Perioperative Care and Complications of Gynecologic Surgery

Khara M. Simpson

Stacey A. Scheib

PREOPERATIVE CARE

The main objectives of the preoperative assessment are:

• Completion of a thorough history and physical examination

• Selection of the ideal surgery

• Identification of potential limitations

• Optimization of the patient's medical condition

The goal is to decrease perioperative morbidity and complications and to optimize outcomes.

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Informed Consent

• Informed consent should include the rationale and explanation of the procedure as well as alternatives such as expectant management, nonsurgical interventions, and other surgical options. An interactive dialogue should occur between physician and patient. When more than one option is available, the surgeon should provide education and guidance without coercion. Ultimately, the patient must determine which of the options is appropriate.

• Risk discussion should address the specific procedure as well as general surgical risks and should be accompanied by a discussion of interventions intended to minimize those risks. These risks include, but are not limited to, bleeding and possible blood transfusion (Table 27-1), organ injury (bladder, ureter, bowel, vessel, or nerve), unanticipated organ removal, need for additional surgery, myocardial infarction, congestive heart failure, thromboembolic complications, infection, and perioperative death. Injury and failure rates should be cited based on personal data and current literature when available. Discussion of interventions such as perioperative antibiotics, deep vein thrombosis (DVT) prophylaxis, and postoperative incentive spirometry should be included. Possible changes in plans due to intraoperative surgical findings should be included in the consent document, as well as the possibility of a change in mode of access (e.g., laparoscopic to open procedure, vaginal to abdominal procedure).

Medical Evaluation and Optimization

Preoperative Evaluation

• Preoperative evaluation: History and physical examination are essential for evaluating surgical eligibility and the need for further testing or consultation. Identifying occult disease and optimizing preexisting conditions are of utmost importance. Abnormal findings and comorbid conditions need to be evaluated appropriately. Routine health maintenance evaluation and screening should be considered especially in the absence of regular medical care. It may be beneficial for patients with complex preexisting conditions to be comanaged with a medical specialist. Preoperative consultation with an anesthesiologist is important for the medically

complicated patient, those with known difficult airways, and those with a history of anesthesia complications.

• Preoperative testing and imaging: Preoperative testing should be based on risk factors for abnormal physiology, including comorbid conditions, tobacco use, exercise intolerance, and irregular examination findings. Mild and even asymptomatic conditions that may be exacerbated by medical and surgical interventions should be anticipated. Guidelines are available from the American Society of Anesthesiologists (ASA) and American Heart Association (AHA)ZAmerican College of Cardiology.

• Gynecologic patients are strongly advised to have current Pap smear and mammography results. Red blood cell type and screen should be performed on most patients, with exceptions made for very minor outpatient procedures. A pregnancy test will be required on all reproductive age women (of activity or greater without chest pain, dyspnea, or fatigue.

๎ A MET is a unit equal to the metabolic equivalent of oxygen uptake while quietly seated. Four METs is equal to walking on a flat surface or climbing a flight of stairs. If the patient can perform 4 MET s of activity without dyspnea or fatigue, she is considered to have a normal functional status and may proceed to intermediate-risk surgery without further cardiac testing. If her functional status is 2 mg/dL).

• For gynecologic surgeries that are considered high risk (prolonged surgeries that involve large fluid shifts), patients with a functional capability 1,500 mL of blood loss).

• Postoperative antibiotic prophylaxis has not been shown to be effective.

• Preoperative treatment of bacterial vaginosis (BV) is recommended. BV is a known risk factor for SSI, and treatment with metronidazole 4 days prior to surgery has been demonstrated to decrease the risk of cuff cellulitis.

• Antibiotic prophylaxis for subacute bacterial endocarditis: The AHA no longer recommends routine prophylaxis for bacterial endocarditis for routine genitourinary (GU) or gastrointestinal (GI) tract procedures.

TABLE 27-3 Antibiotic Prophylaxis for Gynecologic Procedures

³Regimen of choice in patients with a history of immediate hypersensitivity to penicillin.

⁴Ciprofloxicin or levofloxacin or moxifloxacin.

⁵Including diagnostic and operative procedures (e.g., sterilization).

⁶Including diagnostic and operative procedures (e.g., endometrial ablation, sterilization).

⁷Only in cases with dilated fallopian tubes.

Adapted from American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2009;113:1180-1189, with permission.

coagulopathic effects.

• These medication adjustments should be arranged in coordination with the patient's primary care physician. Postoperative instructions should address resumption of any discontinued medications.

• Perioperative beta-blockade should be continued for patients who are already on them to prevent cardiac events associated with surgery.

INTRAOPERATIVE COMPLICATIONS

Hemorrhage

• Incidence of pelvic hemorrhage in major gynecologic surgery is reported as 1% to 2% in abdominal hysterectomy and 0.7% to 2.5% for vaginal hysterectomy. Other procedures associated with higher rates of hemorrhage are Burch colposuspension, abdominal sacrocolpopexy, and lymph node dissection. Previous surgery, large malignant or benign masses, history of pelvic inflammatory disease, and endometriosis can cause anatomic distortion predisposing a patient to injury and pelvic hemorrhage.

• Control of pelvic bleeding starts with preventive measures, such as proper patient positioning, choosing an appropriate incision to ensure adequate exposure, meticulous surgical technique, and limited blunt dissection. Once hemorrhage is encountered, communication with anesthesia and operating room staff is essential.

• Hemorrhage management is centered on four basic actions: (a) assess vital signs, (b) obtain adequate intravenous access, (c) resuscitate with judicious use of fluid or blood components, and (d) achieve hemostasis.

๎ Direct pressure should be applied to sites of bleeding, allowing time for proper identification and control with electrocautery, ligation, or surgical clips.

๎ Hypogastric artery ligation may be used for uncontrolled venous bleeding, as it lowers pulse pressure.

๎ Topical hemostatic agents, such as fibrin glue, Gelfoam, and Surgicel, can be applied to small venous bleeding sites.

๎ Pelvic packing, using moist laparotomy pads, may be used temporarily for continued hemorrhage or left intra-abdominally with postoperative intensive care

P.347 unit monitoring. The patient is usually returned to the operating room in 48 to 72 hours to remove the packs, irrigate, and close the abdomen.

• See also Chapter 3.

• Postoperative bleeding may be detected through changes in vital signs consistent with hypovolemia, patient restlessness, disproportionate pain relative to surgery or analgesics, abdominal ecchymosis, and abdominal distention. A larger than anticipated reduction in postoperative hematocrit should raise suspicion. These findings should prompt further evaluation to determine whether active bleeding is present. Orthostatic blood pressures, serial blood counts, and imaging studies (i.e., ultrasound or CT) should be performed as indicated. A stable hematoma can often be managed conservatively. Active bleeding requires blood replacement, and reexploration is often necessary. With the availability of interventional radiology, pelvic artery embolization has clinical success rates of 90% for postsurgical and posttraumatic hemorrhage and avoids the additional morbidity of reoperation.

Ureteral Injury

• Ureteral injury rates have been reported from 0.4% to 2.5% during benign pelvic surgery, and only one third are recognized intraoperatively. Most commonly reported rates of injury are 0.1% to 1.7% during abdominal hysterectomy and 0% to 0.1% for vaginal hysterectomy. The highest rates are seen in laparoscopic surgery, with an odds ratio of 2.6 when compared to the abdominal route. During vaginal hysterectomy, the ureter can be traumatized at its entry point at the trigone. Laparoscopic procedures, especially ablation of endometriosis, carry an increased risk of ureteral injury near the uterosacral ligament.

• Prevention and detection: Steps taken to avoid ureteral injury during hysterectomy include development of the vesicouterine space, skeletonization of the uterine arteries, and cephalad traction on the uterus, all of which deflect the ureters laterally and downward. These measures are equally important in laparoscopic and abdominal surgery. The ureter can be visualized in the pararectal space on the medial leaf of the broad ligament. The pelvic ureter approaches within 1 cm of the infundibulopelvic ligament, lies approximately 1.5 cm lateral to the internal cervical os, and approaches within 0.9 cm of the upper third of the vagina. These distances are important during dissection, clamp placement, and in the consideration of thermal injury with the use of electrosurgery. Preoperative intravenous pyelograms (IVP) and ureteral stenting have a questionable role in decreasing ureter injury risk.

• Intraoperative cystoscopy with indigo carmine is an excellent test for assessing ureteral integrity and allows immediate corrective surgery to be undertaken if injury is detected. This technique is recommended for all urogynecologic surgery and major gynecologic surgery to identify and prevent sequelae of intraoperative urinary tract injury, as well as decrease liability from an undetected injury.

• Management: In cases of crush injury without transection, stenting the ureter for an extended period and placing a drain at the site of injury may be sufficient therapy. Complete transection above the pelvic brim or partial transection is repaired by suturing the defect end-to-end (uretero-ureterostomy). Reimplantation into the bladder (uretero-neocystostomy) is performed if the injury is within 6 cm of the ureterovesical junction. Mobilization of the bladder along the external iliac vessels with attachment to the psoas tendon (psoas hitch) can be used to bridge the gap and decrease tension at the anastomotic site when necessary. In cases of insufficient residual ureteral length, a Boari flap or ileal interposition can be performed. Transuretero-ureterostomy for injuries high in the pelvis is no longer recommended. Drains should be placed near the anastomosis to prevent urinoma

P.348 formation and detect leakage. Delayed diagnosis of a ureteral injury may require retrograde pyelography with cystoscopy and stent placement or percutaneous nephrostomy with antegrade stent placement. The recovery potential of the kidney depends on the duration of the obstruction, the degree of obstruction, the degree of backflow, the presence or absence of infection, and the extent to which each kidney was functional before the injury.

Bladder Injury

• The rate of bladder injury in benign gynecologic surgery is 0.5% to 1%. The rate during abdominal hysterectomy is 0.2% to 2.3%, which is increased compared to the vaginal hysterectomy rate of 0.3% to 1.5%. Major lacerations may require mobilization of the bladder for tension-free repair. Multiple cystotomies may be joined into one defect. A two-layer closure with 2-0 or 3-0 synthetic absorbable suture is recommended, and the seal assessed by placing sterile milk, indigo carmine, or methylene blue retrograde into the bladder. A Foley or suprapubic catheter is left in place for 7 to 14 days. A small cystotomy that occurs with a trocar during placement of a midurethral sling requires catheterized bladder decompression for only 24 to 48 hours.

• A missed bladder or ureteral injury usually results in postoperative urinary ascites or urinoma, abdominal or flank pain, and distention with fever, chills, oliguria, nausea, and vomiting. These patients may have elevated blood urea nitrogen and creatinine levels and may respond to aggressive hydration and bladder rest. Unrecognized surgical injuries are the most common cause of GU fistulas in the developed world.

Bowel Injury

• Inadvertent bowel injury occurs most often in gynecologic surgeries from an abdominal approach and is reported in 0.1% to 1% of abdominal hysterectomies and 0.1% to 0.8% of vaginal hysterectomies.

• A systematic evaluation of the bowel should be performed at the end of procedures where extensive lysis of adhesions is performed. Serosal injuries can be closed with permanent or delayed absorbable 3-0 suture. Gastrostomies, enterotomies, or colostomies may be closed in two layers using a continuous mucosal repair with 2-0 absorbable suture and an imbricating seromuscular interrupted 2-0 permanent suture.

• Suture lines should be perpendicular to the longitudinal axis of the lumen to avoid luminal constriction. In cases of multiple enterotomies, the bowel may be resected and anastomosed. A nasogastric tube can be used for decompression in stomach and small bowel injuries. Distal colonic injury does not warrant colostomy except in cases of previous radiation or infection.

Nerve Injury

• Malpositioning or retractor placement is the usual cause of nerve injury in gynecologic surgery. However, hematoma formation, a foreign body, or transection can also be complicating factors.

• Common peroneal nerve injury is most often caused by compression at the lateral epicondyle from the stirrups and may result in a transient, postoperative foot drop.

• Lateral femoral cutaneous nerve injury can result from placement of selfretaining retractors or hyperflexion of the hips in lithotomy position and results in anterior lateral thigh paresthesia and pain. One should be aware of the location, depth, and the exact pressure exerted by the lateral sidewall retractors on the iliopsoas muscle.

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• Femoral nerve injury can result in motor or sensory injury, or both, and may occur when the deep retractors rest on the psoas muscle or when the thighs are severely flexed on the abdomen in the lithotomy position. Passing below the relatively firm inguinal ligament, the femoral nerve is vulnerable to compression at that point. Postoperatively, the patient may experience weakness in the quadriceps muscle and difficulty walking.

• The sciatic nerve can be injured when the surgical assistant rests on the dorsal aspect of the thigh during vaginal surgery or when the hip is flexed and the knee is suddenly straightened. This tends to happen more commonly with free hanging (“candy cane”) stirrups. As with common peroneal nerve injury, this injury typically leads to foot drop.

• The obturator nerve may be injured during dissection or with leg positioning. Excessive external rotation at the hip may result in a stretch injury. Patients may complain of difficulty walking and will have weakness of the internal compartment muscles and demonstrate deficiency in adduction.

• The iliohypogastric and ilioinguinal nerves are at risk for injury or entrapment when a Pfannenstiel incision extends beyond the lateral margin of the inferior rectus abdominis muscle or during trocar placement and port site closure. Typically, patients report a sharp or burning pain radiating from the incision to the suprapubic area or paresthesias in this area.

• Most compression and stretch injuries resolve completely over several weeks to months. Physical therapy is required in cases with motor deficits. In cases of ilioinguinal or iliohypogastric injury, infiltration of local anesthesia in this area can help in diagnosis of this type of nerve injury and provide temporary relief of the symptoms. Neurectomy is usually indicated if a local nerve block is found to be effective. The key to treatment is prevention: proper patient positioning, periodic reassessment during long surgeries, proper retractor placement, and careful dissection.

Complications Specific to Laparoscopy

• One analysis of 70,000 cases in Finland reported complication rates (per 1,000) as follows: overall, 3.6; major complications, 1.4; intestinal injury, 0.6; ureteral injury, 0.3; bladder injury, 0.3; and vascular injuries, 0.1.

• Port placement: The majority of injuries during laparoscopy occur during access. A recent Cochrane review found that Veress entry technique had an increased risk of preperitoneal insufflation and false tracking. However, open entry may be prudent in patients with a history of multiple lower abdominal surgeries or inflammatory bowel disease. The left upper quadrant or “Palmer point” is an alternate site for insertion of the Veress needle for creation of a pneumoperitoneum and primary trocar insertion when significant periumbilical adhesions are suspected. The gastric contents must be aspirated with a nasogastric or oral gastric tube prior to using this method. The skin incision is made between the left midclavicular and anterior axillary lines approximately two fingerbreadths below the left costal margin to avoid the superior epigastric vessels. The Veress needle is inserted perpendicularly and shallowly into the peritoneal cavity to allow insufflation; then, a 5-mm trocar can be inserted. This approach offers two advantages: (a) short distance between layers of the anterior abdominal wall and (b) less chance of adhesions in the left upper quadrant in patients with a history of prior abdominal surgery. During primary port placement, the small bowel, iliac artery, and colon are the most commonly injured structures. With secondary ports, abdominal wall vessels, iliac arteries, and aorta are at most risk for injury. A systematic review of the field should be performed in every case

P.350 after gaining primary access prior to Trendelenburg positioning. All secondary ports should be inserted under direct visualization.

• Extraperitoneal insufflation of CO₂: Misplacement of a Veress needle in the preperitoneal space causes this complication and can impair visualization due to peritoneal tenting. In most cases, CO₂ can be allowed to escape and needle placement attempted again. If this is not successful, open laparoscopy is performed. Mediastinal emphysema is an uncommon complication that requires observation for respiratory compromise and, in severe cases, may require ventilation.

• Vessel injury: The Veress needle or trocar may traumatize omental, mesenteric, major abdominal, or pelvic vessels. Trendelenburg position should never be obtained prior to trocar placement; the table should be flat. The sacral promontory should be palpated as a landmark of the aortic bifurcation. In thin patients, the Veress needle is directed at 45 degrees and in obese patients, at 90 degrees. The most accurate confirmation of peritoneal access is an opening pressure of < 10 mm of Hg.

• The superficial epigastric vessels may be identified by transillumination, especially in thinner patients; however, the deeper inferior epigastric vessels should be identified intra-abdominally prior to accessory trocar placement. The inferior epigastric vessels begin their cephalad course between the medial umbilical ligament and the entry point of the round ligament into the inguinal canal. The secondary trocars are inserted perpendicularly, lateral to the edge of the rectus muscles. Maintaining the perpendicular insertion until the peritoneal cavity is entered is essential to prevent damage to the inferior epigastric vessels.

• Management of inferior epigastric vessel injury includes balloon tamponade with a Foley or suture ligature using a Carter-Thomason or Endo Close device. Consider enlarging the incision at the trocar site or proceeding to laparotomy to improve visualization. Damage to major retroperitoneal vessels generally requires emergent laparotomy and consultation with a vascular surgeon.

• Bowel injury: Intestinal injuries have been reported at a rate of away; therefore, extreme caution should be used when using electrosurgery on strands of tissues attached to bowel. Symptoms of bowel injury can range from increased pain at the trocar site to abdominal distention and diarrhea to sepsis. CT scan is the best imaging study to confirm the diagnosis. Access injuries or traumatic injuries often present early, in the first hours or days postoperatively. Thermal injury may present late (3 to 7 days after surgery) due to delayed necrosis at the site of injury and subsequent bowel perforation. Unrecognized bowel injury is one of the most common causes of postoperative death from laparoscopy.

• Bladder injury: Prevention is best achieved by decompression of the bladder with a Foley, avoiding low suprapubic ports and with direct visualization during trocar

P.351 placement. Bladder injury is not restricted to port placement and also occurs during dissection of the vesicouterine space. Low anterior fibroids and history of prior cesarean section increase that risk. Injury may be detected by the presence of air or blood in the drainage bag of an indwelling Foley catheter. The size of the injury dictates treatment. Needle perforations can be managed expectantly. Lacerations 10 mm in diameter. Richter hernias, which typically have a delayed diagnosis, contain a portion of the intestinal wall in a peritoneal defect. General recommendations for fascial closure are to close all defects >10 mm and defects >5 mm that are lateral to the rectus sheath after significant tissue extraction or peritoneal stretch. Both fascia and peritoneum should be closed.

Complications Specific to Hysteroscopy

• Fluid overload: Fluids can be delivered into the uterine cavity with sufficiently high pressure to allow intravasation of the distention media into the vascular system. Serious complications can occur if intravasation is excessive. The risks and allowable fluid deficits vary according to type of distention media used. Absorption is increased as a function of increasing flow pressure, uterine size, and operative time. Automated fluid-monitoring systems have made the exact measurements of input and output of the distending medium much easier. The surgeon should be aware of the deficit at all times and should be updated frequently by operating room staff (Table 27-4).

• Electrolyte-containing media (normal saline and lactated Ringer) are relatively safe, but fluid overload is still possible. These media can be used with bipolar instruments. Alternative fluid media carry increased risk of overload.

• Three percent sorbitol and 1.5% glycine are low-viscosity, hypotonic, electrolytefree solutions. When absorbed into the bloodstream, they cause hyponatremia, arrhythmias, cerebral edema, coma, and death.

• Mannitol 5% is an iso-osmolar media that can also cause hyponatremia.

• Hyskon, a high-viscosity 32% solution of dextran 70, provides a clear field because it does not mix with blood. In the bloodstream, it acts as a volume expander, potentially leading to acute noncardiogenic pulmonary edema. Dextran molecules can trigger disseminated intravascular coagulation and anaphylaxis. In an acute setting, dextran molecules must be removed from the circulation with plasmapheresis.

• Uterine perforation may be managed conservatively, particularly with a blunt instrument, with close monitoring, or overnight hospitalization. In cases of active bleeding or perforation with electrosurgical instruments, conversion to laparoscopy or laparotomy is required.

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TABLE 27-4 Guidelines for Fluid Management during Hysteroscopy

Fluid input and output should be monitored preoperatively and intraoperatively by an individual assigned to this task. Results should be reported to the surgical team at regular intervals.

Low-viscosity, electrolyte-poor fluids: A fluid deficit of 750 mL implies excessive intravasation of fluid. Surgeon should consider termination of procedure in patients with high cardiovascular risk or comorbid conditions.

Nonelectrolyte solutions: A fluid deficit of 1,000-1,500 mL implies excessive intravasation of fluid but depends on patient weight and other factors. The infusion should be stopped, procedure concluded, and electrolyte and fluid status assessed. Diuretics and other interventions should be initiated as needed.

Electrolyte solutions: A fluid deficit of 2,000 mL implies excessive intravasation of fluid. Management is same as previous.

Discontinuing the infusion at lower thresholds should be considered in outpatient settings, with limited acute care and laboratory services.

Automated fluid monitoring systems facilitate early recognition of fluid imbalance.

Adapted from Loffer FD, Bradley LD, Brill AI, et al. Hysteroscopic fluid monitoring guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic

Laparoscopists. J Am Assoc Gynecol Laparosc 2000;7:167-168, with permission; American College of Obstetricians and Gynecologists. ACOG technology assessment in obstetrics and gynecology, number 4, August 2005: hysteroscopy. Obstet Gynecol 2005;106(2):439-442, with permission.

POSTOPERATIVE COMPLICATIONS

Postoperative Fever

• A commonly accepted diagnosis of fever requires a temperature at or above 38ฐC (100.4ฐF) on two occasions at least 4 hours apart. Febrile morbidity within the first 48 hours of surgery has been estimated to occur in up to 50% of gynecologic surgery patients. Atelectasis, an often cited reason for low-grade febrile illnesses, has not been shown to be causal for fever during this period in the literature. Noninfectious etiologies, such as medications, malignant hyperthermia, thrombotic or embolic events, ureteral injuries, cardiovascular events, endocrine abnormalities, and transfusion reactions, should be included in the differential diagnosis and workup for postoperative fever.

• Evaluation: Evaluation should include a review of the patient's history and a thorough examination, with specific attention to sites as follows: pulmonary examination; palpation of the suprapubic region and costovertebral angles; evaluation of incisions, catheter and line sites, and extremities; and pelvic examination to evaluate the vaginal cuff for cellulitis, hematoma, or abscess.

• Testing: Initial laboratory and radiologic assessment should be tailored to the individual patient. Complete blood count with differential, urinalysis, and urine culture should be performed. Urinalysis will be of limited value in patients with bladder catheters. Blood cultures seldom yield positive results except in patients with high fever or risk factors for endocarditis and are most sensitive when drawn at the time of the fever. Imaging studies may include chest and abdominal radiographs, IVP,

P.353 ultrasonography of the pelvis and kidneys, contrast bowel studies, and CT scan. Chest CT or ventilationญperfusion (V/Q) scan should also be considered to rule out pulmonary embolism (PE).

Postoperative Infection

• Urinary tract infection: The bladder is a common site of infection in surgical patients, largely due to contamination with indwelling Foley catheters. Pyelonephritis is a rare complication. The treatment is hydration and antibiotic therapy tailored to the pathogen.

• Respiratory infection: Preventive measures are early ambulation and intensive respiratory therapy (i.e., incentive spirometry, chest physical therapy) for reversal of hypoventilation and atelectasis. Patient education prior to surgery has an important role in compliance with postoperative incentive spirometry. Patients at risk of postoperative pneumonia include those with an ASA status of 3 or higher, preoperative hospital stay of 2 days or longer, surgery lasting 3 hours or longer, surgery in the upper abdomen or thorax, nasogastric suction, postoperative intubation, or a history of smoking or obstructive lung disease. Smoking cessation should be encouraged preoperatively, not only for respiratory complications but also for wound healing.

Wound Infection

• Prevention: Risk factors for SSI include age, nutritional status, diabetes, smoking, obesity, coexistent infections at a remote body site, colonization with microorganisms, altered immune response, and length

of preoperative stay.

• Surgical closure: Studies in cesarean section patients have shown closure of the subcutaneous fat compared with nonclosure reduces wound complications (defined as hematoma, seroma, wound infection, wound separation). In women with fat thickness >2 cm, suture closure of subcutaneous fat decreases the risk of wound disruption. Further trials are justified to investigate suturing materials and techniques. Whether these findings can be extrapolated to gynecologic surgery is unclear. Recent metaญanalyses have failed to show that the routine use of closed suction drains prevents surgical infections.

• Wound care: Wound care has recently shifted away from an aggressive cleaning approach to one that emphasizes a clean but moist environment and minimizes the mechanical irritation caused by frequent dressing changes. Hydrogel applications play an important role, and vacuum systems can aid in wound drainage and facilitation of blood flow to the wound, resulting in a seemingly more rapid closure.

Incisional or Vaginal Cuff Cellulitis

• Fever, leukocytosis, and pain localizing to the pelvis may accompany a severe cellulitis in which adjacent pelvic tissues are involved. Broad-spectrum antibiotic therapy should be initiated. If an abscess is suspected at the cuff or incision, drainage is indicated in the operating room or under ultrasound guidance. Intra-abdominal abscesses are characterized by persistent fever and leukocytosis. Radiologic confirmation with ultrasonography or CT scan is usually needed for diagnosis.

• T reatment involves parenteral antibiotics, with possible drainage in cases of large collections or failure to improve on antibiotics alone. Sonographic or CT scan-guided drain placement has obviated the need for surgical exploration in many circumstances. Reexploration in cases of active infection or abscess is approached with reservation due to associated high morbidity.

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Necrotizing Fasciitis

• Group A Streptococcus can cause a progressive, inflammatory infection of the deep fascia, with necrosis of the subcutaneous tissues. Surgeons must be acutely aware of this potentially life-threatening complication in any patient with a wound infection. Clinically, the infection results in extensive soft tissue destruction, including necrosis of skin, subcutaneous tissue, and muscle. Erythema and induration around the wound should be marked and followed closely. Extensive and aggressive surgical debridement and broad-spectrum antibiotic therapy are warranted at first suspicion. Treatment delay and obesity increase an already high mortality rate.

Venous Thromboembolism

• DVT: DVT can cause unilateral lower extremity swelling, pain, and erythema. A palpable cord may be detected. Duplex Doppler ultrasonographic imaging has replaced venography as the gold standard for diagnosing DVT.

• PE: The signs and symptoms of PE include anxiety, shortness of breath, tachypnea, chest pain, hypoxia, tachycardia, and mental status changes. Symptoms should prompt a thorough evaluation; chest radiograph, ECG, and arterial blood gas assessment are the first-line tests. The chest radiograph helps distinguish between pneumonia and embolism. ECG findings are usually nonspecific except for tachycardia, but they help rule out an ischemic cardiac event. Laboratory evaluation with arterial blood gas test may show hypoxemia, hypocapnia, respiratory alkalosis, and an increased arterial-alveolar gradient.

Imaging

• Radionucleotide imaging (V/Q scan) and contrast-enhanced CT arteriography are the current studies

available for the evaluation of a suspected PE. V/Q scans have a high sensitivity but a low specificity. Contrast-enhanced CT arteriography is rapid, easily accessible in most large hospitals, and less prone to interference from other underlying pulmonary disease. Its sensitivity is greatest for detecting emboli in the main, lobar, or segmental pulmonary arteries. In most institutions, the CT arteriography has replaced the V/Q scan as the first-line diagnostic imaging study.

Therapy

• Intravenous unfractionated heparin (UFH) has been the traditional treatment for DVT and PE. Recent studies have established that LMWH and the pentasaccharide fondaparinux are equivalent to UFH. The half-life of LMWH is longer, the dose response is more predictable, and less bleeding may occur while producing an equivalent antithrombotic effect. When using UFH, oral therapy with Coumadin is started as early as possible, and the patient can discontinue UFH when a therapeutic international normalized ratio value is reached. Placement of a vena caval filter may be necessary in patients with acute thromboembolism and active bleeding or a high potential for bleeding, patients who are on medical therapy with a history of multiple venous thrombi, and patients with a history of heparin-induced thrombocytopenia. Bleeding that occurs after the use of heparin-related compounds can be reversed with protamine sulfate; Coumadin-related bleeding can be reversed with vitamin K or with plasma or factor IX concentrates. The most effective treatment is prevention. See also Chapter 20.

Ileus and Bowel Obstruction

• Diagnosis: Infection, peritonitis, electrolyte disturbances, extensive manipulation of the GI tract, and prolonged procedures may cause postoperative ileus. Postoperative adhesions occur in about 25% but can be up to 90% of patients who undergo

P.355 major gynecologic surgery and represent one of the most common causes of intestinal obstruction. The prevalence of ileus or small bowel obstruction following hysterectomy is 0.2% to 2.2%. Nausea, vomiting, and distention may be present with both. Absent and hypoactive bowel sounds are more likely to occur with ileus, whereas borborygmi, rushes, and high-pitched tinkles are more characteristic of postoperative obstruction. Abdominal radiographs show distended loops of large and small bowel, with gas present in the rectum in the setting of ileus. Single or multiple loops of distended bowel with air-fluid levels are seen in postoperative obstruction. These findings may be difficult to distinguish in the early postoperative period. In prolonged cases, it may be helpful to obtain a study with oral contrast to identify a transition point.

• Treatment: Ileus is treated with bowel rest, intravenous fluids, electrolyte repletion, and nasogastric suction in cases of persistent vomiting. Most cases of partial obstruction will respond to conservative management with bowel rest and nasogastric decompression. Increasing abdominal pain, progressive distention, fever, leukocytosis, or acidosis should increase the suspicion for complete bowel obstruction, which may require reexploration. In cases with delayed improvement, a CT scan may help identify bowel perforation or abscess. Parenteral nutrition should also be considered in patients with prolonged GI compromise.

Diarrhea

• Diarrhea is not uncommon after abdominal and pelvic surgery. Prolonged or multiple episodes, however, may represent a pathologic process, such as impending small bowel obstruction, colonic obstruction, or pseudomembranous colitis. Clostridium difficile-associated colitis may result from exposure to any antibiotics; stool testing can confirm clinical suspicions. Extended oral metronidazole therapy and hydration are needed for adequate treatment, and oral vancomycin may be necessary in refractory

cases.

Genitourinary Fistulae

• In the United States, most GU fistulae are the result of pelvic surgery, usually after an abdominal hysterectomy for benign conditions. In the developing world, most fistulas are due to obstetric trauma secondary to absent or poor obstetric care. Patients may present with persistent vaginal discharge or recurrent urinary tract infections.

• The simplest initial test for a GU fistula is the tampon test. A tampon is inserted into the vagina. The bladder is then filled with methylene blue or indigo carmine through a Foley catheter. The patient is given an oral dose of Pyridium. The appearance of blue dye on the tampon suggests a vesicovaginal fistula. An orange tampon is suggestive of a ureteral-vaginal fistula. Fluid pooling in the vagina can also be sent for a creatinine level. Further workup may include IVP, cystoscopy, voiding cystourethrogram, retrograde ureteral studies, and MRI. Simple fistulas often resolve with drainage by either Foley catheter or percutaneous nephrostomy tube placement to allow healing and decreased inflammation. Surgical repair is necessary if this is unsuccessful.

SUGGESTED READINGS

American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2009;113:1180-1189.

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Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th ed.). Chest 2008;133(6)(suppl 1):299S-339S.

Jones HW, Rock WA. Control of pelvic hemorrhage. In Rock JA, Jones HW, eds. Te Linde’s Operative Gynecology, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.

Tapson VF. Acute pulmonary embolism. N Engl J Med 2008;358(10):1037-1052.

Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association. Circulation 2007;116(15):1736-1754.

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