Complications of Gynaecological Surgery

Chapter 14 Complications of Gynaecological Surgery




Urinary tract injuries


Gynaecological surgery, in common with other surgical specialties, can be associated with complications. Most complications are minor, self limiting and have no long-term consequence for the patient, but they must still be avoided where possible, and actively managed where necessary, to make sure they do not become major complications.


Gynaecological surgery involves close dissection to viscera including the bladder, rectum, ureters as well as the great vessels of the pelvis. Complications can occur during difficult surgical dissections, especially when the anatomy is distorted (e.g. malignancy, endometriosis or infection).


Other complications, such as pulmonary embolus, myocardial infarction, pneumonia, or fluid or electrolyte imbalance are common to all surgery. For the purposes of this chapter, the most common complications related only to gynaecological surgery will be discussed.



Urinary tract injuries



Bladder Injuries


If a bladder injury is suspected intraoperatively, it can be localised by intravenous injection of indigo carmine, retrograde instillation of methylene blue through the urethral catheter or by opening the dome of the bladder and inspecting the mucosa. Subtle injuries can also be diagnosed using cystoscopy. Early involvement of an urologist is advised.


Primary closure of a cystotomy can be performed using a simple one or two-layered running closure with absorbable suture.


In general, it takes approximately 3–4 days for the bladder to re-epithelialise and about 3 weeks to regain its normal strength. A catheter can be left in situ for about 7 days with a cystogram performed just prior to its removal, to confirm healing.


In circumstances where a primary closure is difficult (e.g. vaginal surgery, unstable patient, history of pelvic irradiation) and there is a small injury (3 cm or less) in the bladder dome, a suprapubic catheter can be placed. A Foley catheter is placed through the cystotomy, with the bulb remaining in the bladder and the catheter exiting through a stab wound in the lower abdomen.


Women who have received prior lower pelvic radiation or have severe bladder injury require a stronger repair. A carefully dissected omentum, from the hepatic flexure to the splenic flexure, can be used over the two-layer closure to provide neovascularity.


After any repair to the bladder, it must be ensured that the ureteral orifices near the trigone are not compromised. This can be done by passing a stent, retrograde from the bladder toward the kidney or by dissection and visual identification of the distal ureter.




Management of ureteric injury


Ureteric injury should be managed in consultation with a urologist, or a gynaecologist with subspecialty training in urogynaecology.



The ligation of the ureter should be treated by an end-to-end anastomosis, reimplantation of the ureter into the bladder or by uretero-ureteric anastomosis into the opposite ureter.









Jun 4, 2016 | Posted by in GYNECOLOGY | Comments Off on Complications of Gynaecological Surgery

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