19], using validated, patient-derived outcomes, showed that successful nonoperative treatment of superior labral tears results in improved pain and functional outcomes.

An overhead athlete with significant shoulder pain in their dominant arm should first be rested for 4–6 weeks and be prescribed a short course of a non-steroidal antiinflammatory medication. During this time, a stretching program emphasizing the posterior capsule stretching should be implemented with no resistance. At 6 weeks, a structured physical therapy program is instituted working on scapulothoracic mechanics with rotator cuff strengthening. At 3 months, a gradual return to throwing or overhead activities begins, which is closely monitored by the physical therapist or athletic trainer. If the athlete is not able to return to their previous level, surgical intervention is then recommended in the hopes of returning them to their preinjury level.

## **6. Operative treatment**

SLAP repair technique results have varied widely in the many studies reported in the literature. This is most likely explained by the variety of techniques, which have been used to address and repair the biceps labral complex/SLAP lesion to the glenoid. This includes arthroscopic debridement, the use of arthroscopic suture anchors, staples, metal screws, absorbable sutures, and biodegradable implants [5, 10, 73, 74, 82], and also biceps tenodesis and tenotomy. The high frequency at which labral injuries involve associated pathology [83] of the shoulder makes it difficult to compare the results of studies.

#### **6.1 Debridement**

Arthroscopic debridement of SLAP lesions and in particular type II SLAP lesions was originally described by Andrews and colleagues in 1985 [3]. Altchek and colleagues also reported on the arthroscopic debridement of SLAP lesions in 1992. Interestingly, at 1 year, 72% of patients noted improvement, but by 3 years, that number had dropped significantly to only 7%. They concluded and we agree that arthroscopic labral debridement is not an effective long-term solution for symptomatic relief in the overhead athlete [84].

### **6.2 Arthroscopic repair**

Suture anchors with both simple and mattress repair techniques have been utilized with success for Type II SLAP repair [85]. Morgan et al. [66] reported that stabilization of the detached biceps anchor in shoulders with a Type-II SLAP lesion provided satisfactory clinical results and eliminated the drive through sign [86]. A mattress repair for type II SLAP repairs creates a labral bumper compared with simple repairs while both techniques result in similar biomechanical characteristics [52].

In the surgical treatment of the elite throwing athlete's shoulder with a symptomatic Type II SLAP tears, surgeons are concerned about overtightening the shoulder resulting in a loss of the necessary external rotation [15]. For this reason, it is common practice among some surgeons who treat throwers to use suture anchors placed posterior to the insertion

of the long head of the biceps and to avoid anchors placed anterior to the biceps. This practice is an attempt to restore stability without compromising external rotation [15].

#### **6.3 Tenodesis**

Biceps tenodesis has been proposed as an alternative procedure to SLAP repair for overhead athletes. However, some of the results have been disappointing, with an overall return to play rate of 35% in professional baseball players and only 17% in professional baseball pitchers [62]. Boileau et al. [17] conducted a prospective study to evaluate and compare the results of biceps tenodesis and repair of isolated type II SLAP lesions. In the biceps tenodesis group, 93% (14/15) were satisfied or very satisfied and 87% (13/15) were able to return to their previous level of sports participation. Only 20% (2/10) were able to return to sports participation after SLAP repair. They concluded that arthroscopic biceps tenodesis can be considered an effective alternative to repair of a type II SLAP lesion allowing patients to return to a pre-injury level of activity of sports participation. Reviewing this paper, it is unclear what type of sports they participated in and whether or not they were overhead athletes. Also, the technique of SLAP repair, which placed an anchor anterior to the biceps tendon, which can limit external rotation, may be one of the reasons for the poor results in the SLAP repair group.

Gottschalk et al. [87] also proposed biceps tenodesis as an alternative to repair for type II and type IV SLAP tears, especially in older athletes. There remains some doubt regarding the efficacy of repairing SLAP lesions versus a biceps tenodesis in middle-aged patients [87]. In a group of 26 patients and 29 shoulders available for follow-up with an average age of 46.7 years, 89.6% were able to return to their previous level of activity. However, the vast majority of the patients in their study group were not overhead athletes.

Ek et al. [88] retrospectively reviewed 25 patients comparing type II SLAP repair versus biceps tenodesis. The 15 patients who underwent biceps tenodesis had an average age of 47 years while the 10 patients who underwent type II SLAP repair were 31 years. Both groups showed significant improvement and there was no difference in patient satisfaction, ASES scores, or return to preinjury level of sports. Tenodesis was performed in older patients who showed degenerative or frayed labrums, whereas SLAP repairs were performed in the younger group and more active patients with healthier labrums.

#### **6.4 Tenotomy**

In general, tenotomy is reserve for older, lower demand patients. With a significantly torn and degenerative SLAP lesion in an older patient, this is a very easy and quick procedure. The risk of a "Popeye" deformity in a younger, more active patient and the resultant cramping and cosmetic deformity, which can result, makes tenotomy a poor choice in overhead athletes.

#### **6.5 Author's preferred technique**

Before surgery, it is important that a long course of conservative management with a structured physical therapy and return to overhead sports program has been tried before surgery is performed in the overhead athlete. When this fails and using the proper surgical techniques, most patients can be treated successfully and return to their previous level of play. It is important that a surgeon develop a preoperative "check list" [89] to make sure that all imaging studies are up to date and available and that all the proper equipment is also available in the operating room suite. Besides having the proper anchors for a SLAP repair, the surgeon must be ready and able to address other shoulder pathology including rotator cuff tears, which can also be present at the time of surgery. **Table 1** lists all the equipment that are needed to perform the procedure. In 2019, we described the details of our preferred surgical technique along with a surgical technique video [16], which can be helpful to learn all the many steps that we will describe.

Building the proper surgical team is critical to success. This includes a skilled anesthesiologist who is comfortable with hypotensive anesthesia to control bleeding and allow for adequate visualization at the time of arthroscopy. Visualization is key to any arthroscopic surgery and excessive bleeding can prolong the procedure. A dependable circulating nurse and a skilled assistant are also critical for the procedure. It is not necessary to have another surgeon to assist but rather a good surgical technician can be trained to be an excellent assistant to hold the arthroscope in position and handle other surgical instruments.

The lateral decubitus position is preferred as it allows easier access to the anterior and anterior inferior aspect of the shoulder with less risk of cerebral hypoperfusion. We prefer general endotracheal anesthesia to maintain a secure airway, and this also allows the anesthesiologist better control of the blood pressure. All equipment should be in front of the surgeon so that he can easily check the status of all equipment including shavers, pump, and arthroscopic fluid bags to make sure everything is working properly. We also prefer a suprascapular nerve block, which is easy to administer after the patient is asleep and before beginning the procedure. We feel it is a safer block with less risk than an interscalene block.

Portal placement is key for any arthroscopic shoulder procedure. We first establish a posterior portal two finger breadths down and two finger breadths medial from the posterolateral aspect of the acromion in the interval between the infraspinatus and teres minor muscles. A 30-degree arthroscope is inserted using a 5.5 mm x 8.5 cm "J-lock" metal cannula system (Smith and Nephew/Dyonics). The shorter type of cannula is better for shoulder procedures and easier to maneuver within the shoulder

#### *SLAP Lesions in Overhead Athletes DOI: http://dx.doi.org/10.5772/intechopen.108711*

joint compared to the longer cannula used for knee arthroscopy. It is important to have a 5.5 mm cannula for adequate inflow through the arthroscope, which allows for adequate joint distension compared to a smaller diameter cannula (3.5–4.5 mm).

After entering the glenohumeral joint, the glenoid should be parallel to the floor and the biceps tendon is identified. Next, an anterosuperior portal needs to be created in the rotator interval between the subscapularis and supraspinatus tendons. This portal needs to be high enough in the rotator interval to allow anchor placement in the superior glenoid. If the portal is too low, the angle for anchor placement is compromised. This can be done using an outside-in technique or inside out, depending on surgeon preference. The vast majority of the time I create this portal using an inside-out technique by driving the arthroscope up into the rotator interval, removing the arthroscope but keeping the cannula in place, and then placing a smooth switching stick or rod through the posterior cannula up into the rotator interval where it then tents the skin. A small incision is then made anteriorly over the rod, and it exits out the skin. The assistant then holds the shoulder while a metal 5.5 cannula is inserted over the rod and into the glenohumeral joint.

Using an outside in technique, a spinal needle is placed percutaneously and anteriorly in the rotator interval at approximately 45 degrees to the superior tubercle under the labrum. A small skin incision is made, and the 5.5 metal cannula with a smooth obturator is used to follow the direction of the needle into the glenohumeral joint. This anterior superior portal is then hooked up to outflow (not suction!) to tubing leading to a bucket on the floor. The outflow is controlled by a clamp that the assistant periodically opens to "clear the picture" of blood or debris. The position of this portal is critical for the success of the operation and must not damage the supraspinatus tendon, which can cause postoperative pain and weakness leading to a substandard result.

After the two portals have been established, we then perform a complete 15-point diagnostic shoulder arthroscopy of the glenohumeral joint [65]. The superior labrum is part of this diagnostic examination, and careful attention needs to be made to differentiate a meniscoid-type of labrum from a type II SLAP tear (**Figure 1**). Even among experienced shoulder surgeons, this has proven to be difficult with poor inter and intra-observer reliability with only 48% of them correctly identifying type II SLAP tears [68]. Repairing a meniscoid-type of labrum or a normal labral variant can lead to a loss of external rotation, which can limit the ability of an overhead athlete to return to peak form.

Once the type II SLAP tear is properly identified, preparation for repair begins by replacing the metal 5.5 cannula in the rotator interval with a working portal, a clear, smooth 5.75 mm x 7 cm cannula (Smooth Crystal Cannula/Arthrex). This is done using a switching stick technique to maintain portal placement and avoid damage to the surrounding musculature. This working cannula has a diaphragm, which does not allow water out and therefore keeps joint distension. A 4.0 mm full radius shaver (Smith and Nephew/Dyonics) is then inserted through the anterior-superior portal for debridement of the superior glenoid of all soft tissues extending from the biceps anchor posterior to the extent of the tear.

Decortication of the superior glenoid is then performed using 4.5 mm round burr (Smith and Nephew/Dyonics) via the anterior superior portal with care not to damage the articular surfaces of the glenoid or humeral head. The burr is carefully placed between the labrum and the superior glenoid and decortication of the superior glenoid is performed (**Figure 2**) to punctate bleeding bone (**Figure 3**) and verified with the fluid being turned off. This creates a bleeding surface of growth factors from the marrow, which can enhance healing. The surgeon should stay posterior to the biceps anchor as there is no need to decorticate anteriorly.

#### **Figure 1.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, a type II SLAP lesion is seen here with the superior labrum along with the biceps anchor pulled away from the superior glenoid.*

Once adequate decortication of the superior glenoid is performed with the burr and a bleeding bone bed has been created, a second anterior portal needs to be created for suture passage. This is created at the leading edge of the subscapularis tendon and is referred to as the mid-glenoid portal. Using an outside-in technique with a spinal needle, it is inserted at the leading edge of the subscapularis tendon high enough to allow easier passage of suture and instruments. A 5.75 mm x 7.0 mm clear cannula (Clear Crystal Cannula/Arthrex) with a ring at the end is inserted for twin anterior cannulas (**Figure 4**). This ring at the end of the cannula prevents it from "squirting" out inadvertently during the procedure.

#### **Figure 2.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, decortication of the superior glenoid is performed using a 4.5 mm round burr (Smith and Nephew/Dyonics) via the anterior superior portal. Care is taken not to damage the articular surfaces of the glenoid or humeral head and the burr is carefully placed between the labrum and the superior glenoid and decortication of the superior glenoid is performed.*

## *SLAP Lesions in Overhead Athletes DOI: http://dx.doi.org/10.5772/intechopen.108711*

#### **Figure 3.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, decortication of the superior glenoid is done until punctate bleeding bone can be seen. This is verified with the fluid being turned off and creates a bleeding surface of growth factors from the marrow, which can enhance healing. The surgeon should stay posterior to the biceps anchor as there is no need to decorticate anteriorly.*

Proper anchor placement is one of the keys to success for this procedure. The anchor should be placed posterior to the biceps anchor at approximately the 12 o'clock position. There are multiple steps to anchor placement, and we recommend using them in the order described. The anterior superior portal cannula is placed just below or inferior to the biceps tendon (not above it), and 2.0 mm mini-Revo punch (Conmed/Linvatec) is inserted at a 45-degree angle into the bony bed of the area of decortication. This creates a pilot hole for the anchor. The arthroscope needs to be rotated downward to

#### **Figure 4.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, a second anterior portal is created for suture passage at the leading edge of the subscapularis tendon and is referred to as the mid-glenoid portal. A 5.75 mm* × *7.0 mm clear cannula (Clear Crystal Cannula/Arthrex) with a ring at the end is inserted to create twin anterior cannulas. This ring at the end of the cannula prevents it from "squirting" out inadvertently during the procedure.*

#### **Figure 5.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the arthroscope is rotated downward to the 5 o'clock position in order to adequately visualize the instruments properly. For anchor placement, a pilot hole is created at approximately the 12 o'clock position just posterior to the biceps anchor. The anterior superior portal cannula is placed just below or inferior to the biceps tendon (not above it), and a 2.0 mm mini-Revo punch (Conmed/Linvatec) is inserted at a 45-degree angle into the bony bed of the area of decortication. This creates a pilot hole for the anchor. It is important to adequately visualize the tap going into the bone and not do it blindly and skive posteriorly.*

the 5 o'clock position for a right shoulder in order to adequately visualize the tap going into the bone and not skiving posteriorly (**Figure 5**) and needs to be done under direct visualization and not done blindly. Once the pilot hole has been created, the punch is removed and a 2.5 mm mini-Revo tap (Conmed/Linvatec) is inserted into the pilot hole (**Figure 6**) to create threads for the screw. We have found that in younger patients, the glenoid bone can be quite hard and self-tapping screws do not always seat properly into

#### **Figure 6.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the pilot hole has been created and a 2.5 mm mini-Revo tap (Conmed/Linvatec) is inserted into the pilot hole to create threads for the screw. We have found that in younger patients, the glenoid bone can be quite hard and self-tapping screws do not always seat properly into the bone.*

#### **Figure 7.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the tap is then removed and under direct visualization, the 2.8 mm metal anchor single loaded with a high strength suture (Twin Fix 2.8 mm/Smith and Nephew; Fast-Fix 2.8 mm/Arthrex; or Mini-Revo 2.8 mm/Linvatec/Concept) is inserted via the anterior superior portal into the superior glenoid.*

the bone. A proud anchor can cause significant problems to the articular cartilage of the humeral head, so it is imperative that these anchors are well embedded into the superior glenoid. The tap is then removed and under direct visualization, the 2.8 mm metal anchor single loaded with a high strength suture (Twin Fix 2.8 mm/Smith and Nephew;

#### **Figure 8.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the arthroscope is rotated up to approximately the 1 o'clock position. A crochet hook is used for gently pulling one limb of the suture into the mid-glenoid portal. There is now one suture limb through the mid-glenoid portal and the other limb through the anterior superior portal. Suture management is also critical for a good repair. Without proper suture management, the sutures can become entangled and twisted. It is very important to keep the suture limbs separate in each portal for this part of the procedure.*

Fast-Fix 2.8 mm/Arthrex; or Mini-Revo 2.8 mm/Linvatec/Concept) is inserted via the anterior superior portal into the superior glenoid (**Figure 7**). We prefer a metal anchor and have abandoned the use of bioabsorbable anchors or other plastic types of anchors because of the risk of fragmentation, synovitis, and chondrolysis.

We then test for anchor security, which is also a key step. After the anchor has been placed into the superior glenoid, the sutures are released from the driver and the driver is gently tapped out to disengage it from the anchor only a few millimeters. The sutures are then visible in the anchor and the sutures are then tugged to ensure "anchor security" and to make sure that the anchor does not come loose or become "proud." If the anchor is not secure and pulls out even a few millimeters, this can damage the articular surface of the humeral head. If by pulling on the sutures the anchor becomes loose or becomes proud, the driver can easily be slid down on top of the anchor again, re-engaged, and the anchor is seated deeper for full engagement and to make sure it will not come loose or become proud again.

Suture management is also critical for a good repair. Without proper suture management, the sutures can become entangled and twisted. After the anchor is secured into the bone, the arthroscope is rotated up from the 5 o'clock position to approximately the 1 o'clock position to view the two suture limbs coming out of the anchor. A crochet hook (not a grasper, which can damage the suture) is for gently pulling one limb of the suture into the mid-glenoid portal. There is now one suture limb through the mid-glenoid portal and the other limb through the anterior superior portal (**Figure 8**). It is very important to keep the suture limbs separate in each portal for this part of the procedure.

For suture passage and stitching, there are many devices on the market, many of them are one time use, which can be expensive. The Spectrum Soft Tissue device (Conmed/ Linvatec) has different reusable attachments depending on the procedure being performed and the angle that is necessary. For a SLAP repair, we prefer the medium-sized crescent attachment, which easily fits through the 5.7 mm cannula. A #1 PDS suture (Ethicon) loaded into the back of the device, which keeps it out of the way when use the

#### **Figure 9.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the Spectrum Soft Tissue device (Conmed/Linvatec) is used for a SLAP repair. We prefer the medium-sized crescent attachment, which easily fits through the 5.7 mm cannula. A #1 PDS suture (Ethicon) loaded into the back of the device, which keeps it out of the way when using the wheel to deploy the shuttle. The rotator interval portal is then placed above or superior to the biceps tendon and the Spectrum device is placed through this portal and just above the labrum. The arthroscope is rotated down into the 4 o'clock position in order to better visualize the superior labrum.*

## *SLAP Lesions in Overhead Athletes DOI: http://dx.doi.org/10.5772/intechopen.108711*

#### **Figure 10.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, with careful attention not to damage the articular surface of the glenoid, the tip of the device pierces the superior labrum just posterior to the biceps tendon.*

#### **Figure 11.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, after the tip pierces the superior labrum the shuttle is deployed. The suture grasper via the mid-glenoid portal grasps the shuttle and pulls it out the mid-glenoid portal. A shuttling technique is used to then shuttle the mid-glenoid suture through the labrum.*

wheel to deploy the shuttle. The rotator interval portal is then placed above or superior to the biceps tendon and the Spectrum device is placed through this portal and just above the labrum. The arthroscope is rotated down into the 4 o'clock position in order to better visualize the superior labrum (**Figure 9**). With careful attention not to damage the articular surface of the glenoid, the tip of the device pierces the superior labrum just posterior to the biceps tendon and the shuttle is deployed (**Figure 10**). The suture grasper via the mid-glenoid portal grasps the shuttle and pulls it out the mid-glenoid portal (**Figure 11**).

The shuttle is pulled out into the mid-glenoid portal and then clamped with a Kelly clamp to keep it from inadvertently being pulled out. The shuttle relay or PDS

#### **Figure 12.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the PDS shuttle with the suture attached is pulled from the anterior superior portal and the suture is shuttled from the mid-glenoid portal, through the labrum, and then out the anterior superior portal.*

#### **Figure 13.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the first suture has been shuttled through the superior glenoid and this creates a simple knot with one limb through the labrum.*

suture is then used to shuttle the first limb of the suture from the mid-glenoid portal, through the labrum, and out through the anterior superior portal. This is done by creating a "dilator knot" first on the PDS and then proximal to that creating a second knot and passing the limb of the suture through it, securing it, and then pulling on the PDS limb that is in the anterior superior portal to shuttle the first limb of the suture through the labrum (**Figures 12** and **13**). This creates a simple knot, but we prefer to repeat the process to create a mattress stitch.

Using the crochet hook placed into the mid-glenoid portal, the second limb of the suture that has not been passed through the labrum and is in the anterior-superior portal is grasped and brought into the mid-glenoid portal. The PDS suture is used again

## *SLAP Lesions in Overhead Athletes DOI: http://dx.doi.org/10.5772/intechopen.108711*

#### **Figure 14.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the arthroscope is rotated down to the 4 to 5 o'clock position and the Spectrum device with the crescent attachment is again placed into the anterior-superior portal just above the labrum. The tip of the device pierces the labrum approximately one centimeter posterior to the other limb of the suture, which has already been shuttled through the labrum.*

#### **Figure 15.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the process is then repeated with grabbing the shuttle from the mid-glenoid portal, bringing it out the cannula, securing the second limb of the suture outside the mid-glenoid portal with the PDS suture and shuttling the second limb through the labrum and out the antero-superior portal.*

and loaded into the Spectrum device. It is important to cut away the previous knots on the PDS as these knots will prevent the PDS from sliding through the Spectrum device. The Spectrum with the crescent attachment is again placed into the anterior-superior portal just above the labrum. The tip of the device pierces the labrum approximately 1 centimeter posterior to the other limb of the suture, which has already been shuttled through the labrum (**Figure 14**). The process is then repeated with grabbing the shuttle from the mid-glenoid portal (**Figure 15**), bringing it out the cannula, securing the second limb of the suture outside the mid-glenoid portal, and shuttling the second

#### **Figure 16.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, a mattress stitch has been created. This keeps the suture away from the articular surface and has been shown to be biomechanically stronger than a simple stitch [52, 56].*

#### **Figure 17.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the knot is posterior to the biceps and the arthroscopic knot cutter cuts the suture after five half-hitches have been placed leaving a small tail at the end. With the mattress configuration, the knots are tied behind the labrum, off the articular surface, where it will not contact the humeral head or pinch between the glenoid and the humeral head.*

limb through the labrum and out the antero-superior portal creating a mattress stitch (**Figure 16**). The mattress stitch keeps the knot off the articular surface and has been shown to be biomechanically stronger than a simple stitch [52, 56].

Knot tying is the final key step to a good repair. With the mattress configuration, the knots are tied behind the labrum, off the articular surface, where it will not contact the humeral head or pinch between the glenoid and the humeral head. A sliding knot is not used as sliding knots can damage and tear the labrum, which can be thin

#### **Figure 18.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, a different type of SLAP is depicted with anchors and sutures both posterior and anterior to the biceps anchor. Placing anchors and knots anterior to the biceps may limit external rotation by capturing the superior glenohumeral ligament which can be detrimental to the overhead athlete.*

#### **Figure 19.**

*A right shoulder viewing from the posterior portal in the lateral decubitus position, the arthroscope is rotated upward to about the 10 – 11 o'clock position to view the articular side of the supraspinatus tendon. If a partial articular sided cuff tear is identified in the glenohumeral joint, a marker suture technique [65] using a spinal needle can be used to place an absorbable PDS suture into the partial articular sided rotator cuff tear. This helps localize the area of the tear in the subacromial space.*

in some patients. Also, sliding the knots through the anchor can damage the suture and weaken its strength. We recommend a "Revo Knot" [65] popularized by Snyder, which is a series of half-hitches. The arthroscopic knot pusher is placed via the anterosuperior portal, which is above the biceps tendon. It takes two hands to create a good arthroscopic knot so the trained assistant must be able to hold the camera in a steady position or "freeze the frame" to enable the surgeon to use two hands to create a stable knot. The knot is posterior to the biceps and the arthroscopic knot cutter cuts the suture after five half-hitches have been placed leaving a small tail at the end (**Figure 17**).

This mattress knot configuration of placing the knot behind the biceps tendon, off the articular surface, will help resist the peel back mechanism in the late phase of throwing (late cocking) [57]. Only one anchor placed posterior to the biceps is necessary [58]. Placing anchors and knots anterior to the biceps may limit external rotation by capturing the superior glenohumeral ligament (**Figure 18**), which can be detrimental to the overhead athlete.

Once the SLAP repair has been performed, it is important to address other issues inside the glenohumeral joint and the subacromial space including partial rotator cuff tears. If a partial articular sided cuff tear is identified in the glenohumeral joint, a marker suture technique [65] using a spinal needle can be used to place an absorbable PDS suture into the partial articular sided rotator cuff tear (**Figure 19**). The arthroscope is then positioned into the subacromial space. The arm holding suspension device in changed from abduction to adduction to easily facilitate entry into the subacromial space by bringing the humeral head away from the acromion. Once in the subacromial space, it is very important to evaluate for an impingement lesion and any amount of subacromial bursitis. In overhead athletes over the age of 30, it is not uncommon for them to have a significant amount of subacromial bursitis, and we recommend performing an arthroscopic subacromial decompression or "smoothing" in these athletes. We then recommend evaluating the bursal side of the rotator cuff. If a marker suture had been placed, finding the marker

• Always use a mattress stitch with the knot tied behind the labrum

• Always use a half-hitch knot and not a sliding knot as a sliding knot can damage the labrum

## **Table 2.**

*Key points for arthroscopic repair.*

*SLAP Lesions in Overhead Athletes DOI: http://dx.doi.org/10.5772/intechopen.108711*

suture on the top or bursal side of the rotator cuff will help evaluate this side of the rotator cuff. If there is any significant damage to the bursal side of the rotator cuff, the surgeon has different options including debridement, a PASTA repair [65], or completing the tear and converting to a full thickness tear and repairing it. The details of this procedure are being the scope of this chapter, but shoulder surgeons who treat overhead athletes must be experienced in all of these techniques as no one technique is used all the time.

The key points for this procedure are outlined in **Table 2**.

## **7. Postoperative rehabilitation**

Postoperatively, the SLAP repair needs to be protected for a minimum of 4 weeks before any resistive biceps is allowed. A sling is used postoperatively for only 2 weeks, but patients are asked to come out of the sling on postoperative day #1 and do elbow flexion and extension exercises along with gripping of a ball to reduce hand swelling. Pendulum exercises are started on postoperative day #2 and a formal exercise program is started 7–10 days postoperatively. Progressive resistance exercises are started at 6 weeks and a return to sports and throwing program is started at 3 months if motion is normal and patients have regained 80% of their strength. Return to sports including unrestricted overhead sports is allowed at 6 months.

## **8. Discussion**

The published literature reveals that a significant percentage of athletes are unable to return to their prior level of athletic participation after repair of type II SLAP lesions, which is especially true for overhead athletes such a baseball players [10, 21, 22, 83, 90–92]. In baseball pitchers, the success rates for those who have undergone arthroscopic repair of Type II SLAP lesions are even poorer, ranging from 7 to 62% [10, 21, 22, 32, 83, 93–95]. Gorantla et al. [96] in a systematic review of the literature found that only 63% of overhead athletes who underwent type II SLAP repairs were able to return to sports at their previous level of competition.

Shoulder injuries in overhead athletes, especially those who throw, can be a debilitating condition that can severely limit and end the ability to participate [93]. SLAP tears can be challenging to treat in the overhead athlete. Nonoperative and operative treatments have been discussed with nonoperative treatment being the mainstay of treatment for the overhead athlete with a clinical diagnosis of a SLAP tear. As we have seen, SLAP tears can be seen in asymptomatic overhead athletes so initial nonoperative treatment will return most overhead athletes back to their pre-injury level of competition without surgery. When nonoperative treatment fails, which it can, arthroscopic surgical intervention can return most athletes to competition at or near their pre-injury level if the proper surgical techniques are used.

There have been unsuccessful outcomes with debridement alone for Type II SLAP lesions [5, 44, 84]. Arthroscopic debridement was initially recommended by some authors [3, 84], but the long-term results were disappointing. Cordasco et al. reported that arthroscopic debridement of Type II SLAP lesions was not effective with deteriorating results over 3 years. Their initial success rate was 78% at 1 year, 63% at 2 years, and only 45% at 3 years [44].

Initially, high rates of return to play were reported [97–99]. However, in these early studies of SLAP lesions, the outcome data are based largely in retrospective studies

consisting of small numbers of patients using various surgical techniques and fixation options [61]. Many reports of the treatment of SLAP lesions have included patient who had other associated abnormalities making it difficult to clarify the clinical efficacy of treatment of the superior labral lesion alone [22].

Wilke, Andrews, and Meister [42] described the delicate balance of the thrower's shoulder, which has sufficient laxity to allow excessive external rotation and stability provided by the glenohumeral articulation and scapula can be easily disrupted. This has been described as the so-called "Thrower's Paradox" and disruption of this fine balance disables the throwing shoulder. The return to play (RTP) at an athlete's previous level of competition is a measure of the success of the operation.

The overhead athlete has had poor outcomes following the surgical repair of SLAP lesions reported by many different surgeons. The return to play has varied with only 63% of overhead athletes able to return to their pre-injury level [85, 96]. Other authors including Kim et al. [22] in 2002 also reported poor results of shoulder function with overhead athletes with only 22% able to return to their same level of competitiveness in their sport. Sayde et al. [85] reported that 73% of athletes were able to return to their previous level of play, but only 63% of the subset of 198 athletes who were baseball players returned to their previous level. Smith et al. [100] identified 24 major league baseball pitchers reported to have had surgery for a SLAP tear and found that 63% returned to play in the major leagues.

For baseball pitchers, the results are even worse with rates varying from 7 to 62% [10, 21, 22, 32, 83, 93–95]. Fedoriw et al. [93] reported on a case series of professional baseball players with SLAP lesions and found out that the rate of return to their previous level of play was 24% (16/68) after conservative treatment and only 23% (9/40) for those who progressed to surgery. For baseball pitchers, the results were worse and only 7% of baseball pitchers were able to return to play with surgical treatment The reasons for the high failure rates and poor results in this subgroup of overhead athletes are multifactorial and include a lack of a proper diagnosis not only preoperatively but also intra-operatively with a possible normal meniscoid variant being inadvertently repaired. Other nuances of the surgical technique could also be the explanation including anchors placed anterior to the biceps anchor, restricting external rotation, which can decrease the ability of the baseball pitcher to reach maximum torque in their pitching delivery.

Biomechanists and pitching coaches often observe that pitchers returning from injury or from surgical repair of a SLAP lesion look like they are "holding back" [51]. Pitchers in this situation demonstrate a smaller shoulder stride, less forward trunk tilt, and/or are "pushing the ball" [51]. Pushing the ball is a colloquial expression of increased shoulder horizontal abduction and increased elbow flexion seen in pitchers after SLAP repair, most likely due to the loss of external rotation.

Using electromyogram and motion analysis, it has been shown that baseball pitchers after SLAP repair have altered biomechanics including a loss of maximal external rotation of their throwing shoulder with less horizontal abduction causing a decrease in pitching velocity [51, 62]. What is it about SLAP repair that alters the pitching biomechanics resulting in a loss of pitching velocity? More likely than not, it is the technique of placing anchors anterior to the biceps anchor, overtightening the shoulder resulting in a loss of external rotation.

An MRI/MRA finding of a SLAP is not uncommon in overhead athletes and is not an indication for immediate surgery. In our prospective study of 26 elite Olympic volleyball players with no history of any shoulder problems, MRIs of their dominant shoulders showed that 17 had evidence of partial rotator cuff tears, 6 had labral tears including 4

#### *SLAP Lesions in Overhead Athletes DOI: http://dx.doi.org/10.5772/intechopen.108711*

with SLAP tears. The dominant shoulder of overhead athletes undergoes a tremendous amount of repetitive stress and is at risk for damage. However, this damage can remain asymptomatic throughout the athlete's career and any overhead athlete with shoulder pain should also initially be treated with nonoperative management [80]. Nonoperative treatment is the mainstay in overhead athletes and surgery should only be done after a long course of conservative management ranging from 3 to 6 months.

The study of Gobezie et al. [68] of 73 "expert surgeons" who were queried with video clips had a difficult time distinguishing type I from type II SLAP lesions. Only 52% make the correct diagnosis and recommended the appropriate treatment of labral repair. The poor results in the literature of arthroscopic SLAP repair may be a failure of not only diagnosis but also repair of normal variants or SLAP tears that are mistakenly misdiagnosed as normal at the time of surgery [9].

Reviewing the literature of the results of the SLAP repairs, examining the arthroscopic techniques used by different surgeons may help explain the poor results. The techniques have evolved since the original description of SLAP tears in 1985 and we now have a better understanding of the ligamentous anatomy and biomechanics of the shoulder joint. However, many surgeons did not have the benefit of these studies when they first started treated SLAP tears. With any procedure, proper portal placement, anchor placement, and knot tying are keys to a successful surgery.

In 2002, O'Brien and colleagues [90] used a trans-rotator cuff portal for surgical repair of SLAP lesions posterior to the biceps anchor. They describe the use of a cannula but state that to minimize the degree of damage to the rotator cuff, the procedure can be performed without a cannula. However, it is unclear how many patients had a cannula placed. This portal placement with a cannula referred to as the "Port of Wilmington" can damage the musculotendinous portion of the supraspinatus tendon and may explain the poor results. Using this technique, O'Brien et al. reported that only 16 of 31 patients (44%) were able to return to their preinjury level of sports. Despite the poor results, O'Brien stated that "the trans-rotator cuff technique is an effective and safe modality to address superior labral pathology." We would disagree considering the poor results reported and do not recommend violating the rotator cuff with a large cannula for anchor placement. If it is necessary to use the "Port of Wilmington" for posterior superior anchor placement, then it should be done percutaneously without the use of a cannula and using a spinal needle for direction.

Other authors have also reported poor results using a rotator cuff penetrating or trans-rotator cuff portal. In 2006, Cohen and colleagues [83] reported on isolated SLAP lesions treated with arthroscopic fixation using a bioabsorbable tack. Only 48% were able to return to their preinjury level of athletics. In those patients in which the rotator cuff was penetrated for cannula and anchor placement, only 12 of 22 patients (55%) rated their satisfaction as good or excellent. All 10 patients who reported postoperative night pain had undergone a cuff-penetrating surgical approach.

Neri et al. [10] also described a trans-rotator cuff portal for posterior SLAP lesions and reported only a 57% return to their pre-injury level of competition. They also found that the presence of a partial articular sided rotator cuff tear significantly correlated with ability to return to sport and only 13% with a partial cuff tear were able to return to their prior level of play. We do not recommend this technique of violating the rotator cuff for anchor placement, especially with a large diameter cannula but rather prefer our technique of a single anchor placed via a cannula through the rotator interval.

As we have seen from the numerous biomechanical studies that have been performed, placing an anchor anterior to the biceps tendon (**Figure 19**) can entrap the superior glenohumeral ligament (SGHL) and the middle glenohumeral ligament

(MGHL) causing a small but significant loss of external rotation [15, 61]. The biomechanical study by Morgan and colleagues in 2008 showed no advantage of placing an anchor anterior to the biceps tendon to prevent the peel-back mechanism [101].

Tension in the ligaments after SLAP repair may resolve shoulder instability but could negatively impact and affect a pitcher's ability to attain the shoulder external rotation and longitudinal abduction necessary to throw effectively [51]. The most common complication of the symptomatic type II SLAP repair has been reported as refractory post-op stiffness in forward flexion and external rotation, reported at 8.5% [15, 51]. When Katz et al. [102] looked at a cohort of failed SLAP repairs, they found out that 75% of these patient's complained of decreased range of motion.

Other authors have also noted poor results secondary to a loss of external rotation when an anchor is placed anterior to the biceps tendon. Indeed, the majority of failed SLAP repairs complain of not only pain but loss of motion [102]. Chalmers et al. in their analysis of return to play for professional baseball pitchers detected a trend toward a decrease in maximal external rotation in pitchers after SLAP repair as compared to normal controls [62].

Another key point in the arthroscopic technique of type II SLAP repair is the type of stitch configuration used. The mattress stitch with one anchor has shown to be stronger biomechanically than the use of a simple stitch with one or even two anchors [40]. This is also helps re-create the normal superior labral anatomy [52, 56].

With a mattress configuration, the knots are away from the articular surface, are less bulky, and can cause less irritation in the thrower's shoulder, reducing the risk of postoperative pain and mechanical-like symptoms in the thrower's shoulder. Even in experienced hands, these simple knots can be bulky causing significant irritation in the overhead athlete's shoulder reducing their ability to return to their normal level of play [55]. In an analysis of 11 failed SLAP repairs by Park and colleagues [103], patients complained of persistent pain and mechanical clicking in their shoulders when they returned to throwing after surgery. At the time of repeat arthroscopy in five patients, all had the knot positioned on the glenoid and caused damage the articular surface of the humeral head. Arthroscopic removal of the stitches provided pain relief and improved their ability to return to throwing. Rhee and Ha [104] described a case report of knot-induced glenoid erosion after arthroscopic suture anchor repair of a Type II SLAP lesion. The knot can be a source of continued pain after surgery so that is why we recommend a mattress configuration.

SLAP tears rarely occur in isolation [71] and other associated shoulder pathology such as chondral lesions, Bankart lesions with instability, impingement lesions, and partial or complete rotator cuff tears, which are present, may be another reason why SLAP repairs do so poorly. It is important to take a close look at the literature in that some studies that look at only the results of isolated SLAP lesions of the shoulder also have other pathology, most commonly partial rotator cuff tears, which are a confounding variable in looking at surgical results. Brockmeier et al. [61] had 24 of their 47 study patients with partial rotator cuff tears and 24 of 47 had signs and symptoms of impingement requiring a subacromial decompression. SLAP tears rarely occur in isolation and all pathology must be addressed at the time of surgery.

In an analysis of 23 elite collegiate or professional overhead athletes, Neri et al. [10] found that the presence of a partial articular sided rotator cuff tear correlated with inability to return to pain-free preinjury levels of competition. The group of patients with concomitant partial thickness rotator cuff tears demonstrated only 13% return to prior level of play, compared with 80% return in the group without tears. Brockmeier et al. [61] noted no difference in the ability to return to sporting activities in their group of 47

#### *SLAP Lesions in Overhead Athletes DOI: http://dx.doi.org/10.5772/intechopen.108711*

patients, 23 of which had a partial rotator cuff tear treated with debridement. Coexistent partial thickness rotator cuff tears did not appear to have an effect on the outcome parameters but only 74% were able to return to their preinjury level but the majority of these patients were recreational non-overhead athletes. The presence of a rotator cuff tear, even if only a partial tear, can significantly limit the ability of an overhead athlete to return their preinjury level of competition when they have an associated SLAP tear and repair.

Because of the poor results of SLAP repairs in overhead athletes, arthroscopic biceps tenodesis has been proposed as an alternative treatment to SLAP repair in the overhead athlete [17, 63, 87, 88]. In 2018, Chalmers et al. [62] reported on 17 professional baseball players who had a biceps tenodesis for a SLAP tear. Only 35% were able to return to their prior level of play and with baseball pitchers, the results were worse with only 17% able to return to their prior level of pitching.

Some studies have also implicated age as a risk factor for failure of repairs and ultimately worse activity upon return to play [17, 51]. Denard et al. [105] reported that increasing age (>40) may be a factor associated with poorer outcomes after repair of type II SLAP lesions, but the results were not statistically significant. Many of the patients in their study were worker's compensation cases. However, the results of those greater than 40 years old who had a repair of a type II SLAP lesion were 81%, similar to other studies. Among the overhead athletes in their study, 88% (15/17) were able to return to normal activities, but it does not state if they were overhead athletes or what sports they played. Worker's compensation cases had worse results with only 64% of patients (9/14) reporting satisfactory results and return to normal activities.

These results are in similar to the results of Alpert et al. [106], who showed no difference in clinical outcomes after type II SLAP repairs in patients older and younger than 40 years (surgical techniques/suture anchors placed posterior to the biceps anchor) using a technique similar to ours. Provencher et al. [107] found that type II SLAP repair in patients older than 36 years of age was associated with a significantly higher rate of failure. In their study they had a 37% failure rate and 28% revision rate. The relative risk for failure for patients older than 36 years was 3.45. However, the technique used is different from our recommended technique in that they used a transtendinous technique through the rotator cuff for anchor placement. They also used a simple stitch configuration (not a mattress stitch), which may have influenced results.

Schroder et al. [108] reported on patients who had isolated superior labral type SLAP II lesions with long-term follow-up and found no difference was observed between older patients (>40 years) and younger patients (<40 years) in terms of overall satisfaction and functional outcome scores. We have not found this to be true in our patients, and we do not use age as a factor for repairing type II SLAP lesions but rather the quality of the labrum and the activity of the patient.

We have described the technique of the arthroscopic repair of type II SLAP lesions, which has given excellent results in our patients for over 20 years. The procedure can be technically demanding but with attention to all details of the procedure, it can be reproduced and provide excellent results in overhead athletes. The two important points of not violating the rotator cuff with cannula placement and placing an anchor with a mattress suture behind the biceps are key components of a successful surgical repair. However, before proceeding with surgery, it is important to remember that not all overhead athletes with a clinical diagnosis of a SLAP by physical exam, MRI or both, need to have surgery and nonoperative measures should always be exhausted before surgery is performed.

*Updates in Endoscopy*

## **Author details**

William B. Stetson1,2\*, Katie Lutz1 and Kristen Reikersdorfer1

1 Stetson Lee Orthopaedics and Sports Medicine, Burbank, California, USA

2 Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, USA

\*Address all correspondence to<EMAIL_ADDRESS>
© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### *Updates in Endoscopy*

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## **Chapter 5**

## Operative Hysteroscopy Complications

*Anabela Serranito*

## **Abstract**

Operative hysteroscopy is a minimally invasive gynaecological procedure and is considered the gold standard for the treatment of intracavitary uterine pathology. Over the last decades, with the development of new surgical instruments, the popularity of this technique has increased with gynaecologists across the world. However, this minimally invasive technique can be associated with rare but serious complications that can lead to severe morbidity and, if not treated adequately in some cases, ultimately lead to mortality. Any gynaecologist using this procedure should not only train in the operative technique but should also acquire knowledge on what type of complications may arise whilst performing an operative hysteroscopy. The following chapter explores the diagnosis of complications associated with the operative hysteroscopy and management options.

**Keywords:** operative hysteroscopy, complications, uterine perforation, false passage, bleeding, fluid overload, local anaesthetic systemic toxicity, gas embolism, postoperative hematometra, postablation tubal sterilization syndrome

## **1. Introduction**

The first reported hysteroscopy was performed in 1869 by Pantaleoni [1], making it one of the oldest reported endoscopic procedures. Hysteroscopy has greatly evolved since its primordial times and is now considered the gold standard procedure for the investigation of intrauterine pathology and subsequent treatment [2].

With the miniaturization of operative scopes and introduction of new surgical instruments, the outpatient operative hysteroscope is fast surpassing traditional in-patient hysteroscopy performed in an operating theatre [3]. This is due to the fact that office hysteroscopy offers several advantages, including shorter operating times, quicker postoperative recovery, not requiring hospital admission, no risks associated with general anaesthesia and its low cost when compared to inpatient hysteroscopy [4].

Complications during operative hysteroscopy are rare events. In a national multicentre survey in the Netherlands that analysed the complication rate in 13,600 hysteroscopic procedures (11,085 diagnostic and 2515 operative), it was reported that operative hysteroscopies had a significantly higher complications rate in relation to diagnostic procedures (i.e. 0,95% vs. 0.13%). Jansen et al. also found that more than half of the complications were entry related and that certain operative procedures carried a higher complication rate, which they associated with complexity of the

technique used. Intrauterine adhesiolysis, for example, presented the highest complication rate (4,5%), with patients undergoing this procedure having a 12-fold higher complication rate when compared to those having a polypectomy [5]. In another large multicentre study in Germany that included 21,676 operative hysteroscopies, the overall complication rate was 0.22% [5]. In this study, the most common complication was uterine perforations (0.12%), followed by fluid overload (0.06%), bleeding (0.03%), bladder or bowel injury related to uterine perforation (0.02%) and infection (0.01%) [6].

Hysteroscopy in any setting is a safe procedure and surgical complication rates seem to be the same for office hysteroscopy and inpatient hysteroscopy [4]. As this technique moves into an office setting with more operative procedures being performed as an outpatient procedure, it is important to improve the training presently offered. It is imperative that training not only focus on technical skills, but also offers guidance on early diagnosis of complications and prompt management as some of these potential life-threatening complications were traditionally identified by the anaesthesiologist in a theatre setting. It is also important to further research on complications in operative hysteroscopy as the majority of knowledge presently available derives from case studies reporting on adverse outcomes.

Most complications associated with operative hysteroscopy arise during the surgery and need to be carefully discussed with the patient when explaining the procedure and surgical risks involved. However, some complications may only emerge after the procedure and are sometimes forgotten when obtaining an informed consent. It is important that these late complications also be included in the initial discussion with the patient as they may have important implications on future health issues.

## **2. Intraoperative complications**

#### **2.1 Vasovagal**

Vasovagal reactions are a potential complication when performing hysteroscopies in an outpatient setting with incidence rates in published reports varying between 0,17% and 2,83% [7–9]. In a prospective observational study that included 2079 outpatient hysteroscopies, Agostini et al. reported that nulliparous and postmenopausal women had a higher risk of a vasovagal reaction, corresponding to 40% and 33,3% of cases, respectively. The risk is also higher when using larger diameter scopes required for operative hysteroscopy (2,83%).

These reactions are often associated with severe pain, which trigger a physiological response mediated by the parasympathetic nervous system, characterized by bradycardia and hypotension. Triggers during hysteroscopy usually include manipulation of the uterine cervix (e.g. dilatation and entry with hysteroscope) and uterine distention, but may also be triggered by severe anxiety associated with the procedure [10, 11]. If these are not managed in a timely manner, they can lead to vasovagal syncope, also known as *neurocardiogenic syncope.* Vasovagal syncope is usually preceded by prodromal symptoms that may include diaphoresis, nausea and pallor.

Management in a vasovagal reaction includes immediate removal of the stimulus, mainly by extraction of the scope, positioning the patient in reverse Trendelenburg and assessment of vitals, including blood pressure, pulse, respiratory rate and oxygen saturation. Most cases recover spontaneously within minutes. If bradycardia is persistent, an IV line should be sited and intravenous fluids started, oxygen given and local resuscitation team called [12]. If further deterioration occurs, consideration can be given to the administration of atropine.

#### **2.2 Cervical trauma**

Cervical lacerations occur when significant traction is used on handling surgical instruments applied to the cervix. In a study that included 797 operative hysteroscopes, Bigatti et al. report an incidence rate of 0,9% [13]. This type of trauma occurs mainly during the dilation of the cervix and is more frequent in women with cervical stenosis [14]. Risk factors for cervical stenosis include postmenopausal status, nulliparity, previous cervical trauma or cervical procedures. Incidence rates of cervical stenosis after cervical procedures vary between 10,2% after laser conisation and 4.3% after loop electrosurgical excision procedure [15].

Cevical tears may result in significant bleeding due to tissue trauma. Lateral cervical lacerations can extend up towards the uterus and include uterine arteries, producing substantial bleeding [14]. When applying a single-toothed tenaculum, these should be used with caution as they can easily tear the cervix [16]. Preference should be given to a double-toothed tenaculum or valsellum forceps that distribute the force applied to a broader area, providing a less traumatic grasp.

Pre-operative evaluation is important to recognise patients that are at a higher risk of cervical trauma, by identifying relevant antecedents that may increase the risk of cervical stenosis, as well as examination of cervix. In these patients, consideration should be given to the use of cervical ripening agents prior to the intervention. Studies have shown that misoprostol administered pre-operatively reduces the force required to dilate the cervix and intraoperative complications, such as cervical lacerations and false passages [17, 18]. Other options include the insertion of osmotic dilators 24 hours prior to procedure to aid in cervical softening and the use of smaller diameter scopes [19].

Management options include applying pressure with a swab on a stick to the affected area. If bleeding persists, Monsel's solution can be applied or diathermy used. In case of heavy bleeding or an extensive laceration, cervical suturing may be required.

#### **2.3 False passage**

The creation of a false passage is another complication associated with difficult entry into the uterine cavity and one of the factors associated with a failed hysteroscopy [20]. Women with cervical stenosis, abnormal uterine positions (i.e. acute anteflex- ion or retroversion), multiple caesarean sections, Asherman's syndrome or cervical fibroids are at a higher risk of false tracks [21].

False passages occur when the dilator or scope enters laterally into the muscle fibres of the cervix, instead of progressing into the uterine cavity through the internal cervical os. A high degree of suspicion should be held when the slight resistance of the dilator passing the internal cervical os is not present. On inserting the hysteroscope a criss-cross pattern of the cervical muscle fibres will be seen, instead of the normal anatomical landmarks that include a triangular cavity with bilateral tubal ostium. At this point, the operator should slowly remove the scope to correctly identify the true cervical canal for confirmation of the diagnosis.

Once the diagnosis is confirmed, the procedure should be suspended as false passages can be associated with excessive fluid absorption. Further uterine procedures

should be differed for 2–3 months to allow for healing [22]. Recent papers have reported procedures being completed after the diagnosis of false passages, but case numbers are still small and further large-scale studies are required to demonstrate the safety of continuing the procedure once a false passage has occurred [21, 23].

Like any complication, prevention is essential and in high-risk patients extreme caution should be taken if proceeding with cervical dilation, using steady pressure when introducing dilators. Ideally, entry should be done with vaginoscopy with direct visualization and slow introduction of the scope through the cervical canal. If resistance is found on entry through the internal os, maintaining the inflow and closing of the outflow will increase intracervical pressure allowing for hydrodilatation of internal cervical os and allowing for the progression of the scope into the uterine cavity.

In the case of cervical stenosis, medical options such as osmotic dilators and use of cervical ripening agents (i.e. misoprostol, oestrogen in post-menopause) may be considered [24, 25]. Initial dilation with a pipelle® or entry with 2 mm diagnostic hysteroscope may also be considered before advancing with larger operative hysteroscopes [20]. Other options to navigate the stenosed cervix include surgical management (i.e. use of scissors, forceps, bipolar electrode or hysteroscopic morcellators) and ultrasound-guided entry [26–29].

### **2.4 Uterine perforation**

Uterine perforation is the most frequent type of complication associated with hysteroscopy, with the reported rates varying between 0,12 and 3% [30]. A number of individual factors increase the risk of uterine perforation, including menopause, nulliparity, an extremely anteverted or retroverted uterus, history of a previous cervical procedure that can result in a stenosed cervical canal, intrauterine synechiae, use of gonadotropin-releasing hormone agonists and operator inexperience [5, 31].

Around 55% of uterine perforations occur during entry into the uterine cavity, whilst the remaining 45% are procedure-related [5, 32]. Patients with Asherman's syndrome have the highest risk for this type of complication, with an incidence rate as high as 10% [19]. Operator experience also seems to have an important role in the risk of uterine perforation, with around 33% of uterine perforations occurring during the surgeon's first procedure and a further 52% during the first five procedures [33]. Perforations are more frequent in patients undergoing repeat procedures, with one study demonstrating that patients undergoing a repeat endometrial ablation had an eightfold increased risk of uterine perforation [34].

Prevention begins even before the procedure with a comprehensive history that should include past medical and surgical history and completed with a thorough physical examination to help identify potential risk factors. It is important to question the patient on factors that may increase the risk of intra-abdominal adhesions, thus contributing to extreme positions of the uterus (e.g. history of endometriosis, pelvic inflammatory disease, history of peritonitis and previous abdominal surgeries including caesarean sections). Prior to beginning the procedure, it is important to examine the patient so as to determine the size and position of the uterus. One study demonstrated that 64,2% of surgeons routinely examined the patient before beginning the procedure, but 4,7% never examined the patient before the starting the procedure.

In case of uterine perforation, like any complication, early diagnosis and management can reduce severe morbidity, long-term sequalae and ultimately mortality. On blind entry into the cavity, perforation should be suspected when a sudden loss of tissue resistance is felt or the instrument depth in the pelvis seems further than

#### *Operative Hysteroscopy Complications DOI: http://dx.doi.org/10.5772/intechopen.108490*

expected. During the operative procedure, a sudden loss of intrauterine pressure or heavy bleeding should also raise concerns about possible uterine perforation. It can also be confirmed by direct visualization of intra-abdominal organs, such as a loop of the bowel or omentum, in the scope's visual field. The procedure should be suspended if there is suspicion of uterine perforation.

The anterior wall is the most frequent site for uterine perforation, followed by the cervical canal [14]. Anterior wall perforations can lead to bladder lesions, whilst lateral wall perforations are at risk of ureteral injury. Perforations occurring in the lateral walls are also more likely to cause vascular injury that can lead to broad ligament hematomas or significant intra-abdominal bleeding, with haemodynamic instability [16].

When uterine perforation occurs with a dilator, uterine sound or hysteroscope with a diameter below 5 mm and without significant bleeding, it can be managed expectantly [35]. In these cases, overnight admission for observation and a short course of antibiotics are usually the only required treatment. If there are any complaints of abdominal pain or shoulder tip pain, with haemodynamical instability, a prompt diagnostic laparoscopy is warranted. When damage occurs with larger instruments, electrosurgical or laser instruments, a systemic laparoscopic inspection of bladder, ureters, bowel and blood vessels is required to identify possible damage to these structures. In cases where organ lesion is suspected, it is crucial to obtain early support from general surgery, urology or vascular surgery depending on the type of injury. Delayed thermal injury to the bowel can manifest up to 2-week post-intervention. On discharge the patient should be informed that if any signs or symptoms of bowel perforation, such as fever, increasing pain, nausea, or vomiting, should arise they should present immediately to the emergency department.

#### **2.5 Bleeding**

Bleeding during hysteroscopy can result from entry-related complications, as previously described in this chapter, or can be procedure-related. The latter result from the transaction of vessels in the myometrium during the operative procedure. It is the second most common complication after entry-related complications, with rates varying between 0,16% and 0,61% in published reports [5, 36, 37]. Higher incidence rates are described for adhesiolysis (2.51%) and myomectomies that involve intramural components (3–4%) [38, 39].

It is often not problematic as the pressure required for uterine distention prevents loss from venous vessels. Spot electrocautery with rollerball or wire loop can be used to control bleeding from small vessels during the procedure [16]. Continuous-flow systems facilitate the removal of blood from the cavity allowing for prompt continuation of the procedure. On completing the operative procedure, intrauterine cavity pressure should be lowered slightly to identify any occult bleeding and allow for timely management.

Most operative hysteroscopies may be associated with a small amount of bleeding postoperatively, which usually stops promptly. Dilute vasopressin solution (0,05 U/mL) injected into the cervix has been shown to reduce significantly blood loss in patients with a high risk of bleeding during the procedure [40]. Vasopressin stimulates uterine contractions, thus reducing the blood loss during surgery, but it also has a direct vasoconstrictor effect and can result in serious cardiovascular complications, such as bradycardia, arrhythmias, pulmonary oedema and cardiac arrest [41, 42]. When using this medication, it is essential to ensure negative aspiration before injecting the vasopressin to avoid direct administration into a vessel resulting in systemic effects.

After completing the procedure if bleeding persists, a Foley catheter may be inserted and inflated to 20-30ml to tamponade the bleeding [43]. The balloon can be removed up to 24 h after insertion. In cases of persistent and heavy bleeding, uterine artery embolization should be considered and ultimately hysterectomy if all other interventions fail [16].

## **2.6 Fluid overload**

Fluid overload, due to excess absorption of distention medium, occurs in 0.2–6.0% of operative hysteroscopies and is a potentially serious complication [44]. In 2018, ISGE/BSGE joint guideline on fluid management for hysteroscopy, defined fluid overload as a fluid deficit of more than 1000 ml with hypotonic solutions and 2500 ml when using isotonic solutions [45]. Risk factors that increase fluid intravasation include high intrauterine distension pressure, low mean arterial pressure, prolonged surgery, extensive surgical resection and large uterine cavities [39]. Elderly women with cardiovascular, renal or other medical comorbidities are also at a higher risk. In high risk patients the ISGE/BSGE guideline recommends using lower upper limits for defining fluid overload, with 750 ml for hypotonic solutions and 1500 ml for isotonic solutions.

This type of complication can occur with all types of distending medium and the associated pathophysiology is dependent on the type of medium used during the procedure. Fluid distending medium used in operative hysteroscopy can be broadly divided into high viscosity (e.g., dextran 70) and low viscosity, which include hypotonic (e.g. glycine 1.5%, dextrose 5% and sorbitol 3%) and isotonic media (e.g. normal saline, Ringer's lactate and 5% mannitol). High viscosity dextran 70 has fallen out of use due to its safety profile (i.e. risk of anaphylactic reactions) and potential to damage operative instruments due to crystallization [31]. In recent years, with the development of bipolar electrosurgical equipment and mechanical instruments, professional organizations have started recommending the use of isotonic media over hypotonic media due to a better safety profile [45, 46].

When intrauterine pressure exceeds the mean arterial pressure, there is an increased risk of intravasation of the distention media into the vascular system [32]. Fluid overload with hypotonic solutions will lead to hyponatremia with a rapid drop in osmolarity. In the brain, where water easily travels across the blood-brain barrier, the decreased osmolarity will allow For fluid to enter the cells resulting in cerebral oedema if left untreated. This mechanism increases intracranial pressure that can result in hypoxia and lead to cerebral herniation, resulting in irreversible brain damage [47, 48]. Premenopausal women are 25 times more likely to die or have permanent brain damage when developing hyponatraemic encephalopathy [49]. Other risks associated with specific hypotonic medium are hyperammonaemia with glycine that result in muscle aches, visual disturbances and encephalopathy. In case of using sorbital potential complications are associated with hyperglycaemia and haemolysis [14]. The use of isotonic media reduces the risk of dilutional hyponatraemia, but fluid overload can lead to hypervolemia with the accumulation of fluid in the extracellular space, giving rise to pulmonary oedema and congestive cardiac failure.

Signs of fluid overload can include nausea, vomiting, headache, agitation, confusion, visual disturbances, blindness, dyspnoea and chest pain [50]. If not identified and left untreated, the patient may develop seizures, pulmonary oedema, bradycardia and ultimately cardiopulmonary collapse.

Prevention is crucial to avoid fluid overload and careful fluid monitoring throughout operative procedures is essential. In recent years, the introduction of closed

#### *Operative Hysteroscopy Complications DOI: http://dx.doi.org/10.5772/intechopen.108490*

systems and automated fluid measurement systems have brought improvement as they allow for more accurate measurement of the fluid output when compared to manual measurements. During the procedure, the surgeon should use the lowest pressure to achieve a clear view of the uterine cavity, usually between 50 and 80 mmHg. In one study that included 250 operative hysteroscopies, there was no significant fluid absorption when the intrauterine pressure was kept below 80mmHg [51].

Other important measures include obtaining baseline bloods with serum electrolytes prior to beginning surgery in high-risk patients or in those patients where a longer procedure is expected. Symptoms usually present when serum sodium concentration has fallen below 25 mmol L−1, at which point the procedure should be suspended [52]. The use of intracervical injection of dilute vasopressin prior to cervical dilation has been shown to decrease fluid absorption [46]. Consideration can also be given to the pre-operative administration of gonadotrophin-releasing hormone, especially in older women, to help reduce the intravasation of fluid [45].

In cases where the patient develops fluid overload, strict fluid balance monitoring should be started and serum electrolytes measured. Patients with an asymptomatic hypervolaemia with or without hyponatraemia are easily managed with fluid restriction with or without diuretics. In patients who develop symptoms, admission to a high dependency unit may be required and early management by a multidisciplinary team (i.e. anaesthetists and intensivists). Patients should be carefully monitored for any further development of cardiac, pulmonary or cerebral changes. Management includes correction of hyponatremia with 3% hypertonic sodium chloride [45].

#### **2.7 Neuropathies**

Postoperative neuropathy is a rare complication in operative hysteroscopy as most procedures have a short duration. Nevertheless, the hysteroscopic surgeon should be aware of these and how proper patient positioning plays a crucial role in preventing this type of lesion. The most common neuropathies are related to injuries to the femoral, common peroneal and sciatic nerves [53].

The femoral nerve can be injured due to extreme angulation and compression against the inguinal ligament, caused by excessive hip flexion or extreme abduction and external rotation of the thigh when positioning the patient [54]. This type of neuropathy will result in difficulty in hip flexion/adduction and knee extension. These patients will present with inability climbing stairs in severe cases with motor damage. Patients may also complain of paraesthesia over the anterior and medial aspects of the thigh or medial aspect of the calf and foot [55].

Injury to the common peroneal nerve can occur by compression, as this nerve is in close proximity with the fibular head. Correct positioning of the patient lower limbs in padded boot stirrups can help prevent this type of lesion by avoiding direct contact of the knee or lower leg with a hard surface that can lead to nerve compression [56]. Lesions to this nerve result in the inability to perform foot dorsiflexion, lateral rotation of the ankle and extension of the toes. These lesions result in paraesthesia in the calf and dorsum of the respective foot, accompanied by foot drop.

Sciatic nerve injury, similar to the femoral nerve lesion, can occur due to excessive stretching of the respective nerve when the patient is inappropriately positioned in lithotomy with excessive hip flexion with knee extension or hip abduction with excessive external rotation of the thighs at the hips [57]. This type of neuropathy can result in paraesthesia over the posterior part of the thigh, calf and sole of the foot and cause weakness in hip extension and knee flexion [58].

#### **2.8 Local anaesthetic systemic toxicity**

Complications associated with anaesthesia in an operating theatre go beyond the scope of this chapter, but as operative hysteroscopy becomes more frequent in an outpatient setting the gynaecologist should be aware of complications arising from the use of local anaesthetics. Local anaesthetic systemic toxicity (LAST) although rare is a life-threating adverse event. Important risk factors in the hysteroscopic patient include the type and dose of local anaesthetic administered, age > 60 years, and renal and cardiac disease [59, 60].

Clinical manifestations are highly variable, but are associated with neurological and cardiac toxicity. Neurological manifestations are the most common feature, occurring usually in 68–77% of cases, and usually precede the cardiac manifestations [61]. Initial symptoms may include metallic taste, tinnitus, perioral paraesthesia, agitation and dysarthria [60]. Central nervous system toxicity can progress to seizures and ultimately coma if not managed. Cardiac signs usually manifest initially as excitation (i.e. hypertension, tachycardia or ventricular arrhythmias), and posteriorly as depression (i.e. bradycardia, conduction block and asystole) [62].

Toxicity with local anaesthetic can occur with the unintentional intravascular injection or administration of toxic doses. An important preventative measure is to aspirate before injecting the local anaesthetic to confirm that it is not being directly administrated into a blood vessel. The use of premixed syringes with epinephrine also helps reduce systemic absorption. Gynaecologists should be aware of the maximum doses for the different types of local anaesthetic [63].

If any symptoms of LAST should develop prompt consideration should be given to initiating general resuscitation measures. Administration of the local anaesthetic should be immediately stopped stop and further assistance requested. Intravenous access should be sited, standard monitoring with cardiac monitoring started, the emergency trolley should be made available and local anaesthetic/resuscitation team contacted. In severe cases, treatment with 20% intravenous lipid emulsion may be required [61].

#### **2.9 Gas embolism**

Gas embolism during operative hysteroscope is a rare complication, but extremely fatal with a mortality rate of up to 46% [64]. The pathological mechanism associated with a gas embolism is complex and triggered by the entry of gas into the systemic venous system when a pressure gradient is created between the surgical site and the right atrium [65, 66]. In operative hysteroscopy, gas can derive directly from the room air or from gas products subsequent to electrosurgical vaporization. A lethal dose can range from 3 to 5 ml/kg. With room air lethal doses can be as low as 50 ml, due to the fact that it is rich in nitrogen that is less soluble than carbon dioxide or oxygen [53, 67].

During operative hysteroscopy, air can be inadvertently introduced into the uterus due to inappropriate purging of distention fluid systems pre-operatively, multiple entries into the womb during the surgical procedure which can inject air into the cavity or in cases where there is extensive vascular lesion during procedure or cervical trauma and air can directly enter the venous system when the cervix and vagina are left open. When positioning a patient in Trendelenburg, a pressure gradient is created, facilitating the entry of gas into the incised or open veins, as the patient's head is lower than the surgical site thus increasing venous return to heart and any air bubbles present.

During hysteroscopic procedures, the intrauterine pressure created by distention fluid can reach a pressure of up to 100 mm-hg, which surpasses the mean venous

#### *Operative Hysteroscopy Complications DOI: http://dx.doi.org/10.5772/intechopen.108490*

pressure. This creates a dangerous gradient that facilitates fluid absorption directly from the cavity, but also the entry of any air bubbles present in the cavity into the venous system. Dyrbye et al. demonstrated that during operative hysteroscopy gas embolism was not dependent on the type of electrosurgical equipment used, but the grade of the gas embolism was more severe when the intravasation of the distension fluid surpassed one litre [68].

When entering the venous system, the gas bubbles travel to the right ventricle and can progress further to the pulmonary circulation. In the right ventricle, larger volumes of gas can occlude the outflow tract and pulmonary artery, leading to cardiovascular collapse. Likewise, when smaller amounts of gas bubbles travel to the pulmonary circulation, it can lead to pulmonary vasoconstriction, increased pulmonary artery pressure, increased resistance to right ventricular outflow, and subsequently right ventricle failure [69]. There is also a reduced ventricular preload, with a subsequent decrease in left cardiac output that leads to systemic cardiovascular failure [70]. Gas emboli can also trigger an intense inflammatory response that results in bronchoconstriction and pulmonary capillary leakage leading to pulmonary oedema and alveolar collapse [68].

During an office hysteroscopy, the gynaecologist should consider an air embolism in the differential diagnosis when the patient complains of a sudden onset of chest pain or difficulty breathing, as this can be the presenting symptom in 20–52% [63]. On pulmonary auscultation, wheezing or rales can be detected, as signs of bronchospasm and pulmonary oedema. The classic sign in cases of air embolism is the 'mill wheel' murmur, due to intracardiac air emboli [71]. A decrease in oxygen saturation can be identified in 30–72% of patients. In patients under general anaesthetic, gas embolism presents with a fall in the end-tidal CO2, decrease in saturation of peripheral oxygen and cardiovascular symptoms [64].

In case of any suggestive symptoms or signs, the gynaecologist should have a high degree of suspicion as early identification and prompt management is crucial for patient survival. The procedure should be halted immediately to avoid further entry of air into the venous circulation. The surgeon ought to remove all instruments, and deflate the uterus and occlude the cervical os (e.g. uterine dilator and wet swabs) to avoid further entry of gas. It is also important to place the patient in reverse Trendelenburg to reduce the passage of further air emboli to the heart. The patient should additionally be placed in the left lateral position (Durant's Manoeuvre), in an attempt to move the gas emboli into the right atrium away from the right ventricular outflow tract [72]. At this point, it is crucial to initiate basic life support and that the emergency rapid response team be contacted promptly.

Prevention is a crucial step in avoiding this serious complication. During operative hysteroscopy in an office setting, patients should be monitored with pulse oximetry and if there are any signs of decreased oxygen saturation, accompanied by bradycardia or tachycardia, consideration should be given to suspending the procedure immediately. Before beginning the procedure, the surgeon should ensure that the irrigation system is fully purged of all air bubbles. When dilating the cervix, leaving the last dilator in the cervix until inserting the hysteroscope will avoid the entry of room air into the cavity. During the procedure, the surgeon should not place the patient in Trendelenburg position and limit instrument exchanges to a minimum (e.g. removal and reinsertion of the resectoscope during a procedure). Whilst performing the procedure distension pressures should be kept to the minimum required for adequate vision [63]. Pre-operative priming with GnRH agonists to reduce venous sinuses and the administration of cervical vasopressin preoperatively may help reduce the degree of intravasation during the procedure, thus reducing the risk of gas embolism [22, 73].

## **3. Post-operative complications**

#### **3.1 Infection**

Complications associated with infection after an operative hysteroscope are rare events and the incidence ranges from 0.3% to 1,6% [74]. These include urinary tract infections, endometritis, pyometra and pelvic inflammatory disease [31].

Women with a history of pelvic inflammatory disease seem to be at an increased risk of developing infectious complications. Other risk factors are associated with the duration and type of intervention. The risk is higher in patients undergoing longer procedures, in hysteroscopic interventions with extensive endometrial destruction that may leave necrotic tissue fragments in the uterine cavity and surgeries that require multiple reinsertions of the operative instruments through the cervix [16].

Studies have demonstrated that the use of prophylactic antibiotics provides no statistical difference in relation to the incidence of postoperative infections [75–77]. Antibiotic prophylaxis is required in women with cardiac conditions at risk for endocarditis and in those patients with insertion of laminaria for cervical dilatation [19]. Some authors also recommend the administration of antibiotics in women with a history of pelvic inflammatory disease [16, 19].

Management of post-hysteroscopic infections complications should include broadspectrum antibiotics and patients usually respond within 48 h of beginning treatment.

In patients with pyrexia, leukopenia and abnormal liver function tests not responding to antibiotics, although extremely rare, disseminated herpes should be considered. Price et al. describe a fatal case of fulminant hepatic failure in a healthy woman after a hysteroscopy due to herpes simplex virus [78], demonstrating the importance of differing hysteroscopic procedures if active genital herpes is identified.

#### **3.2 Postoperative hematometra**

Postoperative hematometra is a complication that occurs mainly after endometrial ablation/resection or intrauterine adhesiolysis for Asherman's syndrome [19]. Its incidence rate is estimated to be between 1 and 3% in patients undergoing endometrial ablation [79, 80]. Postoperative hematometra can develop centrally or in the cornual areas.

The patient is usually amenorrhoeic and presents with cyclic pelvic pain during the menstrual phase of the cycle. Symptoms can begin a few weeks after the procedure, with some patients presenting up to 16 months after the intervention. Hematometra occurring centrally result from the regeneration and sloughing of residual endometrium behind a cervical or lower uterine segment stenosis resulting from the previous hysteroscopic procedure [81]. In cornual hematometra, there is usually both a proximal and distal cornual obstruction that does not allow for decompression of the menstrual bleeding and patient will complain of homolateral pelvic pain [82].

Diagnosis is made by pelvic ultrasound, whilst the patient is symptomatic, but in cases of smaller cornual hematometra pelvic MRI may be required. In most cases, central hematometra treatment is simple requiring only cervical dilatation [83]. In recurrent cases, stent placement may be considered. Treatment of cornual hematometra involves a higher degree of complexity, with a high risk of uterine perforation due to difficulty in access, extensive adhesions and also due to the fact that the myometrium in these areas is thinner. Hysteroscopic treatment should be done under ultrasound guidance and the remaining endometrium should be resected/ablated to prevent recurrence. In case of recurrence of cornual hematometra, hysterectomy should be considered.

#### *Operative Hysteroscopy Complications DOI: http://dx.doi.org/10.5772/intechopen.108490*

In order to reduce the risk of postoperative hematometra some authors recommend that when performing endometrial resection or ablation the destruction of the endometrium be terminated at the lower uterine segment, avoiding trauma to the internal cervical os that can lead to cervical stenosis.

#### **3.3 Post-ablation tubal sterilization syndrome**

Post-ablation sterilization syndrome (PATSS) is another complication associated with focal-residual endometrial tissue in uterine cornea with retrograde menstruation into an occluded tube, resulting in a hemosalpinx. It was first described by Townsend et al. in 1993 and later confirmed by Webb et al. [84, 85]. The true incidence of this syndrome is unknown with the reported incidence rates ranging from 3 to 10%, but it is believed to be underestimated as it may go undiagnosed [86, 87].

Similarly, for cornual hematometra women, PATSS will present with lateral or bilateral pelvic pain coinciding with the menstrual period. On physical examination, when symptomatic, the patient may have significant adnexal tenderness, but with no significant adnexal mass. Symptoms may start as early as 2 months post-procedure, but in one study with a 10 year follow-up some patients were diagnosed with symptoms presenting as late as 20 months after the procedure [86].

A high degree of suspicion is required in symptomatic women with a history of tubal ligation, as ultrasound may be reported as normal in cases with minimal hemosalpinx. In these cases, a T2 image-weighted MRI will aid in identifying the hemosalpinx. When diagnostic exams are performed out of the menstrual cycle, findings may be reported as normal as blood in the fallopian tube may be absorbed [80]. As this is a rare and fairly unknown pathology, the radiologist should be made aware of the clinical impression when ordering diagnostic exams.

Treatment involves laparoscopic salpingectomy and hysteroscopic adhesiolysis to prevent further cornual hematometra recurring. Salpingectomy should be performed bilaterally as there are reports of contra-lateral recurrence [39]. In cases of recurring pelvic pain, consideration should be given to a hysterectomy.

When performing endometrial ablation with first-generation equipment, the destruction of endometrial tissue in the cornual area may be challenging, due to concerns of uterine perforation in these areas where the myometrial thickness is the thinnest. MRI studies performed on women who underwent endometrial ablation with rollerball demonstrated that 95% had persistent endometrial tissue, most frequently identified in fundal area close to the ostium [85]. Second generation equipment, with shorter operating times and less complications, have gained popularity over the last few years, but also seem to be associated with PATSS [88, 89].

#### **3.4 Intrauterine adhesions**