244Intraoperative Complications

VASCULAR INJURY

•   Venous lacerations should be repaired using 6-0 gauge Prolene sutures, in an interrupted or running fashion. Irrigation with heparinized saline can be used to visualize the repair. If the vein is large caliber, distal and proximal control should be obtained using pressure or Judd-Allis clamps. If there is a large hole, a lesser vein can be harvested and opened using Potts scissors to create a patch and sewn in place with interrupted sutures. Omentum can be placed on top to help vascularize. If sutures start to tear through the vein, pledgets (small pieces of cellulose) can be used to avoid suture tension.

•   Arterial damage should be approximated in a similar fashion. If the edges are ragged, consider complete resection and approximation. If there is a large hole, a vein graft can be used to patch the artery; 100 to 150 units/kg of IV heparin can be given before cross clamping the vessel. This dosing can continue every 50 minutes until circulation is re-established.

NERVE INJURY

The nerve should be repaired using 7-0 gauge Prolene sutures to align the fascicle bundles. Only the epineurium should be approximated. Nerve growth is estimated at 1 mm per day, or 1 inch per month.

GASTROINTESTINAL INJURY

•   Small bowel injuries:

        Serosal injuries can be observed if they are small, but should be primarily oversewn with 3-0 gauge silk or Vicryl sutures if large. If radiation therapy (XRT) has been administered, serosal injuries should always be oversewn.

        A seromuscular injury is evident if bulging of the bowel wall is seen. Repair should be double layered with 3-0 gauge silk or Vicryl.

        If there is luminal injury, a double-layered closure is indicated. Double-layered repair can be with 3-0 gauge Vicryl for the mucosal layer and either Vicryl or silk for the serosal layer.

•   Large bowel injury should be evaluated for a transmural defect. If no transmural defect is identified, a primary single-layered repair can be performed using 3-0 gauge silk or Vicryl. If there is a transmural defect and no evidence of fecal contamination, a primary double-layer closure can be attempted. If there is an extensive defect, consideration should be given to resection with reanastomosis. If no bowel preparation was given, consideration should be given to a diverting loop or end colostomy with mucous fistula.

245URINARY TRACT INJURY

•   Urinary tract injury occurs in 1% to 2.5% of gynecologic surgeries. Intraoperative cystoscopy with 1 ampule of IV indigo carmine or 0.25 to 1.0 mg of fluorescein should follow most hysterectomy procedures to detect and provide early repair of these injuries (1–3).

•   Bladder injury should be identified with direct visualization, IV fluorescein, or IV indigo carmine. The bladder should be closed in two layers using absorbable suture. This is usually with an inverting stitch of 2-0 gauge Vicryl or chromic for the first layer, and Vicryl for the second. If there is trigone injury, cystoscopy should be performed to ensure the ureters are intact. The bladder should be drained with a Foley catheter for 5 to 14 days.

•   Ureteral injury is recognized at the time of surgery in 20% to 30% of cases. Injury can be via transection, ligation, crush injury, angulation, or ischemia. Injury is commonly at the level of the uterine artery, at the infundibulopelvic ligament, or at the level of the pelvic brim. Ureteral stenting should occur for most ureteral injuries. This is done via cystoscopy, cystotomy, or ureterotomy. A Jackson–Pratt (JP) drain should be placed in all cases. If there is concern for further ureteral leakage, the JP fluid can be checked for a creatinine level and compared to a serum creatinine. Stenting is maintained for 6 to 12 weeks followed by intravenous pyelography (IVP) after stent removal.

        If there is a crush injury identified, the clamp should be released, and the ureter observed and mobilized. An ampule of IV indigo carmine should be given. If no extravasation is seen, consideration should be given to stenting the ureter.

        A partial transection can be treated with stenting and primary closure using 4-0 gauge to 6-0 gauge delayed absorbable suture (PDS).

        If there is complete transection, the ends should be dissected out, mobilized, and trimmed. The location of transection dictates repair.

             A distal transection (below the pelvic brim) can be managed with ureteroneocystostomy/reimplantation. There is debate as to the benefit of tunneling the ureter into the bladder. Reimplantation can also be via a Boari flap, a psoas hitch, the Demel technique, or use of intestinal interposition with an ileal segment.

             If there is middle pelvic transection, ureteroureterostomy or ureteroileoneocystostomy can be performed.

             If the transection is above the pelvic brim, a transureteroureterostomy or ileal intestinal interposition can be performed. Care should be taken with a transureteroureterostomy as this procedure can compromise the opposite kidney.

INTRAOPERATIVE HEMORRHAGE

When there is life-threatening, severe intraoperative hemorrhage, the use of a “massive transfusion protocol” (MTP) may be indicated. This transfusion protocol decreases the use of blood components, as well as turnaround times, costs, and mortality (2).

•   Initiate MTP.

        Issue 4 units packed red blood cells (PRBC) and 4 units fresh frozen plasma (FFP) in cooler.

        Once the first package is issued, prepare the second package as a “Stay Ahead” order and add a 6 pack (1 dose) of platelets.

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