Gynecology EXIMIUS

Post-operative Management of Complications (Part 2) 2021

Dr. Corazon W. Adviento March 2020

Deep Venous Thrombosis Ø Signs and symptoms

o Induration of calf muscles
Ø 50%- 1st 24 hours o Minimal edema
Ø 75%- within 72 hours o Calf tenderness
Ø 15%- after 7th postop day o Difference of >1 cm in the diameter of the leg
Ø Diagnosis: o Acute onset of severe pain and swelling-
o PE- insensitive iliofemoral thrombosis
o Imaging studies o Homan sign
§ necessary to establish diagnosis
Ø Direct causes of mortality in gyne patientsà 40%
Ø PE: incidence of fatal PE in Gyne surgeries-0.2%
Ø Incidence: without prophylaxisà 7-45%, averageà 15%
Ø Risk factors
o Obese and older women
§ increased incidence due to dilatation
of their venous system
o Hormonal therapy
§ 2-4 fold increase
o Duration of therapy
§ 1-2 hrs-15% of women develop the
disease
§ >3 hrs –greater risk Ø Diagnosis
o Sx: fever, tachycardia (greater than what is
expected of fever)
o PE: high index of suspicion, false positive in 50%
o D-dimer: protein from cross-linked fibrin after it
has been degraded by plasmin and fibrinolytic
process
§ Also increased with trauma, surgery,
pregnancy, intravascular hemolysis,
inflammatory states
o Phlebography- Ascending Contrast Venography
§ MOST ACCURATE
§ 95% in peripheral disease
§ 90% in iliofemoral disease
§ Rarely used
o Duplex Sonography
§ Combination of Doppler and real- time
B-mode ultrasound AND color Doppler
§ High sensitivity and specificity
§ Advantages:
• Non-invasive
• Easy to use
• Highly accurate
• Objective
• Simple reproducible
Ø Thrombus formation usually begins at the calf deep veins
§ Disadvantage:
Ø 75% of pulmonary emboli originate from the leg veins
• Limited accuracy to small
Ø If one leg is involved, the other leg will also have a
vessels
thrombus in 33%
Ø Treatment
Ø 50% risk of PE if femoral vein is not treated
Ø Three key predisposing factors in thrombus production
(Virchow, 1854)
o Increase coagulation factors
o Damage to vessels
o Venous stasis

TRANSCRIBERS Cabalza, JKB. 1

 Gynecology EXIMIUS
Post-operative Management of Complications (Part 2) 2021
Dr. Corazon W. Adviento March 2020

Pulmonary Embolism Ø 40% of nosocomial infections, 60% are related to IFC, 1%

Ø Undiagnosed in 50%
Ø 10% die within the 1st hour
Ø 8% mortality if treated and 30% if untreated
Ø No pathognomonic signs and symptoms
Ø Most common symptoms:
o Chest pain, dyspnea and apprehension
Ø Classic triad:
o Shortness of breath
o Chest pain
o Hemoptysis, 20%
Ø Tachycardia, tachypnea, rales and increase in 2nd heart
sounds over the pulmonic areaà most common
Ø Low grade fever- 15%
Ø Diagnosis:
o Imaging techniques (Helical CT)- GOLD
STANDARD
o Clinical assessment: accurate
o Others: ECG, CXR, CBGs, trop, D- Dimer (not for
post-op)
Ø Treatment:
o IV unfractioned Heparin or full dose LMWH
o Vena cava filters for patients with
contraindication for heparin treatment
o Maintenance with warfarin or LMWH for 3
months with monitoring of bleeding parameters
will develop bacteremia
Ø Symptoms: develop after 24-48 hrs after catheter removal
o Lower: frequency and mild dysuria
o Older women: mental status changes
o Upper: high grade fever, chills and flank pain
Ø If UTI persists after antibiotic therapy- obstruction should
be evaluated
Ø catheterize specimen: 102 CFU/ mL is significant
Ø Treatment should be extended for 3 days
Ureteral Injury and Urinary Fistula
Ø Vesicovaginal and uretrovaginal fistulas are rare but
significant complications of gyne surgeries
o 75% abdominal hysterectomy
§ 1/200 abdominal hysterectomy
o 25% vaginal surgeries
Ø Symptomatic:8-12 days up to 25-39 days postop
Ø Classic clinical symptom of urinary tract fistula
o Painless and almost continuous loss of urine
usually from the vagina

Urinary Tract Problems

Ø Inability to void
Ø UTI
Ø Ureteral injury and Urinary Fistula

Inability to Void

Ø Complex cause
o Direct trauma and edema produced by the
surgical procedure to the perivesicle tissues
o Overdistension from excessive hydrations and
dyssynchronous contractions from the bladder
neck
o Anxiety
o Mechanical interference, obstruction by swelling
and edema
o Neurologic imbalance
o Drug-induced detrusor hypotonia
Ø Management:
o Most resolve sponataneously
o Straight catheterization
o Drugs:
§ phenoxybenzamine- hypotension
§ bethanecol- 10 to 50 mg orally q6-8 hrs
Ø Treatments:
Urinary Tract Infections o Bladder trauma- IFC for 3-5 days, heals
Ø catheter associated UTI spontaneously
Ø most common hospital acquired infection o Cystoscopy- post hysterectomy can be done
Ø most frequent cause of Gram negative bacteremia o Vesicovaginnal fistula- operative repair, IFC for
10 days
§ Latzko operation
TRANSCRIBERS Cabalza, JKB. 2
 Gynecology EXIMIUS
Post-operative Management of Complications (Part 2) 2021
Dr. Corazon W. Adviento March 2020

o Ureteral injuries- percutaneous nephrostomy § Hypoactive/ absent bowel sounds

and ureteral catheters § Tympanitic abdomen
o Reimplantation of ureters- for injuries on the § Abdominal tenderness
lower 3rd of the ureters Ø Diagnosis:
Ø GI complications: o Clinical
o Post-operative diet o Diagnostic imaging
o Glycemic control § X-ray (U/S/L)
o Postop hyperglycemia § CT scan differentiate between
§ Increase mortality >200 mg/dL adynamic ileus from obstruction
§ Metformin not used perioperatively:
lactic acidosis
Ø Glucose monitoring q4-6 hours and 150 mg/dL glucose
should be treated if:
o With history of insulin resistance
o Morbidly obese
o > 60 years old
o Sliding insulin treatment
Ø Postop Nauses and GI Function
o Nauseaà 12-24 hrs postop
o Flatusà within 48 hrs
o BMà 3-4 days postop
Ø Diet Progression
o General liquid 6 hrs post-op then immediate
advancement of regular diet
Ø Preventive measure and Treatment:
o Serotonin- 5 hydroxytryptamine receptors (5-
HT3)
o Antagonist- ondansetron
o Anti-emetics
Ø Treatment:
o

Ileus

Ø Delay in the normal return of bowel function caused by an

inhibition of the normal propulsive reflexes of the bowel
that are regulated by an ANS
Ø Stomach returns to motility within 24 hrs
Ø Small intestines- resumes peristalsis 6 hrs post-op
Ø Right colon full motility in about 24 hrs
Ø Left colon in 72 hrs

Adynamic Ileus

Ø Delayed bowelfunction in the absence of obstruction

Ø Result from lack of coordinated motor activity of the
intestines which results in disorganized propulsive activity
Ø Generalized or isolated
Ø Causes:
o Increase neurologic inhibition of the intestinal
motility caused by sympathetic nerve activity
o Inflammation within the bowel wall
o Post-op narcotics stimulates ipioids receptors,
increasing dyssynchronous contractions
Ø Classic symptoms:
o Asence of flatus
o Abdominal distension
o Obstipation
o Associated with:
§ Nausea and vomiting

TRANSCRIBERS Cabalza, JKB. 3

 Gynecology EXIMIUS
Post-operative Management of Complications (Part 2) 2021
Dr. Corazon W. Adviento March 2020

o Oral administration of radiocontrast- diagnostic Rectovaginal Fistula

and therapeutic
o Early carbohydrate intake and enteral feeding Ø Usually an obstetric complication
o Carbohydrate load night before surgery and Ø Gyne procedures
fluids 4 hours before surgery o TAH with repair of eneterocoele- upper 3rd of the
o Self-limiting condition- rest, fluids, time vagina
o Serum electrolytes determination and correction o TAH with posterior colporrhaphy- lower 3rd of
of deficits vagina
Ø Other causes
Intestinal Obstruction o Carcinoma
o Radiation therapy
Ø Causes: o Perirectal abscess
o Adhesions- most common cause of postop o IBD
obstruction o LGV
o Hernias o Trauma
o Mesenteric defects Ø Signs and symptoms:
o Intussusception o Occurs in 7-14 days post-op
o Volvulus o Passage of blood clots per rectum
o Neoplasm o Passage of gas per vagina
Ø Signs and symptoms: o Passage of fecal materials per vagina
o Occurs 5-7 days post-op o Classic s/ sx:
o Have a brief period of normal intestinal function § Chronic foul- smelling vaginal
o Abdominal pain is intermittent, colicky and sharp discharge
o Bowel sounds are loud, high pitched and rushing § Subsequent dyspareunia
o NGT Ø Diagnosis:
o Associated with: o Methylene blue technique
§ Nausea and vomiting o Contrast enemas
§ Abdominal distension o Colonoscopy
§ Constipation Ø Treatment
o Patient should be obstipated with low residue
diet and diphenoxylate hydrochloride
o 1 in 4 heal spontaneously
o Surgical repair
§ Timing is important
§ Pre-op evaluation

Antibiotic-induced Diarrhea

Ø Occurs in 1/3 of patients receiving antibiotics- both

parenteral and oral
Ø Disrupts normal intestinal flora
Ø Table 25.8à refer to table on page 3 Ø Other causes:
Ø Treatment: o Contrast media
o Early detection o Diabetic foods with artificial sweeteners
o Early treatment- decompression of small o Cardiac medications
intestines and adequate replacement of fluids Ø Signs and symptoms:
and electrolytes o Mild, without fever, abdominal exam is
§ Decompression- NGT unremarkable- stop antibiotics and supportive
§ Serial CBC monitoring care
§ Serial PE and radiographic examination o Temperature > 38oC
§ Expectant management can be done o Leukocytosis
§ 40% require surgery o Abdominal tenderness
o Severe abdominal distension
o Bloody diarrhea
o Persistent diarrhea
Ø Treatment for C. difficile infection
o Metronidazole 500 mg PO TID or 250 mg PO q6
§ 90% cure rate, cost effective
§ 1st line
TRANSCRIBERS Cabalza, JKB. 4
 Gynecology EXIMIUS
Post-operative Management of Complications (Part 2) 2021
Dr. Corazon W. Adviento March 2020

o Vancomycin 125 mg PO q6 Ø Fever within 48 hours

§ 98% cure rate o Clostridium spp
§ Used if metronidazole is ineffective § Boggy and edematous and discharge
has sweet odor
o B- hemolytic Streptococci
§ Swollen, red and with odorless
discharge
Ø Treatment:
o Open and drainage
o GS and culture should be done
o Periodic irrigation
o Antibiotic treatment
o Primary vs. secondary intention

Wound Complications
Ø Prevention
Ø Infection
o Foundation
Ø Wound dehiscence and evisceration
o Prophylactic antibiotic
Infections o Consideration of local and systemic factors

Ø Incidence: 5%
Ø Rate for abdominal hysterectomy- 3.9%
Ø Minimally invasive – 1.8%
Ø Prolongs hospital stay for 2-6 days
Ø Classification:
o Superficial: skin and subcutaneous tissue
o Deep: includes fascia and muscles

Wound Infection

Ø Gynecologic infections- polymicrobial

Ø Pathophysiology depends on the number and virulence of
bacteria and resistance of the woman
Ø 100, 000- 1,000, 000 bacteria/ gram of tissue to produce
infection
Ø Superficial skin infection- directly related to length of
procedure
o Each additional hour doubles the incidence of
infection
Ø Signs and symptoms: Necrotizing Fasciitis
o Appears between 5th-10th post-op days Ø Virulent, rapidly progressive soft tissue infection
o 90% first 2 weeks
Ø Relative minor changes in the skin in early part
o Fever Ø Signs and symptoms:
o Tachycardia
o local pain with systemic symptoms
o Incisional erythema, induration, tenderness and § tachycardia
pain § fever
o Development of fluctuant or firm mass
§ marked tenderness
sometimes crepitus § necrotic tissue, hypoesthetic or
o Purulent discharge
completely numb
§ wound edges- darken, crepitus with
bullae formation

TRANSCRIBERS Cabalza, JKB. 5

 Gynecology EXIMIUS
Post-operative Management of Complications (Part 2) 2021
Dr. Corazon W. Adviento March 2020

Ø involves subcutaneous tissue and superficial fascia Ø Treatment:

Ø life threatening and debridement should be done asap o Prompt reclosure
Ø mortality is 30-50% o Broad- spectrum antibiotics
Ø Risk factors:
o DM Wound Care for Obese Patients
o Malnutrition Ø Obesity- most significant risk factor for dehiscence and
o Immunosuppression infection
o Malignancy Ø Techniques to improve wound healing
o Obesity o Maintain normothermia
o Poor tissue perfusion o Supplemental oxygen
o Subcutaneous closure
o Preop antibiotics increased ( example: Cefazolin
from 2g to 3 g)
o Maintain euglycemia
o techniques to decrease wound disruption

Dehiscence and Evisceration

Ø Failure of normal healing and refers to a disruption of any

of the layers of the surgical incision
Ø Strength of the skin incision increases rapidly on the first 4
months and slower for the 1st year
Operative Site Complications
Ø Dehiscence: separation of the skin, subcutaneous tissue,
fascia but not the peritoneum Ø Pelvic Cellulitis and Abscess
Ø Evisceration: completed breakdown of all layers of Ø Granulation tissue
abdominal wall with bowels or omentum presenting thru Ø Incisional Hernia
the fascia Ø Prolapsed Fallopian Tube
Ø Preventive management: Ø Lymphocyst
o Vertical or horizontal skin incision- little effect Ø Postop Neuropathy
o Choice of suture
o Consideration of local and systemic factors Pelvic Cellulitis and Abscess
Ø Signs and symptoms:
Ø Infection to the contiguous retroperitoneal space
o Occurs between 5th-8th postop day
immediately above the vaginal apex
o Spontaneous passage of copious serosanguinous
Ø Polymicrobial
discharge
Ø Signs and symptoms:
o Smead- Jones technique
o Fever- prominent between 3rd- 5th postop day
o Running mass closure using monofilament
§ Becomes spiking as infection
suture
progresses
Ø Vaginal cuff dehiscence and evisceration
o Lower quadrant pain
Ø Presents with:
o Pelvic pain
o Sudden vaginal dscharge
o Leukocytosis
o Bleeding
Ø Psychologic sequelae:
o Pain
o Pain relief
Ø Risk factors:
o Psychosexual problems and depression
o Mental status changes
Ø Follow-up and discharge

TRANSCRIBERS Cabalza, JKB. 6