Gynecology PostOperative Care and Complications

1
Gynecology Post-Operative Care and Complications

• Dana Redick - August 2006

2
(No Transcript)
3
Estimates of Complications

• Abdominal Hysterectomy
• 0.9 (including minor complications 3-15)
• Vaginal Hysterectomy
• 1.2
• Laparoscopic Hysterectomy (LAVH and TLH)
• 1.7
• Laparoscopic Procedures
• 0.1 to 1.7 (including minor complications 8)
• Pelvic support procedures
• 0.33 mortality rate
• 4.8 readmission

Mcpherson, K BJOG 2004 Chapron, C et al. Human
Reproduction 2002 Levy, BS, et al. JAAGL1994 Shen
CC, et al. JAAGL 2003 Hasson HM - Obstet Gynecol
- 2000 Sultana CJ et al. Am J Obstet Gynecol
1997 Telindes Gynecology, 2001
4
Types of Complications

• Organ Injury
• Vascular
• Bowel
• Bladder
• Ureteral
• Infectious Morbidities
• Sepsis
• Wound infection
• Pneumonia
• Urinary Tract infection
• Neuropathies
• Other
• Thromboembolic
• Adhesions
• Fistulas
• Lymphedema
• Incision Hernia

.but first a few quick reminders before entering
the Operating Room
5
In Office Procedures

• Same Informed Constent Process (written constent
  for IUD placement and LEEPs)
• Appropriate equipment, staff assistance, and good
  technique

6
Peri-operative Strategies

• Consent process
• Designated appointment for pre-operative
  discussion
• Written materials
• Family involvement
• Blood transfusion
• Medical evaluation
• Focused Cardiac and Respiratory History
• Smoking cessation
• Risk assessment for DVT prophylaxsis
• Discussion of Contraceptives and Hormone
  Replacement
• Bowel, skin and vaginal preparation
• Low residue diet, oral antibiotic and/or
  mechanical bowel preparation
• Perioperative Antibiotics
• Topical estrogen for atrophic tissues

7
BLEEDING

• Excessive bleeding in 1-3 of hysterectomies
  generally recognized intraoperatively
• Post Operative Recognition
• Vital sign changes
• Decreased urinary output
• Vaginal Bleeding
• Flank pain with retroperitoneal bleeding
• Decreasing Hematocrit
• Post Operative Management
• Physical examination
• Return to OR

8
Bowel Injuries and Illeus

• 4-5 Incidence of Illeus and 0.3 Incidence of
  Bowel injury and with hysterectomies
• Recognition and Management of Illeus
• Nausea, vomiting, and distended abdomen
• Adequate hydration and electrolyte management
• Bowel rest and consider use of Nasogastric tube
• Recognition and Management of Injury
• Visually with immediate repair
• Nausea, emesis, fever, peritionitis
• Difficult at times to discern injury vs illeus
• Delayed recognition requires return to OR

9
Bladder Injuries

• 0.1 to 0.5 incidence
• Recognition
• Visual inspection
• Retrofilling
• Cystoscopy
• Management
• Surgical Repair Immediately
• Post-operative drainage
• Fistula Repair

10
Ureteral Injuries

• 0.2-1.3 incidence
• Lowest with Vaginal approach
• Highest with Laparascopic approach
• Recognition and Management
• Visualize uterers (palpation inadequate)
• Stents not proven to be helpful
• Cystoscopy with Indigo Carmine
• Surgical Repair (Consult Urology)

11
Infectious Morbidities

• Combined 9 incidence of wound infection, pelvic
  cellulitis, vaginal cuff abscess, and pelvic
  abscesses among women who received prophylactic
  antibiotics with hysterectomy
• 1-5 rate of symptomatic urinary tract infection
• 30-50 of women undergoing hysterectomy develop a
  fever post operatively
• Recognition and Management
• Remember 5 Ws (Wind, Wound, Water, Walking,
  Wonder Drugs)
• History, Physical Exam, and Labs/Studies
• Treat with incentive spirometry, ambulation, and
  Antibiotics

12
Thromboembolic Complications

• Deep Venous Thrombous
• 7-45 incidence in general and malignant
  gynecologic surgeries
• Asymmetric Edema, Warmth, Tenderness
• Ultrasound (90 sensitive for proximal leg veins)
• Anticoagulation
• Pulmonary Embolus
• 0.1-5 incidence
• Tachycardia, Tachypnea, Decreased oxygen
  saturation
• Spiral CT, VQ scan
• Anticoagulation

13
Neuropathies and Nerve Entrapment

• 1.9 Incidence in one University of Florida
  Series
• Generally related to positioning and retractor
  placement
• Presents with motor weakness and sensory defects
• Treatment with physical therapy or sometimes
  exploration for painful nerve entrapment

14
Case 1

• 24 year old female who presents with nausea,
  anorexia, and abdominal pain. She is now POD 3
  from a laparoscopic left oopherectomy and lysis
  of adhesions for dermoid cyst
• Cyst ruptured during case
• Bowel resected from cyst and left pelvic side
  wall
• Discharge 2 hours after surgery without
  complications

What next?
15
Case 2

• 45 year female now POD1 who underwent a vaginal
  hysterectomy for menorhagia and has failed to
  void after removal of foley catheter.
• Any additional history questions
• Physical Exam
• Studies, Labs, and/or Other intervertions

What next?
16
Case 3

• 72 year old female now POD2 from a vaginal
  hysterectomy, anterior repair and uretheral sling
  placement. Nurse calls reporting patient trying
  to remove IV and seems confused.
• Additional History Questions
• Physical Exam
• Studies, Lab, and/or other inventions

What next?