Postoperative care

Published on 09/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 2841 times

CHAPTER 9 Postoperative care

Saad A. Amer

Chapter Contents

INTRODUCTION 116
ROUTINE POSTOPERATIVE CARE 116
RECOGNITION AND MANAGEMENT OF POSTOPERATIVE COMPLICATIONS 120
KEY POINTS 126

Introduction

The postoperative period is the span of time from the end of a surgical procedure until resumption of normal life activity. The duration of this period varies according to the nature of the procedure and the fitness of the patient. It is characterized by restoration of normal physiological functions, healing of tissues from the surgical trauma and a gradual return of physical strength. In the first few hours whilst the patient is recovering from the anaesthetic, she gradually regains her respiratory, cardiovascular and neurological functions, and establishes homeostasis. Recovery of the gastrointestinal tract and mobilization occur in the first 1–3 days after uncomplicated surgery. Healing of tissues and return of full physical strength continue for a variable length of time (1–6 weeks) after discharge from hospital. Although most of the complications from surgery occur in the early postoperative phase, they can still arise after discharge from hospital. Measures should therefore be put in place in collaboration with the general practitioner/primary care doctor and community nurse to support the patient whilst at home and to ensure recognition of any late adverse event.

The last decade has witnessed a dramatic change in the postoperative care of the gynaecological patient. Whilst it was previously routine for women to remain in hospital with bed rest for up to 2 weeks following a hysterectomy, most units nowadays discharge these patients after 3 days. More recently, a growing number of gynaecological units routinely perform laparoscopic hysterectomies as day cases. These changes have been driven by a number of factors, including a realization of the risks associated with prolonged immobilization and hospital stay, such as infective and thromboembolic complications. In addition to these clinical reasons, pressures on hospital beds and funding have driven down length of stay.

Good postoperative care will lead to a smooth and quick recovery from surgery with reduction of complications and a shorter hospital stay. There are three main objectives of postoperative care:

• supporting the patient during restoration of physiological functions;
• promoting healing of tissues; and
• recognizing and managing complications.

Postoperative care should be tailored to each individual’s circumstances with attention to the particular needs of every patient. Standardization of care can be developed, but should be applied with a degree of flexibility to allow the individualization of care.

Postoperative care should be provided by well-trained and skilled nursing staff with input from the surgical team as well as members of a multidisciplinary team including physiotherapists, dieticians, pharmacists and microbiologists. Other specialist postoperative management should be provided as necessary, such as wound care and rehabilitation.

Routine Postoperative Care

Fluid and electrolyte balance

Patients undergoing gynaecological surgery, excluding minor and day-case procedures, require intravenous (IV) fluid administration until oral fluid intake is fully resumed. The daily requirement of fluid should be calculated accurately and the patient should be monitored carefully to ensure adequate hydration. This is important to avoid fluid overload (which could lead to pulmonary oedema) or dehydration (which could result in renal tubular necrosis). When calculating the fluid intake, one should consider the normal fluid requirement (approximately 2.5 l/24 h), intraoperative blood loss and insensible losses (e.g. due to raised temperature). Other factors to be considered when calculating fluid intake include preoperative depletion of fluids, long operative procedures, pyrexia, fluid loss through drains, excessive vomiting, bowel distension, oral fluid intake, extravascular fluid accumulation (third space) and previous fluid replacement.

Urine output monitoring should be used to determine the status of the intravascular volume and total body water. The normal urine output is 30 ml/h. Patients voiding less than 17 ml/h are oliguric. Other clinical signs of dehydration include mucous membrane dryness, slow skin turgor, tachycardia and raised temperature. Patients should also be monitored for features of fluid overload such as jugular venous distension, mucous membrane turgor, pulmonary rales, third heart sound and pitting oedema. Central venous pressure monitoring should be considered when there is difficulty assessing intravascular volumes. Invasive direct measures of cardiac output that enable accurate measurement of intravascular filling (e.g. measurements of pulmonary wedge pressures and transoesophageal echo) are rarely required after gynaecological surgery.

Oliguria can be prerenal, renal or postrenal. Postoperative oliguria is most commonly prerenal and is caused by insufficient fluid replacement. This can be confirmed by a fluid challenge with the infusion of 250 ml of a colloid such as gelofusin over 15 min. Improvement of urine output after this fluid challenge confirms prerenal oliguria, which can be corrected by increasing the rate of IV fluid administration. If there is no improvement in urine output with the fluid challenge, the patient should be assessed for evidence of pulmonary oedema and renal impairment (due to tubular necrosis). In the elderly or those with known cardiac disease, fluid challenges should be given with caution as this may exacerbate pulmonary oedema.

If prerenal and renal causes of oliguria have been excluded, a postrenal aetiology such as ureteric obstruction should be considered. Diagnosis can be made with renal ultrasound. If this is inconclusive, ureteric catheters can be used for diagnosis and treatment.

The majority of gynaecological patients undergoing surgery are healthy and usually resume their diet within 24–48 h. Postoperative monitoring of electrolytes is therefore not required routinely in these patients. However, electrolyte imbalance may occur under certain circumstances such as persistent vomiting, prolonged IV fluid administration, and after surgery involving extensive tissue damage or excessive drainage from the surgical site. In addition, patients with renal impairment, diabetes or those receiving certain medications (e.g. potassium-sparing diuretics) are at increased risk of electrolyte disturbances. These patients should be monitored for electrolyte imbalance and treated promptly for any abnormality. Both hypo- and hyperkalaemia can result in cardiac arrhythmias and therefore require assessment by electrocardiogram (ECG). Hypokalaemia usually results from delayed oral intake or excessive vomiting. It can be corrected by increasing the potassium content of the IV fluid (20 mEq KCl/l). Hyperkalaemia can occur in patients undergoing extensive surgery due to shift of potassium from traumatized cells into the extracellular space. Moderate or severe hyperkalaemia (potassium level >6 mEq/l) is a medical emergency; if not corrected promptly, it can lead to severe cardiac arrhythmias and death. An input from the medical team should therefore be sought. It can be corrected by IV administration of glucose and insulin to promote potassium shift into the cells. Calcium gluconate is also given to protect the heart from dysrhythmias. Hyponatraemia is usually secondary to excessive fluid administration or absorption of excessive amounts of irrigating fluid during hysteroscopic surgery, and hypernatraemia is secondary to dehydration.

Bladder care

In women undergoing major gynaecological surgery, a urinary catheter is usually inserted just before the operation to keep the bladder empty throughout the procedure. This helps to minimize the risk of bladder injury and allows good access to the surgical field. Post operatively, the catheter is kept in place during the acute recovery phase for the patient’s comfort, to allow monitoring of urine output and to avoid urinary retention due to the general anaesthetic or pain. The catheter should be removed as soon as the patient is able to mobilize and void comfortably. Early removal of the catheter is important as prolonged catheterization may be associated with an increased risk of urinary tract infection (Schiøtz and Tanbo 2006). In patients who sustained a bladder injury during surgery, the catheter should be kept for 7–10 days to allow full healing of the bladder wall, and many gynaecologists would perform a systogram prior to removing the catheter.

Postoperative voiding difficulty is a common problem in gynaecological surgery, especially following bladder neck operations, and can be due to spasm, oedema or tenderness of parauretheral tissue. It is also common following radical hysterectomy due to extensive perivesical dissection that interferes with the nerve and blood supply to the bladder. Other contributing factors include cystitis and psychogenic factors. Failure to pass urine could also occur as a result of regional anaesthesia (which may cause bladder overdistension and atony) and abdominal pain, which may inhibit the initial voluntary phase of voiding. Following bladder neck surgery, most voiding difficulty resolves within 1 or 2 weeks of surgery, but up to 20% of women can continue with this problem for an extended period (up to 6 months) before being able to void normally (Smith and Cardozo 1997).

If the patient does not pass urine for 4–6 h after catheter removal, residual urine volume should be measured after micturition using a bladder ultrasound scan. This should also be performed in women undergoing bladder neck surgery or radical hysterectomy. Voiding difficulty is diagnosed if the residual volume is consistently greater than 100 ml. If this problem persists after several voiding attempts, a catheter should be inserted for 24 h. The catheter is then removed and further residual volume measurements are carried out. If still high, the patient should be allowed home with an indwelling catheter for 7–10 days. Failing this, the catheter could be left in the bladder for a longer period. Eventually, if voiding difficulty persists, the patient should be trained to perform intermittent self-catheterization.

A suprapubic catheter should be considered during surgery in patients expected to have postoperative voiding difficulty. This allows easier and more accurate measurement of residual volumes. The catheter is clamped and the patient is asked to void urine. This is followed by measurement of residual urine passing through the suprapubic catheter. Another advantage of this catheter is the reduced risk of urinary tract infections compared with the urethral catheter.

Drains

Although not necessary in the majority of routine gynaecological procedures, drains can be helpful in certain cases. The main indication for placing a drain during gynaecological surgery is surface oozing following extensive pelvic surgery such as adhesiolysis, treatment of extensive endometriosis or complicated hysterectomy. Drainage in these cases is necessary to prevent haematoma formation and to allow early recognition of significant postoperative internal haemorrhage. However, the drain should not be used as a substitute for meticulous intraoperative haemostatesis. Other indications for pelvic drainage include pelvic infection (e.g. tubo-ovarian abscess) and clotting disorders, which could result in persistent postoperative oozing.

Intraperitoneal (pelvic) drains have been associated with an increased incidence of infection, and should only be used when the benefits outweigh the risks. Evidence from recent randomized trials and systematic reviews is against the routine use of drains. A recent large randomized trial of drains compared with no drains following radical hysterectomy and pelvic lymph node dissection concluded that drains can be safely omitted in the absence of excessive bleeding during surgery or oozing at the end of surgery (Franchi et al 2007). A systematic review evaluating the value of routine suction drains after retroperitoneal lymphadenectomy in gynaecological tumours concluded that the prophylactic use of continuous suction drains is associated with a significant increase in morbidity and should be avoided (Bacha et al 2009). On the other hand, drainage of surgical wounds (especially clean-contaminated wounds) using a closed-suction system has been used prophylactically to reduce wound infection (Panici et al 2003).

There are two main types of drains: passive (non-suction) and active (suction). Passive drains, which drain by overflow assisted by gravity, are preferred for the peritoneal cavity, where soft tissue can block the fenestrations of suction drains. Passive drains should not be brought out through the incision, to avoid the risk of wound infection. Suction drains are sealed systems with a vacuum to drain a potential space created by surgery such as the subcutaneous or subfascial space. They are also used to drain lymphatic fluid from the groins after lymphadenectomy.

Early removal of drains is recommended to avoid infection and aid mobilization. The precise timing for removal of a drain should be determined on an individual basis and depends on the reasons for its insertion. Drains that were placed prophylactically to avoid the accumulation of blood, pus or lymph can usually be removed when drainage is <100 ml in 24 h, usually by 2 or 3 days after surgery. Drains placed for drainage of an abscess should be managed according to the resolution of the condition.

Postoperative pain management

Effective relief of postoperative pain is of paramount importance as it offers significant psychological and physiological benefits to the recovering patient. Not only does it mean a smooth postoperative course with earlier discharge from hospital, but it also helps to reduce the incidence of complications (Nagaratnam et al 2007). In addition, there is evidence that good pain relief can reduce the onset of chronic pain syndromes. Inadequate pain management could lead to reduced deep breathing, causing impaired oxygenation. It can also cause inability to cough and clear lung secretions which may lead to lung atelectasis. Pain reduces a patient’s mobility, leading to slower recovery and increased risk of morbidities such as deep vein thrombosis (DVT). The benefits of good postoperative pain management are summarized in Table 9.1.

Table 9.1 Benefits of effective postoperative pain relief

Improved recovery Patient satisfaction
Wound healing
Early mobilization
Early hospital discharge
Reduced morbidities Respiratory complications
Tachycardia and dysrhythmias
Thromboembolic events
Acute coronary syndromes
Chronic pain syndrome

The first step in achieving good pain control is preoperative prediction and accurate postoperative assessment of the degree of pain. Such pain is subjective and can vary greatly in severity between patients from almost no pain to very severe pain. There are two main factors determining the degree of postoperative pain: firstly, the nature, extent and site of the surgery; and secondly, factors related to the patient including fear, anxiety and pain threshold. A previous experience of postoperative pain may also infuence the patient’s expectation and perception of pain. It is therefore important to plan postoperative pain management through consultation between the surgeon and the anaesthetist based on the predicted pain severity. It is also important to explain to the patient the expected degree of pain and the steps that will be taken to ensure effective pain relief afterwards. It is usually helpful to establish the patient’s expectations of pain before surgery. This approach has been shown to minimize the patient’s fear and anxiety from pain and to reduce the requirement for postoperative analgesia (Karanikolas and Swarm 2000).

Methods of assessment

After surgery, pain can be assessed using one of several methods such as the visual analogue scale (VAS) or the verbal response score (VRS). With the VAS, the patient chooses a number between 0 and 10 to represent her pain. Zero indicates no pain and 10 means pain as severe as can be imagined. The VRS utilizes a simple five-point scale which either correlates pain severity to words (no pain, mild, moderate, severe, excruciating) or to a number (0–4). The pain should be assessed at regular intervals, preferably charted in graphical form and should form part of the routine postoperative observation.

The analgesic ladder

The World Federation of Societies of Anaesthesiologists’ analgesic ladder, which has been developed to treat acute pain, can be utilized for postoperative pain (Charlton 1997; Figure 9.1). In women undergoing major gynaecological surgery, the initial pain can be expected to be severe and may need injections of strong opioids [e.g. morphine, preferably by a patient-controlled analgesia (PCA) system], which can be combined with local anaesthesia. As pain decreases with time, analgesia can be stepped down and parenteral opioids can be gradually replaced by the oral route. Strong oral opioids (e.g. oromorph) can be given, to be gradually replaced with a combination of peripherally acting agents (e.g. paracetamol and non-steroidal anti-inflammatory drugs) and weak opioids (e.g. codeine phosphate). The final step is when the pain can be controlled by peripherally acting agents alone.

image

Figure 9.1 The World Federation of Societies of Anaesthesiologists’ analgesic ladder. Local anaesthesia indicates epidural, spinal or peripheral nerve or wound block. NSAID, non-steroidal anti-inflammatory drug.

Source: Charlton JE (1997) The management of postoperative pain. Update in Anesthesia 7: 2–17 (www.anaesthesiologists.org).

Opioid analgesia

PCA is an effective way of providing opioid analgesia where the patient titrates the dose to her need by pressing a button that delivers a small bolus (e.g. 1 mg morphine). The PCA system is preset by the anaesthetist to a minimum interval between boluses to prevent overdosage. It is therefore safe and offers high patient satisfaction. Continuous epidural analgesia provides great pain relief for up to 72 h and is more effective than PCA. In addition, it is associated with improved pulmonary function, short convalescence and a lower incidence of morbidities such as pulmonary complications, venous thromboembolism, gastrointestinal side-effects and central venous system depression. It is usually sited by the anaesthetist in theatre and left in for a few days after surgery. Its routine use may be limited by insufficient trained nursing staff to manage it and to treat potential side-effects.

Wound care

Good wound care will promote healing and minimize complications such as infection, haematoma formation or dehiscence. Wound care begins during surgery with careful handling of tissues, avoidance of cautery for skin incision, meticulous haemostasis, good closure techniques and avoidance of excessive traction on the skin edges (Boesch and Umek 2009). At the end of surgery, a wound dressing is applied, mainly to cover the fresh wound to prevent seepage of serum or blood, but this does not have any protective effect against infection. It should be removed on the first postoperative day when the wound has become dry. Any serous or serosanguinous discharge can be squeezed out by gentle pressure on the wound edges. Patients can be allowed a shower, but should keep the wound dry and clean. Sutures and staples can be removed from transverse wounds after 4–5 days, but vertical wounds usually require 7–10 days to heal.

Wound infection

Wound infection occurs in 3–5% of clean wounds and 10–20% of clean-contaminated wounds in the absence of antibiotic prophylaxis. It usually presents by the fifth postoperative day as erythema, induration and pain in the area surrounding the incision, and may be associated with pyrexia. A wound swab should be taken for culture, and broad-spectrum antibiotics should be given. If the infection progresses to pus formation under the suture line, this should be drained. Usually, at this stage, the wound separates either partially or completely, allowing drainage. However, if the wound remains intact or if the separation is only small, the wound should be opened (in theatre if necessary) to allow drainage. If there is a significant delay in healing with development of devitalized tissue, the wound should be opened in theatre, explored, debrided and packed with gauze, followed by twice-daily dressing changes. At this stage, the tissue viability team and microbiologists should be involved in the care of this chronically infected wound to ensure that the most appropriate dressings and treatments are given. Negative pressure wound therapy may be considered in these wounds to promote the production of granulation tissue and encourage neovascularization (Walsh et al 2009).

Necrotizing fasciitis

Necrotizing fasciitis is a rare but life-threatening and rapidly progressive infection of the superficial fascia and subcutaneous tissues (Addison et al 1984). It often occurs in diabetic and immunosuppressed patients, but can also affect women with other chronic illnesses. It is characterized by dusky and friable subcutaneous tissue with serous drainage from a small wound that may be separate from the original incision wound. It can also occur on the vulva or perineum, often not related to surgery. There is extensive tissue necrosis and a moderate or severe systemic toxic reaction. Very radical excision is essential with antibiotics and supportive therapy.

Postoperative feeding

Traditionally and for many years, postoperative oral intake of fluid and food has been delayed until the recovery of bowel function (return of bowel sounds and passage of flatus) from the temporary postoperative ileus. This was believed to be necessary to avoid vomiting and severe paralytic ileus. However, this practice has not been supported by good scientific evidence. A recent systematic review of early (<24 h) compared with delayed oral intake after major abdominal gynaecological surgery has provided evidence in favour of early oral intake. The study has shown early postoperative feeding to be safe and associated with a reduced length of hospital stay, but with an increase in the incidence of nausea (Charoenkwan et al 2007). Early feeding was not associated with an increase in complications such as ileus, vomiting or abdominal distension. However, the authors concluded that the timing of postoperative feeding should be individualized according to each patient’s circumstances. In patients undergoing benign gynaecological procedures without significant insult to the gastrointestinal tract, early postoperative oral intake should be encouraged. On the other hand, feeding should be delayed in women at high risk of paralytic ileus (e.g. following extensive and prolonged procedures with excessive handling of the bowel).

Mobilization and physiotherapy

The benefits of early postoperative mobilization have been established since the 1940s (Brieger 1983). It reduces the muscle loss associated with inactivity, hastens recovery and reduces the incidence of pulmonary complications. Other benefits include a reduction in the risk of thromboembolic disease and respiratory infection. Mobilization involving an upright position appears to be of greatest benefit in the early postoperative period, with evidence of improvements in pulmonary function (Nielsen et al 2003), prevention of functional decline and possibly a positive effect on depression and anxiety (Brooks-Brunn 1995). Early involvement of skilled physiotherapists is essential to facilitate early mobilization and to deal with the problems arising from prolonged postoperative recovery. In particular, physiotherapists play an important role in the prevention and treatment of respiratory infection.

Recognition and Management of Postoperative Complications

Haemorrhage

Primary haemorrhage occurs in the immediate postoperative period and is usually a result of inadequate intraoperative haemostasis or slipped ligatures due to poor surgical technique. Patients undergoing complex gynaecological procedures such as treatment of endometriosis, division of extensive adhesions or myomectomy are at increased risk of primary postoperative haemorrhage. Secondary haemorrhage is delayed and usually has an infective aetiology. It is more commonly associated with vaginal procedures.

All patients undergoing major gynaecological surgery should be monitored closely for signs of internal haemorrhage in the immediate postoperative period. This can be achieved with regular observations of the pulse, blood pressure, urine output and abdominal distension. It is important to bear in mind that most gynaecological patients who are young and fit compensate very well for hypovolaemia, sustaining a normal blood pressure until late stages when the compensatory mechanisms fail with sudden collapse. It is therefore important, especially in high-risk patients, to watch for the early signs of hypovolaemia including tachycardia, peripheral vasoconstriction (manifested by cold hands and feet) and signs of anaemia (pallor and low haemoglobin). Although oliguria is another sign of hypovolaemia, it often occurs due to dehydration rather than haemorrhage. In cases of major and rapid haemorrhage, which is beyond the compensatory mechanisms, the patient will experience a rapid fall in blood pressure. In women with intra-abdominal drains, the volume of blood draining could be used as an indication of the severity of blood loss. However, lack of significant drainage does not exclude massive intra-abdominal bleeding, especially when a small drain is used which could get blocked. When there is uncertainty with the diagnosis, an abdominal ultrasound scan, if one is readily available, may aid the diagnosis by confirming intra-abdominal blood collection. The scan can also help in establishing the severity of the condition by estimating the amount of intra-abdominal blood. However, the diagnosis should be primarily based on clinical assessment of the patient.

When internal haemorrhage is suspected, whole blood should be immediately cross-matched and transfused as soon as available. In the mean time, hypovolaemia should be corrected by a colloid or crystalloid intravenous fluid until blood becomes available. The debate over the value of colloid vs crystalloid preparations for volume replacement remains unresolved. A recent Cochrane systematic review by Perel and Roberts (2007) concluded that the continued use of colloids in favour of crystalloids is not supported by evidence from randomized controlled trials and does not improve the outcome of treatment. An urgent full blood count and coagulation screen should be arranged. The coagulation status should be monitored repeatedly during the resuscitation of the patient due to the risk of consumptive coagulopathy. A haematologist should be consulted if there is any abnormality with the clotting system. The next step is for the surgeon to decide whether or not the patient should be taken back to theatre for exploration and achievement of haemostasis. Timing in these cases is critical as any delay in decision could have fatal consequences if the patient enters a state of irreversible shock or disseminated intravascular coagulopathy. On the other hand, rushing the patient back to theatre when conservative management may have been enough will unnecessarily subject the patient to the risks of repeated anaesthetic and surgery. More often, the bleeding is due to generalized ooze, and adequate haemostasis will be difficult to achieve surgically. In some cases, therefore, it may be better to continue the transfusion and correct any coagulation defect rather than to re-explore.

If a decision is made for surgical exploration, the patient should be taken to theatre after initial resuscitation. Patients bleeding vaginally after a hysterectomy could be examined vaginally under anaesthesia. The vault can be reopened and, if a bleeder is identified (usually vaginal branch of uterine artery in one of the angles), it can be secured with a suture. Once haemostasis has been achieved, the vaginal vault can be reclosed and a pack inserted if necessary. In all other cases, a relaparotomy should be performed and all the pedicles should be examined carefully. More recently, laparoscopy has been used successfully for exploration and establishment of haemostasis in patients with postoperative haemorrhage (Sobolev et al 2005). Intra-abdominal bleeding frequently originates from ovarian vessels. These must be identified clearly and separated from the ureter before the application of diathermy or a ligature. Sometimes, it can be difficult to localize the bleeding point and it may be venous rather than arterial. In these situations, compression with large packs for a few minutes can be effective, or will at least reduce the general ooze, allowing the main bleeding sites to be visualized clearly and dealt with. It is always important to ensure safety of the ureter by palpation or dissection before suturing. If effective haemostasis cannot be achieved, bilateral internal iliac artery ligation or angiographic embolization of bleeding vessels should be considered provided that expertise is available. Failure of haemostasis could be due to coagulopathy, which should be corrected promptly with input from the haematologist. Fresh frozen plasma, which contains all the protein constituents of plasma including the coagulation factors, is used to replace these factors in consumptive coagulopathy. Cryoprecipitate contains a high concentration of fibrinogen that may be required in massive blood transfusion. If haemostasis is impossible, the bleeding site could be compressed with several large packs, followed by closure of the abdomen. The packs should be removed under general anaesthetic after 24–48 h.

Haematoma formation

Vault

Vault haematoma following hysterectomy is relatively common, affecting approximately 20–30% of patients. In most cases, the haematoma is asymptomatic and is only detected on pelvic ultrasound scan. Frequent presentations include lower abdominal pain, low-grade temperature or vaginal discharge. Haematomas are usually self-limiting and will either resolve or discharge via the vaginal vault in the second week following surgery. Infected vault haematomas do not usually contaminate the peritoneal cavity, and generalized peritonitis is rare in these cases. The majority of haematomas can be managed conservatively until they subside. Prophylactic antibiotics can be given to minimize the risk of abscess formation. A large vault haematoma may require drainage, especially if there is evidence of sepsis or if conservative management fails. Drainage is usually performed in theatre under general anaesthetic via a vaginal approach. If interrupted sutures have been used, the removal of one or two may be sufficient to introduce a finger into the gap. Continuous vault sutures will need to be replaced completely when divided to enter the vault. With bimanual compression, the organized clot can be expelled but the blind use of instruments should be avoided. A large bore drain may be required at the end of the procedure to ensure complete drainage.

Wound

Abdominal wound haematomas are also common following open abdominal surgery. They usually cause swelling and bruising around the wound, associated with significant pain. Like the vault haematomas, they are self-limiting and will resolve with time. Management is usually conservative with reassurance of the patient. Large haematomas may require drainage, especially if there is evidence of infection or if they are associated with severe pain. This is usually carried out in theatre with opening of all or part of the incision. If a subfascial haematoma is suspected, the rectus sheath should also be opened.

Infection and pyrexia

In recent years, hospital-acquired infection has received a great deal of attention from the health authorities. The Department of Health has taken several measures to reduce the transmission of hospital infection, especially against the so-called ’hospital super bugs’ (e.g. meticillin-resistant Staphylococcus aureus and Clostridium difficile). Most hospitals in the UK now have a dedicated infection control team led by a microbiologist who monitors the rates of hospital infections and develops local protocols on the use of antibiotics to minimize bacterial resistance. All hospital staff working in clinical areas receive regular infection control training. The main emphasis of infection control policies is on proper hand hygiene and maintenance of a clean patient environment.

Most major gynaecological procedures (e.g. abdominal and vaginal hysterectomy) fall into the clean-contaminated category (see Chapter 7) and are associated with an infection rate of 10–20% in the absence of antibiotic prophylaxis. In a meta-analysis of 25 randomized controlled trials, involving a total of 3604 women, antibiotic prophylaxis was found to reduce the incidence of infection after total abdominal hysterectomy from 21% to 9% (Mittendorf et al 1993). On the other hand, clean wounds which are performed under complete aseptic conditions are associated with infection rates of 1–5% without prophylaxis. Clean procedures include most adnexal surgeries, laparoscopic procedures and subtotal hysterectomy. Antibiotic prophylaxis does not decrease infection rates following these procedures and should not be given.

Postoperative fever occurring within the first 48 h is not usually caused by an infective process, but may be associated with haematoma formation or pulmonary atelectasis. Later development of pyrexia (after 72 h) is more likely to be infective in origin. The most common site of postoperative infection is the urinary tract (day 3), followed by wound infections (day 5) and collections. Non-infective causes of pyrexia such as DVT should also be considered in the differential diagnosis. Urinary tract infections are not usually associated with urinary symptoms; when suspected, this should be confirmed with urine microscopy and culture. The incidence of urinary tract infection is not changed by the use of prophylactic antibiotics (Brown et al 1988), and is mainly increased with the use of perioperative catheterization. Wound infection usually becomes manifest on the fifth postoperative day (see above). Swinging pyrexia, which persists despite intensive antibiotic therapy, may indicate an infected collection (e.g. pelvic abscess). An ultrasound or computed tomography (CT) scan of the pelvis and abdomen should be performed in these cases to detect any collection. If identified, infected collections not responding to antibiotics may need surgical evacuation. This could be carried out either via a vaginal route (especially after vaginal hysterectomy) or through a laparotomy.

Sepsis is a systemic response to infection which, in severe cases, can lead to septic shock manifested by hypotension and multiple organ failure (Wheeler and Bernard 1999). This requires prompt resuscitation (in an intensive care unit) and aggressive eradication of the source of infection with broad-spectrum antibiotics and surgery if appropriate (Tamussino 2002).

Venous thromboembolism

In the absence of thromboprophylaxis, patients undergoing major (>30 min) general and gynaecological surgery have a significant risk of both asymptomatic (approximately 30%) and symptomatic (approximately 8%) venous thromboembolism (Table 9.2). The risk increases with the number of risk factors (Scottish Intercollegiate Guidelines Network 2002). Women in the high-risk category should be counselled carefully before surgery, and referred to a haematology clinic for risk assessment and advice on perioperative management. The risk factors and thromboprophylaxis have been discussed in Chapter 7.

Table 9.2 Risks of venous thromboembolism following general and gynaecological surgery in the absence of thromboprophylaxis

Type of venous thromboembolism Risk (%)
Asymptomatic DVT 25
Asymptomatic proximal DVT 7
Symptomatic DVT 6
Symptomatic non-fatal PE 1–2
Fatal PE 0.5

DVT, deep vein thrombosis; PE, pulmonary embolism.

Source: Scottish Intercollegiate Guidelines Network 2002 Prophylaxis of Venous Thromboembolism. SIGN, Edinburgh.

Diagnosis of deep vein thrombosis

It is always good practice to have a high index of suspicion for DVT following major gynaecological surgery, especially in high-risk patients. The majority of patients with DVT are asymptomatic and could go unrecognized until complicated with life-threatening pulmonary embolism (PE). The calf is the most common site for DVT and usually manifests with swelling, erythema and pain. Examination usually reveals low-grade pyrexia with a swollen, tender and warm calf. Patients with these manifestations should be treated as having DVT until proved otherwise. Diagnosis can be confirmed with Doppler ultrasound on the leg veins. Intravenous venography may be necessary in some cases, but is associated with risk of embolism. Ultrasonography has an average sensitivity and specificity of 97% for proximal DVT. If there is high probability of a DVT but a negative leg Doppler ultrasound, anticoagulation treatment should continue and Doppler studies should be repeated in 1 week.

Diagnosis of pulmonary embolism

Clinically, the ’classic’ presentation of PE is an abrupt onset of pleuritic chest pain, shortness of breath and hypoxia. Other less frequent symptoms include haemoptysis and dyspnoea. However, many patients with PE are either completely asymptomatic or have vague and non-specific symptoms such as back pain, shoulder pain, upper abdominal pain, syncope, painful respiration, high fever, productive cough, hiccoughs and wheezing. Therefore, a high level of suspicion should be practised in any postoperative patient presenting with any chest symptoms, especially if no other cause has been found for these symptoms. The main physical signs in patients with PE include tachypnoea, tachycardia, low-grade fever, rales and accentuated second heart sound. Each hospital should develop its protocol for the diagnosis of PE.

Screening for pulmonary embolism

The partial pressue of oxygen (PO2) in arterial blood should be tested, although this test has little predictive value in patients clinically suspected to have PE. Another screening test is measuring the D-dimer, although it is likely to be raised in the postoperative period. A negative D-dimer in patients with mild-to-moderate clinical suspicion rules out venous thromboembolism. If the result is positive and/or if there is a high probability of PE, diagnostic imaging should be carried out. Other screening tests include ECG and a chest X-ray. The most common ECG findings in PE are tachycardia and non-specific ST–T wave abnormalities. Other findings include S1Q3T3, peaked P waves (p pulmonal), right axis deviation, right bundle-branch block or atrial fibrillation. ECG abnormalities are only present in approximately 20% of cases of PE. ECG is therefore a good positive test in PE (i.e. a positive ECG may be suggestive of PE, but a negative result does not exclude it). Chest X-ray should be performed to exclude other causes for chest symptoms (e.g. pneumothorax, pneumonia). Findings will usually be normal at presentation, although they may rarely show the Westermark sign (i.e. dilatation of the pulmonary vessels proximal to an embolism along with collapse of distal vessels). Over time, chest X-ray may show atelectasis or focal infiltrates, with a picture very similar to infectious pneumonia.

Definitive diagnosis of pulmonary embolism

Definitive diagnosis is by contrast pulmonary angiography. However, due to the invasive nature of this technique, other imaging modalities are more commonly used. Spiral CT scan has recently been shown to be comparable in accuracy to pulmonary angiography, and is now accepted as the preferred primary diagnostic tool. If this is not available, ventilation/perfusion scan (V/Q scan) can be used instead. If V/Q scan shows low probability, bilateral leg Doppler ultrasound studies should be performed. If both are negative with low clinical suspicion, PE can be ruled out. If, however, there is continuing clinical suspicion despite negative V/Q scan and leg Doppler studies, further imaging should be considered such as spiral CT scan, magnetic resonance imaging or angiography.

Treatment of venous thromboembolism

Confirmed or clinically suspected venous thromboembolism awaiting diagnostic confirmation requires immediate treatment with either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). If the diagnosis is confirmed by spiral CT, treatment should continue. If a V/Q scan suggests a high or medium probability of PE, therapeutic anticoagulation should be continued. If the V/Q scan suggests a low probability of PE and ultrasound studies of the legs are positive, therapeutic anticoagulation should be continued. Where the V/Q scan suggests a low probability of PE and ultrasound studies of the legs are negative, anticoagulation can be discontinued if clinical suspicion is low.

LMWHs are the preferred initial treatment of choice. They are more effective than UFH with lower mortality and fewer haemorrhagic complications in the initial treatment of DVT, and are as effective as UFH in the initial management of PE. Systematic reviews have confirmed LMWH as a safe alternative to UFH with the advantage of a fixed-dose regimen reducing the need for monitoring. Long-term use of LMWH is associated with a lower risk of heparin-induced thrombocytopenia, osteoporosis and bone fractures than UFH. However, intravenous UFH remains the preferred treatment in massive PE because of its rapid effect and extensive experience of its use.

LMWH should be commenced and converted to oral anticoagulants once the patient is in the stable postoperative period and the risk of bleeding has reduced. The LMWH should be continued until an international normalized ratio of 2.0–3.0 is achieved. The haematology and anticoagulation clinic should be informed to continue the treatment on discharge and to perform other investigations as necessary.

Life-threatening massive PE requires an immediate multidisciplinary approach involving a senior anaesthetist, haematologist, physician, gynaecologist and intensivist. Cardiopulmonary resuscitation, thrombolytic therapy, percutaneous catheter thrombus fragmentation or surgical embolectomy may be needed in some cases.

Urinary tract injuries

Bladder

Bladder injury is the most common visceral injury in gynaecological surgery. The risk is increased in women with previous surgery, particularly caesarean section and anterior wall myomectomy, where the bladder becomes firmly adherent to the cervix and upper vagina. The damage usually occurs during dissection of the bladder from the cervix, even when applying gentle and blunt methods. The dome of the bladder is the usual site of injury. Intraoperative recognition of the injury is crucial in order to avoid long-term consequences such as fistula formation, which can be difficult to treat. Primary injuries are usually recognized at the time of surgery, although they can easily be missed. In women at high risk of bladder damage, it is usually good practice to exercise a high level of suspicion. Careful inspection of the bladder will usually reveal the injury. If still in doubt, a methylene blue test could be used to check for any bladder tears. A Foley catheter is inserted in the bladder (transurethrally) and methylene blue dye in saline solution is injected through the catheter to fill the bladder. The bladder is then observed as it distends for any leakage of the dye. If a defect is detected, it should be repaired in two layers with absorbable suture material. This can usually be performed by the gynaecologist. In cases of extensive bladder damage or lacerations, an urologist should be involved with this repair. Following surgery, the bladder should be drained continuously for 10–14 days. It will also be advisable to arrange a cystogram before removal of the catheter to ensure complete healing. An unrepaired bladder injury will result in vesicovaginal fistula, which usually presents in the first postoperative week. Fistulae presenting later may be the end result of a pelvic haematoma or vascular necrosis of the bladder wall.

Ureter

Ureteric damage is less common than bladder injury during gynaecological surgery, with an incidence that varies between 0.5% and 2.5% depending on the underlying pathology. The risk is particularly increased in patients with extensive endometriosis and/or adhesions, which could distort the course of the ureter. The incidence of ureteric damage is also increased in women who received pelvic radiotherapy prior to their surgery. The irradiated tissue is more difficult to dissect and takes longer to heal. The ureteric damage can either occur as a result of direct trauma to the ureter with sharp instruments at the time of surgery, or indirect damage due to delayed avascular necrosis resulting from excessive dissection of the ureter with damage of its blood supply. Delayed ureteric necrosis and damage could also result from thermal injury during the use of electrosurgery. Another form of ureteric damage results from ureteric obstruction due to involvement of the ureter in a suture. Intraoperative recognition of direct ureteric injury can be difficult and requires a significant amount of experience. It is always good practice to suspect ureteric injury in high-risk patients. Careful inspection of the ureter from the pelvic brim downwards will help to detect direct injuries. Common sites of damage are at the angle of the vagina and near the pelvic brim. If in doubt, a ureteric stent should be inserted by the urologist. Repair of ureteric damage should only be undertaken by a urologist. Injury near the brim of the pelvis is managed by end-to-side anastomosis or, more commonly, by end-to-end anastomosis to the opposite ureter. Damage near to the bladder is better repaired with ureteric reimplantation into the bladder using either a psoas hitch or bladder flap. Unrecognized ureteric injury will result in extravasation of urine, which collects in the pelvis causing pelvic discomfort and pyrexia. Urine may also leak from an abdominal or vaginal incision. Ureteric obstruction may cause loin pain and pyrexia in the postoperative period. It may also go completely unrecognized, and be discovered many years later as an incidental finding. Percutaneous nephrostomy may be required if hydronephrosis develops. Cystoscopy and retrograde insertion of ureteric stents is an alternative but often less satisfactory approach.

If a fistula is suspected in the immediate postoperative phase, a urinary catheter should be inserted immediately to assess urine output. A three-swab test will help to identify vesicovaginal fistula, but urine leakage around the catheter may be misleading. Other tests that may help to establish the diagnosis include ingestion of indigo carmine with later vaginal inspection to determine whether a fistula is present. Intravenous urography will help in locating the site of damage, but small fistulae may be difficult to see.

Spontaneous healing of a damaged bladder is dependent upon the extent of the urinary leakage. A small leakage usually heals in approximately 7–10 days and can therefore be managed conservatively. If this fails or if the leakage is more significant, surgical repair of the defect should be undertaken by a urologist.

Bowel complications

Bowel obstruction

Mechanical bowel obstruction caused by adhesions or twisting of a loop of bowel is rare in gynaecological surgery. It usually occurs approximately 1 week after surgery and presents with persistent vomiting and abdominal pain with absence of passage of flatus or faeces. Signs include abdominal distension and tenderness with tinkling bowel sounds. An abdominal X-ray would show dilated loops of bowel. It usually settles within 48–72 h with nasogastric aspiration plus IV fluids. If there is no improvement, contrast imaging should be performed to identify the site of obstruction for surgical correction. The presence of clinical evidence of peritonitis requires immediate surgery.

Paralytic ileus

Abdominal gynaecological surgery is usually followed by a physiological ileus due to manipulation of the bowel. The small bowel typically regains function within hours. The stomach regains activity in 1–2 days and the colon regains activity in 3–5 days (Cameron 2001). Postoperative adynamic ileus or paralytic ileus is defined as gut ileus persisting beyond 3 days following surgery (Livingston and Passaro 1990). Paralytic ileus is uncommon following benign gynaecological procedures as they are not usually associated with significant insult to the bowel.

Paralytic ileus manifests with abdominal distension, nausea and vomiting with delayed passage of flatus or faeces. A distinguishing feature is absent or hypoactive bowel sounds, unlike the high-pitched sound of mechanical obstruction. The abdomen of ileus reveals no discernible peristalsis or succession splash. An abdominal X-ray will reveal dilated loops of bowel.

The majority of patients will improve with conservative management by resting of the bowel, IV fluids and nasogastric tube drainage. Electrolyte imbalance, especially hypocalcaemia, should be corrected. Unresolved cases should be investigated for potentiating factors such as intraperitoneal abscess or retroperitoneal haematoma, which should be drained under radiological control (Gerzof et al 1981).

Bowel injury

Fortunately, inadvertent bowel injury is uncommon during benign gynaecological surgery with an incidence of 0.3–0.8%, with the majority (70%) being minor lacerations (Dicker et al 1982). The small bowel is the site of injury in approximately 75% of cases. Abdominal rather than vaginal or laparoscopic surgery is associated with a higher rate of damage. The incidence of bowel damage during laparoscopic surgery is 0.5% (Garry and Phillips 1995). The site, extent and timing of presentation of bowel injury will determine the presentation, management and outcome. Postoperative large bowel leak is a serious and life-threatening complication. Risk factors for bowel injury include adhesions, endometriosis, sepsis, obesity, and previous pelvic or abdominal radiotherapy.

Intraoperative detection of bowel injury

There are three main types of bowel injury: direct trauma with sharp instruments, thermal injury with electrosurgery, and devascularization with subsequent necrosis due to extensive dissection. The former injury results in intraoperative perforation or laceration. This is not always easy to recognize and requires a significant amount of experience. The damage may be detected if it occurs on a visible bowel surface or when there is an obvious leak of bowel contents (e.g. faeces). However, in a significant proportion of patients, neither of these is obvious and the damage can easily be missed. Small bowel contents are not usually easy to notice, which leads to 60% of small bowel injuries being missed (Hill 1994). To minimize the possibility of missing bowel damage, it is important to have a high level of suspicion, especially in difficult or high-risk cases. Consideration should be given to asking a colorectal surgeon to explore the bowel for suspected damage. In patients suspected to have bowel injury during extensive laparoscopic surgery in the cul-de-sac, a 30 cc Foley catheter could be inserted into the rectum. With clamping the bowel above the site of dissection, the pelvis is filled with physiological solution and air injected through the Foley catheter by a 100 cc syringe. The appearance of bubbles in the solution will indicate perforation. Alternatively, a 50% betadine solution could be injected and the bowel observed for trailers of betadine leakage.

Delayed presentation of bowel injury

Indirect bowel injuries cannot be appreciated during surgery and usually present several days later. It is therefore important that patients at high risk should be watched carefully in the first few postoperative days for signs of bowel injury. Patients undergoing day-case surgery present a major concern as they may develop bowel injury at home, which could potentially be fatal if not diagnosed early. It is therefore important to warn all day-case patients about early signs of bowel damage, and advise them to return to the hospital immediately rather than seeking help from their family doctors.

In women who sustain a direct trauma to the bowel that was missed during surgery, symptoms of bowel leak will present 48–72 h later. On the other hand, thermal bowel damage or delayed necrosis due to devascularization may not manifest itself until 6–8 days after surgery.

Minor laceration or Veress needle puncture

Most of these injuries heal without any consequences except if there is an obstruction distal to the injury. This may result in leak from the bowel a few days after surgery.

Large bowel leak

Large bowel leak is a serious and life-threatening complication, especially if there is delay in the diagnosis. The early symptoms of abdominal pain and distension associated with nausea and vomiting could be mistaken for postoperative symptoms. The diagnosis may not be apparent until septic shock and collapse supervene. Large bowel leak usually presents with generalized peritonitis, giving widespread peritonism and guarding with absent bowel sounds and marked deterioration of the patient’s general well-being. In some cases, leaking may be localized with abscess formation, giving rise to swinging temperature which does not respond to antibiotics, vomiting and abdominal distension. Abdominal X-ray reveals gas under the diaphragm or distended loops of small bowel, although plain films are not usually helpful. It is important to ask a colorectal surgeon to review the patient at an early stage if bowel injury is suspected. An early resort to laparotomy and exploration may be crucial to achieve a good outcome.

Small bowel leak

The early symptoms of small bowel leak are less pronounced than those of the large bowel. Abdominal pain and distension associated with vomiting are the main early features. Initially, bowel sounds may still be present with passage of flatus and stool per rectum. With time, symptoms will worsen with localized signs of tenderness and development of a pelvic mass.

Faecal fistula

Rarely, a rectovaginal faecal fistula may develop following a difficult hysterectomy in patients with severe endometriosis with obliteration of the pouch of Douglas. If the large bowel leak is close to the vault, it can discharge through the vault resulting in a fistula. This is usually easily diagnosed with a speculum on vaginal examination, although a small fistula may be difficult to see.

Management of bowel injury

If the damage is recognized during surgery, a bowel surgeon should be summoned to theatre to manage the damage. Depending on the site and extent of the damage, the treatment will either be oversewing the injury, local resection and reanastomosis, or resection with a temporary defunctioning colostomy.

In patients with delayed presentation of bowel injury, laparotomy through a midline incision should be undertaken. If the leak is from the large bowel, diversion proximal to the leak may be required. A small bowel leak may be treated with resection and reanastomosis. Most of these patients are usually generally unwell and should receive postoperative care in an intensive care unit.

A rectovaginal fistula can be treated with resection of the affected bowel segment with closure of the rectal stump and colostomy (Hartmann’s procedure). A small rectovaginal fistula can be managed conservatively with a defunctioning colostomy.

Pulmonary complications

Postoperative pulmonary complications after abdominal surgery include chest infection, atelectasis, pulmonary oedema and pulmonary embolism. Atelectasis is the most common pulmonary complication, and has been estimated to occur in 20% of patients having upper abdominal surgery and 10% of patients having lower abdominal surgery (Bartlett 1980).

Risk factors for postoperative pulmonary complications include smoking, old age, obesity, upper respiratory tract infection, positive cough test (recurrent coughing after deep inspiration and initial cough), perioperative nasogastric tube and long duration of anaesthesia (McAlister et al 2005, Pappachen et al 2006). Arterial blood gas analysis will determine the severity of the problem. Initial treatment is a higher concentration of oxygen supplied via an oxygen mask. Consideration of assisted ventilation should be made in patients unable to maintain saturation >90% or with PO2 <8.0 kPa with referral to a critical care specialist.

Cardiovascular complications

Any patient receiving a general anaesthetic is at increased risk of developing myocardial ischaemia, especially if there is underlying heart disease. Obtaining a good medical history of cardiac disease is very important in predicting cardiac complications. Elective surgery should be delayed in patients with a history of myocardial infarction within the preceding 6 months (Doshani and Shafi 2003).

Cardiac complications include arrhythmias or myocardial infarction, which can present in the immediate postoperative period. Prolonged arrhythmias may lead to hypotension and exacerbate the effects of hypovolaemia secondary to surgery, resulting in further deterioration of tissue perfusion. Cardiac function may be further compromised by acidosis, hypoxaemia and fluid overload as a consequence of excessive fluid replacement to correct hypovolaemia.

Patients experiencing chest pain after surgery should be investigated for a cardiac cause. It is important to remember that chest pain may be masked by strong postoperative analgesia. Other important signs to raise the possibility of cardiac complications include unexplained tachycardia and hypotension, the presence of a new murmur or evidence of pulmonary oedema. These findings may indicate myocardial infarction and should be investigated with serial cardiac enzymes and ECG. Patients presenting with arrhythmias should be investigated for an underlying cause such as sepsis, hypovolaemia, pyrexia, electrolyte imbalance or drug toxicity. Referral to a cardiologist should be arranged when a cardiac problem is suspected. Thrombolytic therapy is contraindicated within 5 days of surgery.

KEY POINTS

1 Careful preoperative assessment and medical optimization prior to surgery improve postoperative care.
2 Appropriate choice of operation performed by those appropriately trained is the most important factor in minimizing postoperative complications.
3 Whilst most gynaecological procedures do not induce major fluid and electrolyte problems, gynaecologists need to be aware that certain circumstances could lead to electrolyte imbalance such as ileus and persistent vomiting.
4 Be alert to potential hyponatraemia if there are significant deficits of fluid following hysteroscopic procedures.
5 Effective postoperative analgesia using patient-based methods allows early mobilization and reduces respiratory complications.
6 Atelectasis and urinary tract infection are the most common causes of postoperative pyrexia.
7 Pelvic haematomas are common after hysterectomy and may be the cause of postoperative pyrexia or unexpected anaemia.
8 There is a significant risk of DVT after major gynaecological procedures, and each patient must be given appropriate prophylaxis relevant to risk status.
9 The majority of DVTs which precede PE are not recognized clinically, so be vigilant to detect potential DVTs.
10 If postoperative complications occur, it is the responsibility of the operating gynaecologist to liaise with the appropriate specialty and ensure that the patient is investigated and treated promptly.
11 Gynaecology patients are most often young and fit before surgery, and thus may not reveal signs of internal haemorrhage until the late stages and then quickly decompensate.
12 Early recognition of bowel and urinary tract damage reduces the risk of serious morbidity.
13 Damage to bowel and urinary tract should only be repaired by experienced practitioners.
14 Local audit will identify areas of concern in surgical technique and infection control.

References

Addison WA, Livengood CH, Hill GB, Sutton GP, Fortier KJ. Necrotizing fasciitis of vulvar origin in diabetic patients. Obstetrics and Gynecology. 1984;63:473-479.

Bacha OM, Plante M, Kirschnick LS, Edelweiss MI. Evaluation of morbidity of suction drains after retroperitoneal lymphadenectomy in gynecological tumors: a systematic literature review. International Journal of Gynecological Cancer. 2009;19:202-207.

Bartlett RH. Pulmonary pathophysiology in surgical patients. Surgical Clinics of North America. 1980;60:1132.

Boesch CE, Umek W. Effects of wound closure on wound healing in gynaecologic surgery: a systematic literature review. Journal of Reproductive Medicine. 2009;54:139-144.

Brieger GH. Early ambulation. A study in the history of surgery. Annals of Surgery. 1983;197:443-449.

Brooks-Brunn JA. Postoperative atelectasis and pneumonia: risk factors. American Journal of Critical Care. 1995;4:340-349.

Brown EM, Depares J, Robertson AA, et al. Amoxycillin-clavulanic acid (Augmentin) versus metronidazole as prophylaxis in hysterectomy: a prospective, randomised clinical trial. BJOG: an International Journal of Obstetrics and Gynaecology. 1988;95:286-293.

. Current Surgical Therapy. Cameron JL, editor, 7th edn. Mosby, Chicago, 2001.

Charlton JE. The management of postoperative pain. Update in Anesthesia. 1997;7:2-17.

Charoenkwan K, Phillipson G, Vutyavanich T 2007 Early versus delayed (traditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database of Systematic Reviews 4: CD004508.

Dicker RC, Greenspan JR, Strauss LT, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. The Collaborative Review of Sterilisation. American Journal of Obstetrics and Gynecology. 1982;144:841-848.

Doshani A, Shafi M. Pre- and post-operative care in gynaecology. Current Obstetrics and Gynaecology. 2003;13:151-158.

Franchi M, Trimbos JB, Zanaboni F, et al. Randomised trial of drains versus no drains following radical hysterectomy and pelvic lymph node dissection: a European Organisation for Research and Treatment of Cancer–Gynaecological Cancer Group (EORTC–GCG) study in 234 patients. European Journal of Cancer. 2007;43:1265-1268.

Garry R, Phillips R. How safe is the laparoscopic approach to hysterectomy. Gynaecological Endoscopy. 1995;105:77-80.

Gerzof SG, Robbins AH, Johnson WC. Percutaneous catheter drainage of abdominal abscesses. New England Journal of Medicine. 1981;305:193-197.

Hill DJ. Complications of the laparoscopic approach. Baillières Clinical Obstetrics and Gynaecology. 1994;8:865-879.

Karanikolas M, Swarm RA. Current trends in perioperative pain management. Anesthesiology Clinics of North America. 2000;18:575-599.

Livingston EH, Passaro EPJr. Postoperative ileus. Digestive Diseases and Science. 1990;35:121-132.

McAlister FA, Bertsch K, Man J, Bradley J, Jacka M. Incidence and risk factors for pulmonary complications after nonthoracic surgery. American Journal of Respiratory and Critical Care Medicine. 2005;171:514-517.

Mittendorf R, Aronson MP, Berry RE, et al. Avoiding serious infections associated with abdominal hysterectomy: a meta-analysis of antibiotic prophylaxis. American Journal of Obstetrics and Gynecology. 1993;169:1119-1124.

Nagaratnam M, Sutton H, Stephens R. Prescribing analgesia for the surgical patient. British Journal of Hospital Medicine. 2007;68:M7. M10

Nielsen KG, Holte K, Kehlet H. Effects of posture on postoperative pulmonary function. Acta Anaesthesiologica Scandinavica. 2003;47:1270-1275.

Panici PB, Zullo MA, Casalino B, Angioli R, Muzii L. Subcutaneous drainage versus no drainage after minilaparotomy in gynecologic benign conditions: a randomized study. American Journal of Obstetrics and Gynecology. 2003;188:71-75.

Pappachen S, Smith PR, Shah S, Brito V, Bader F, Khoury B. Postoperative pulmonary complications after gynecologic surgery. International Journal of Gynaecology and Obstetrics. 2006;93:74-76.

Perel P, Roberts I 2007 Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 17: CD000567.

Schiøtz HA, Tanbo TG. Postoperative voiding, bacteriuria and urinary tract infection with Foley catheterization after gynecological surgery. Acta Obstetricia et Gynecologica. 2006;85:476-481.

Scottish Intercollegiate Guidelines Network. Prophylaxis of Venous Thromboembolism. Edinburgh: SIGN; 2002.

Smith RN, Cardozo L. Early voiding difficulty after colposuspension. British Journal of Urology. 1997;80:911-914.

Sobolev VE, Dudanov IP, Alontseva NN, Bogdanova VS. [The role of laparoscopy in the diagnosis and treatment of early postoperative complications]. Vestn Khir Im I I Grek. 2005;164:95-99.

Tamussino K. Postoperative infection. Clinical Obstetrics and Gynecology. 2002;45:562-573.

Walsh C, Scaife C, Hopf H. Prevention and management of surgical site infections in morbidly obese women. Obstetrics and Gynecology. 2009;113:411-415.

Wheeler AP, Bernard GR. Treating patients with severe sepsis. New England Journal of Medicine. 1999;340:207-214.

Related posts:

Default ThumbnailFertility control Default ThumbnailViolence against women Disorders and investigation of female reproduction Sexual differentiation: normal and abnormal Principles and new developments in molecular biology Chronic pelvic pain