247Postoperative Care Protocols

RADICAL VULVAR SURGERY

•   Drains:

        Groin Jackson–Pratt (JP) drains should be discontinued when output is less than 30 mL per day.

        Foley catheter: depending on site of resection and reconstruction, the Foley can be left in for 7 days with prophylactic antibiotics, or removed postoperative day (POD) 1.

•   Antibiotics: oral prophylactic antibiotics can be given starting on POD 1 and until groin and vulvar wounds are well healed. Coverage for Streptococcus with antibiotics has been shown to decrease the incidence of lymphedema due to beta-hemolytic Streptococcus.

•   Wound care: this is mainly pericare with soap and water squirt bottle to the perineum TID and after each bowel movement. The area can be blown dry with a hairdryer on cool setting after each cleaning.

•   Deep vein thrombosis (DVT) prophylaxis: combination injectable anticoagulant and sequential compression devices (SCDs) should be employed until the patient is fully ambulatory. Ambulation should occur as soon as possible with control for pain, physical therapy consultation, and documentation of wound integrity.

•   Nutrition: low-residue diet as tolerated

•   Complications: lymphocysts—percutaneous drainage can be performed if symptomatic by palpation or with image guidance. If they are recurrent, they can be sclerosed with talc, tetracyclines, or alcohol.

•   Follow-up: 6 weeks

RADICAL HYSTERECTOMY

•   Drains:

        JP drains: discontinue when less than 30 mL/day output.

        Foley catheter: should be discontinued POD 3 to 4. A post-void residual should be checked immediately after the first self-void. The Foley should be replaced if the residual volume is greater than 100 mL, and the Foley then continued for 1 week. If at recheck, the post void residual is still elevated, the patient should be educated on self-catheterization. Bladder dysfunction can occur in up to 10% of patients due to denervation from cardinal and uterosacral ligament resection.

•   Antibiotics: consider daily oral antibiotics for suppression when a Foley catheter is in place.

•   Wound care: keep clean and dry. Staples: remove staples POD 3 for transverse or Maylard incisions. Remove staples POD 10 for midline incisions.

•   Deep vein thrombosis (DVT) prophylaxis: combination injectable anticoagulant and SCDs should be used until the patient is fully ambulatory. Four weeks of postoperative anticoagulation should be considered. Ambulation should occur as soon as pain is controlled and strength permits.

•   Nutrition: regular diet as tolerated

•   Complications: lymphocysts: can occur in up to 25% of patients but are symptomatic in about 5% of patients. If infected or symptomatic, broad-spectrum antibiotics should be employed. Percutaneous drainage can be attempted if spontaneous resolution does not occur or if vessel or organ obstruction/compression occurs. They can also be sclerosed with talc, alcohol, or tetracyclines.

•   Follow-up: 6 weeks

URINARY CONDUITS AND PELVIC EXENTERATION

•   Drains:

        If a nasogastric tube was inserted during surgery, it should be removed at the end of the operation.

        Malecot (for continent conduits): should be placed to dependent drainage for 7 to 10 days. Irrigation every 4 to 6 hours with 40 mL of normal saline should be performed to prevent the accumulation of mucus.

        Red rubber catheter in continent conduits: it should be left sewn in place until ready to self-catheterize at 7 to 10 days.

        JP drains: should be left in place for 7 to 10 days or until output is less than 30 mL/day.

        Gracilis flap JP leg drains: leave for 7 days or until output is less than 30 mL/day.

•   Antibiotics: if the patient has a conduit, consider discharge home with PO prophylaxis.

•   Wound and flap care: keep clean and dry. Pericare should be performed TID. The area can be blown dry with a hairdryer on cool setting after each cleaning. Staples should be left in place for 10 days, including those on the legs for gracilis flaps.

•   DVT prophylaxis: combination injectable anticoagulant and SCDs should be employed until the patient is fully ambulatory. Consider 4 weeks of postoperative injectable anticoagulation. Ambulation should occur as soon as pain is controlled, strength permits, and wound integrity is documented.

•   Nutrition: total parenteral nutrition (TPN) should be started postoperatively if the patient is suspected to be nothing by mouth (NPO) for greater than 7 days or if the patient was malnourished prior to surgery. Begin PO feedings with bowel sounds.

•   Complications: evaluation of the urinary tract by intravenous pyelography (IVP) or ultrasound should be part of a postoperative fever workup. Stomas should be checked daily; if they are dusky, endoscopy should be performed.

•   Other:

        Ureteral stents: should be sewn in with chromic suture, which will spontaneously dissolve and separate between days 10 and 14.

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