Introduction

Any operation, major trauma or other surgical admission may be attended by complications, many of which are preventable. Complications cause added pain and suffering and may even put the patient’s life at risk. Also, an anastomotic leak or a wound dehiscence can double the cost of an elective colonic resection.

While some complications are to some extent inherent in the condition being treated (e.g. deep venous thrombosis following lower limb fractures) or arise from some co-morbid (pre-existing) condition such as myocardial ischaemia, others arise from failure to visit or examine a patient when called, errors of judgement (e.g. misdiagnosis), poor nursing practice (e.g. allowing pressure sores to develop) or even frank negligence (e.g. operation on the wrong side). Poor communication between hospital staff is a frequent cause of avoidable complications, for example failing to record important events in the patient’s treatment (and the date or name of the doctor), or to record a drug allergy in the case record, or neglecting to inform the operating department about a late change to an operating list.

A large proportion of complications can be prevented or minimised by anticipation, by taking prophylactic measures, by attention to detail and by early recognition and treatment of problems as they develop. With potentially serious complications (e.g. bowel anastomotic leak), early diagnosis and reoperation is crucial, as delay often leads to catastrophic ‘snowballing’ sepsis and multi-organ failure. Once two or more body systems become impaired, survival falls to only about 50%. If, for example, acute respiratory distress syndrome (ARDS) and renal failure complicate an operation for obstructive jaundice in a patient with liver impairment, the odds are heavily stacked against survival.

In operative surgery, complications can be either those of any operation or specific complications of individual operations. Both groups can be subdivided into immediate (during operation or within the next 24 hours), early postoperative (during the first postoperative week or so), late postoperative (up to 30 days after operation) and long-term.

Surgical complications fall into the five broad categories listed in Box 12.1. ‘Medical’ complications are discussed in Chapter 8. Complications of specific operations are discussed in Chapters 18–51, as appropriate.

• Injuries resulting from falls from trolleys or from the operating table during positioning

• Injury to diseased bones and joints from manipulation or positioning. These include dislocation of rheumatoid atlanto-axial joints and dislocation of a prosthetic hip joint

• Ulnar, lateral popliteal and other nerve palsies resulting from pressure

• Electrical burns from wet or poorly contacting diathermy pads or misuse of the diathermy probe

• Excess pressure on the calves causing deep venous thrombosis

• Excess heel pressure causing pressure sores

• Cardiac pacemaker disruption by diathermy equipment

Perioperative haemorrhage

Haemorrhage occurring during an operation (primary haemorrhage) should be controlled by the surgeon before the operation is completed.

Early postoperative haemorrhage

Haemorrhage immediately after operation usually indicates inadequate operative haemostasis or a technical mishap such as a slipped ligature or unrecognised blood vessel trauma. Occasionally it is due to a bleeding disorder.

If an operation involves major blood loss and large volume transfusion of stored blood, haemorrhage may be perpetuated by consumption coagulopathy, in which platelets and coagulation factors have been ‘consumed’ in a vain attempt at haemostasis. Disseminated intravascular coagulopathy (DIC) can be one facet of the systemic inflammatory response syndrome (SIRS) with widespread intravascular thrombosis and exhaustion of clotting factors. Occasionally bleeding results from preoperative use of aspirin or aspirin-like drugs (responses vary greatly between patients), uncontrolled anticoagulant drugs or, less commonly, a pre-existing but unrecognised bleeding disorder. Any patient giving a history of excess bleeding should have a platelet count and coagulation screen checked before operation.

Operations at particular risk of early postoperative haemorrhage include:

This type of postoperative haemorrhage has been traditionally described as reactionary in the belief that it was a ‘reaction’ to the recovery of normal blood pressure and cardiac output. This concept is probably misleading and should now be discarded, especially since it may hinder the decision to reoperate urgently.

Later postoperative haemorrhage

Haemorrhage occurring several days after operation is usually caused by infection eroding blood vessels near the operation site; this is known as secondary haemorrhage. Treatment involves managing the infection, but exploratory operation is often required to ligate or suture the bleeding vessels.

Unavoidable tissue damage

Anatomical structures, particularly nerves, blood vessels and lymphatics, may be unavoidably damaged during operation. This is particularly true in cancer surgery, illustrated by facial nerve excision during total parotidectomy. If anticipated, the probability must be discussed with the patient beforehand (ideally by the surgeon performing the operation) and accepted as part of the operative risk. Sometimes the integrity or location of vulnerable structures can be established before operation, allowing better planning of the operation. For example, indirect laryngoscopy may be done to assess vocal cord integrity prior to thyroid surgery.

Inadvertent tissue damage

Structures may be inadvertently damaged during operation. Examples include recurrent laryngeal nerve damage during thyroidectomy, or trauma to bile ducts during laparoscopic cholecystectomy. The main factors are inexperience, anatomical anomalies, attempts at arresting precipitate haemorrhage and tissue planes obscured by inflammation or malignancy. Signs of damage to structures at particular risk should be sought in the postoperative period; for example, hoarseness after thyroidectomy or jaundice after cholecystectomy.

Minor wound infections

The most common infective complication is a superficial wound infection within the first postoperative week. This relatively trivial infection presents as localised pain, redness and a slight discharge. Organisms are usually staphylococci derived from skin and the infection usually settles without treatment. The exception is the patient into whom a prosthesis such as an arterial graft or artificial joint has been inserted. For these, antibiotics must be given to prevent the devastating consequences of infection around the prosthesis.

Wound cellulitis and abscess

More severe wound infections occur most often after bowel-related surgery, when staphylococci (meticillin-sensitive or resistant varieties) or faecal organisms are usually incriminated. Most present in the first postoperative week but they may occur as late as the third week, sometimes after leaving hospital. These infections commonly present with a pyrexia; wound examination reveals spreading cellulitis or localised abscess formation (Fig. 12.1).