Postoperative Complications and Postoperative Emergencies
Brent E. Seibel
Emergencies following gynecologic surgery may present as immediate, early, and late occurring events that require proper diagnosis and management by the gynecologic surgeon and/or emergency physician. In this chapter, postoperative complications are discussed as they pertain to the gynecologic or obstetric patient after abdominal, vaginal, and minimally invasive procedures. This chapter is divided into potential problems encountered after surgery, including wound complications, urinary tract injuries, gastrointestinal complications, infectious complications, and other postoperative emergencies that are more specific to gynecologic procedures and therefore possibly less familiar to the emergency physician. Complications such as pneumonia, pyelonephritis, deep vein thrombosis, pulmonary embolus, and other conditions that may be encountered postoperatively, but are not unique to this setting, are not emphasized.
WOUND COMPLICATIONS
The most common wound complications associated with gynecologic surgery include hematoma, seroma, infection, fascial dehiscence, and hernia. Risk factors include obesity, diabetes, immunosuppression, cardiovascular disease, smoking, cancer, malnutrition, previous surgery or radiation, and infection. Surgical factors include contamination, devitalization of tissues, the presence of foreign bodies, prolonged operating time, extensive wound dissection, and the presence of dead space in the surgical wound. Strategies for the prevention of wound complications obviously address these issues when possible and include prophylactic antibiotics when appropriate, proper surgical preparation and sterile technique, avoiding excessive dissection or devitalization of tissues, and closure of subcutaneous spaces when appropriate. A 2004 metaanalysis by Chelmow et al. (1) reviewed six studies addressing subcutaneous fat closure during c-section and found a 34% decrease in the risk of wound disruption when the subcutaneous fat thickness is >2 cm. In a randomized trial of abdominal hysterectomy patients, subcutaneous closure, when this layer was >2.5 cm, was associated with a significantly lower incidence of wound disruption (2). The type of incision is dictated by the requirements of the specific surgery, prior surgical scars, and body habitus of the patient. Incisions utilized in obstetrics and gynecologic procedures include longitudinal or median, transverse, infraumbilical, and those associated with laparoscopy. Although infection, hematoma, seroma, dehiscence, and hernia can be seen with any type of incision, wound dehiscence and hernia occur at a higher rate following vertical midline incisions (3).
Hematoma and Seroma
Over 1.2 million cesarean section deliveries and nearly 600,000 hysterectomies, two of the most common obstetric and gynecologic procedures, were performed in the United States during 2005 (4). The estimated incidence of wound infections ranges from 3% to 15% for cesareans and 3% to 8% for abdominal hysterectomies. An additional 3% to 14% of cesareans are complicated by wound seroma and
hematoma (5). Practicing physicians must the refore be familiar with the recognition and management of these conditions. Hematomas are collections of blood that accumulate in the subcutaneous tissues due to failure of primary hemostasis or a bleeding diathesis. Similarly, collections of serum are responsible for seromas. They both usually occur in the immediate or early postoperative period but may not present until much later with swelling, pain, drainage, and even incisional separation. Seromas may not pose a serious threat to patients but the sudden release of copious amounts of serosanguinous drainage can create significant anxiety often prompting them to seek care in the emergency department. In these circumstances, the truly emergent condition of fascial dehiscence must be ruled out. Seromas and hematomas also are associated with increased risk of wound infection.
hematoma (5). Practicing physicians must the refore be familiar with the recognition and management of these conditions. Hematomas are collections of blood that accumulate in the subcutaneous tissues due to failure of primary hemostasis or a bleeding diathesis. Similarly, collections of serum are responsible for seromas. They both usually occur in the immediate or early postoperative period but may not present until much later with swelling, pain, drainage, and even incisional separation. Seromas may not pose a serious threat to patients but the sudden release of copious amounts of serosanguinous drainage can create significant anxiety often prompting them to seek care in the emergency department. In these circumstances, the truly emergent condition of fascial dehiscence must be ruled out. Seromas and hematomas also are associated with increased risk of wound infection.
Hematoma and seroma can usually be identified by inspection, palpation, and partially opening or probing the wound. Ultrasonography can be used to differentiate subcutaneous fluid collections from subfascial or bladder-flap hematomas. Small and asymptomatic seromas and hematomas may simply be observed. If staples are present over the fluctuant or draining area, they should be removed. The remaining staples should be left in place until the nature and extent of the defect are known. Incisions secured with subcuticular sutures may need to be opened to adequately drain and assess the wound. Cultures should be obtained if an infection is suspected. After opening part or all of the wound, copious irrigation may be required to debride tissues or express clotted blood. Digital palpation or sterile swab is then used to check the fascial layer as the integrity of the fascia must be established.
Treatment options include secondary closure of the uninfected wound, either immediate or delayed, versus wound care and healing by secondary intention. Secondary closure in this setting has been found to be successful in over 80% of patients and significantly reduces healing time over secondary intention without risks of serious complications (5,6,7).
Total hysterectomy by any route and vaginal repair procedures can result in postoperative hematomas above the vaginal cuff or at the site of vaginal closure. These patients may present with vaginal bleeding or complaints of pain and pressure as well as anemia. Fever and leukocytosis may be observed in the presence of infection. If a mass is not observed or palpated on examination, pelvic ultrasound or computed tomography (CT) scan may help identify a pelvic hematoma. If no systemic infection is evident, the hematoma may be allowed to gradually resolve over time. Opening the vaginal repair or vaginal cuff and evacuating the clot in the emergency department or operating room may be necessary. CT-directed drainage of a pelvic hematoma can sometimes be achieved.
Laparoscopic procedures can result in significant hematomas of the abdominal wall even though trocar incisions appear small. In a review of the Finnish National Registry, 1,165 laparoscopic hysterectomies were associated with a vascular injury rate of 1.2% (8). Large vessel injuries are typically recognized intraoperatively, whereas superficial vessels and inferior epigastric injuries may not present themselves until after the patient has been discharged home from outpatient surgery. Patients may present with pain, induration, echymosis, and occasionally bleeding from the trocar site. Hemotomas can be large with discoloration of the anterior abdomen and can radiate around to the flank or back. CT or ultrasound can be used to determine the extent of the hematoma. Such hematomas may result in anemia which may require transfusion. These hematomas are usually self-limited and eventually resolve with observation but surgery may be required if bleeding persists or infection develops. Embolization of the inferior epigastric artery was recently described when other interventions failed to control hemorrhage of a lateral accessory trocar site (9).
Surgical Site Infections
Surgical site infections are classified by the CDC as superficial incisional (involving only the skin or subcutaneous tissue of the incision), deep incisional (involving fascia and/or muscular layers), and organ/space. They occur in 2% to 5% of patients undergoing inpatient surgery in the United States, resulting in approximately 500,000 infections each year (10). Many gynecologic procedures and all cesarean sections are classified as “clean contaminated” procedures as the genitourinary tract is entered, thus increasing the risk of wound infection. Infections usually present late in the first postoperative week with erythema and either subcutaneous pockets of exudate (if the epithelium is intact) or frank serosanguinous or seropurulent drainage from an open incision. Staphylococcus aureus is common but enteric or vaginal flora is also commonly involved. Wound cultures should be obtained initially due to the increasing rate of methicillinresistant Staphylococcus aureus (MRSA). Fascial integrity must be established as described above. The wound should be adequately opened for drainage and debridement performed as indicated followed by dressing changes or wound vacuum. Hospitalization and antibiotics may be required in cases of extensive involvement or sepsis, diabetes, obesity, immunosuppression, and suspected MRSA or when adequate outpatient wound care is not possible.
Necrotizing fasciitis represents a life-threatening soft-tissue infection primarily involving the superficial fascia. It is characterized by skin discoloration, skin and subcutaneous necrosis, crepitus, and sometimes hypesthesia as cutaneous nerves become ischemic. Systemic toxicity and multiorgan involvement can occur quickly. Wong et al. reviewed 89 consecutive patients over a 5-year span with necrotizing fasciitis and reported the following: polymicrobial synergistic infection was the most common cause with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus followed by advanced age. These factors and a delay in surgery of >24 hours adversely affected the outcome. Multivariate analysis showed that only a delay in surgery of >24 hours was correlated with increased mortality. Similarly, Bilton et al. reviewed 68 cases of necrotizing fasciitis, finding that the major predictor of favorable outcome was prompt aggressive surgical debridement (11,12). When such a treatment was delayed, mortality occurred in more than one third of cases, compared with <5% with prompt aggressive surgical debridement (11,12). To summarize, when necrotizing fasciitis is suspected, prompt diagnosis, aggressive surgical debridement, supportive care, and broad-spectrum antibiotics appear to be the keys to avoiding overwhelming sepsis and death.
Fascial Dehiscence and Hernia
Dehiscence describes the separation of any of the layers of the abdominal wall, but the term is commonly used when partial or complete fascial disruption occurs. This separation may be associated with evisceration where small bowel and abdominal contents herniate through the defect. When the fascial layer does not heal properly, evisceration may occur in the early postoperative period, while such failure of healing may present later as an incisional hernia.
Fascial dehiscence as a complication of pelvic laparotomy performed for hysterectomy and other gynecologic surgeries occurs at a rate of 0.3% to 0.7%. Dehiscence occurs more frequently in midline incisions as opposed to transverse incisions (13). Age, underlying medical disease, obesity, infection, and malignancy increase the risk. Dehiscence tends to occur during the first 1 to 2 weeks of postoperative period and can present with the skin layer either open or intact. The most common associated complaint is serosanguinous discharge
from the wound. The patient may also describe an associated sudden tearing or popping sensation brought on by coughing, lifting, or Valsalva maneuver. The fascia must be evaluated in such situations digitally or by probing with a sterile Q-tip. Imaging studies such as ultrasound, MRI, or CT scan may reveal the disrupted fascia with herniated abdominal contents when the skin is intact or the examination is inconclusive. Wound dehiscence should be considered a surgical emergency as it is associated with a mortality rate of up to 10%.
from the wound. The patient may also describe an associated sudden tearing or popping sensation brought on by coughing, lifting, or Valsalva maneuver. The fascia must be evaluated in such situations digitally or by probing with a sterile Q-tip. Imaging studies such as ultrasound, MRI, or CT scan may reveal the disrupted fascia with herniated abdominal contents when the skin is intact or the examination is inconclusive. Wound dehiscence should be considered a surgical emergency as it is associated with a mortality rate of up to 10%.
Initial treatment involves protecting the wound with a large moist sterile dressing and arranging for prompt surgical debridement and fascial closure in the operating room. The patient must be medically stabilized, cultures obtained, and broad-spectrum antibiotics initiated as wound infection or sepsis is often present. If the fascia cannot be reapproximated without tension, incorporating a synthetic fascial graft into the repair may be necessary. Skin and subcutaneous layers are typically left open for wound care and healing by secondary intention. Secondary closure may be an option once the wound appears adequately healthy.
Incisional hernia implies that superficial layers and peritoneum have healed but a facial defect is present. Hernias can be expected in nearly 1% of uncomplicated surgeries, in 10% when wound infection has occurred, and in 30% of patients with fascial repair after dehiscence (14). Once again, the incidence is higher with midline incisions but ventral hernias have been described in essentially all incisions employed in gynecologic surgery. Most incisional hernias present within the first 2 years following surgery with over 50% occurring within the first 6 months. Patients typically complain of a bulge beneath the surgical scar which may or may not be associated with discomfort and often exacerbated by straining or Valsalva maneuver.
If the contents of the hernia become entrapped in the fascial defect, incarceration with strangulation or obstruction can occur. Pain, peritoneal signs, and symptoms of bowel obstruction differentiate this patient from the easily reduced hernia and require stabilization and emergent surgical repair.
Minimally invasive procedures can also result in symptomatic hernias despite the relatively small incisions utilized. Reported incisional bowel herniation rates after laparoscopy range from 0.02% to 0.17% and are related to larger trocar size, multiple ancillary ports, tissue extraction, and longer operative times (15,16,17). In spite of recommendations to close the fascia on all trocar sites 10 mm and larger, 18% of the hernias cited in the AAGL (American Academy of Gynecologic Laparoscopists) survey cited above occurred despite fascial closure. Any laparoscopic patient with unusual pain at the incision site, the presence of a bulge, nausea, and vomiting, or symptoms of bowel obstruction must be evaluated for port site herniation and potential infarction of herniated omentum or bowel.
Vaginal Cuff Dehiscence
Unique to gynecologic surgery is the potential for postoperative vaginal cuff dehiscence and vaginal evisceration. Although vaginal evisceration can be associated with vaginal trauma, spontaneous rupture of a large enterocele, or large uterine perforation with suction curettage, it should be suspected in the symptomatic posthysterectomy patient. An extensive review of the literature by Ramirez and Klemer in 2002 (18) found that although a rare event, with only 59 patients reported, vaginal evisceration represents a surgical emergency. Of those cases reported, 37 (63%) occurred following vaginal hysterectomy, 19 (32%) after abdominal hysterectomy, and 3 (5%) after laparoscopic hysterectomy. Small bowel was the most common organ to eviscerate. The most common presenting symptoms among these cases of vaginal evisceration were vaginal bleeding, pelvic pain, or a
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