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SURGICAL COMPLICATIONS
Jose Ravelo T. Bartolome, MD, FPCS. Chairman & Assistant Professor
Department of Surgery FEU- NRMF Institute of Medicine

OBJECTIVES

THAT AT THE END OF THE SESSION, THE STUDENTSUNDERSTAND BASIC PRINCIPLES
IN RECOGNITION AND MANAGEMENT OF SURGICAL COMPLICATIONS...
UNDERSTAND THE MECHANISMSLEADING TO
SURGICAL COMPLICATIONS...
UNDERSTAND THE IMPORTANCE OF EARLY RECOGNITION AND MANAGEMENT OF
SURGICAL COMPLICATIONS.

surgical complications
General considerations...

POSTOPERATIVE COMPLICATIONS:
May result from any of the following:
o The Primary Surgical Disease
o The Operation/ Surgical Procedure
o Unrelated Factors

Occasionally one complication may lead or a result of another ( eg, acute
myocardial infarction as a result of massive postoperative bleeding)
Clinical signs of disease often blurred in the immediate postoperative period
Early detection is crucial; diligent and periodic monitoring by the surgical team
Prevention of complication starts in the preoperative period; evaluation of
patients disease and risk factors; goal is improvement of health of patient
prior to surgery
Examples:
o Cessation of smoking 6 weeks before surgery decrease incidence of
pulmonary complication from 50%top 10%.
o Correction of gross obesity decreases intra-abdominal pressure and
risk of wound and respiratory complications; improves ventilation
Informed consent must be clearly explained by the surgeon
Short preoperative hospital stay to minimize cost and exposure to antibiotic
resistant microorganisms
pre-operative training in respiratory exercises.
Early mobilization, proper respiratory care and careful attention to fluids and
electrolytes needs are important
Comprehensive preoperative preparation of the patient is of outmost priority

SURGICAL COMPLICATIONS

1. WOUND COMPLICATIONS
a. Hematoma
b. Seroma
c. Wound dehiscence
d. Miscellaneous problems

2. RESPIRATORY COMPLICATIONS
3. CARDIAC COMPLICATIONS
4. PERITONEAL COMPLICATIONS
5. POSTOPERATIVE PAROTITIS
6. COMPLICATIONSOF ALTERED GASTROINTESTINAL MOTILITY
a. Gastric Dilatation
b. Bowel obstruction
c. Postoperative fecal impaction

7. POSTOPERATIVE PANCREATITIS
8. POSTOPERATIVE HEPATIC DYSFUNCTION
9. POSTOPERATIVE CHOLECYSTITIS
10. CLOSTRIDIUM DIFFICILE COLITIS
11. URINARY COMPLICATIONS
a. Postoperative urinary retention
b. Urinary tract infection

12. CENTRAL NERVOUSSYSTEM COMPLICATIONS
a. Postoperative cerebrovascular accident
b. Seizures

13. PSYCHIATRIC COMPLICATIONS
a. Delirium Tremens
b. The ICU syndrome
c. Sexual dysfunction

14. COMPLICATIONSOF INTRAVENOUSTHERAPY AND HEMODYNAMIC MONITORING
a. Air embolism
b. Phlebitis
c. Cardiopulmonary complications
d. Ischemic necrosis of finger
15. POSTOPERATIVE FEVER


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WOUNDCOMPLICATIONS

complications related to the surgical wound...

I. WOUND HEMATOMA

Collection of blood or clot in the wound
One of the most common wound complication
Imperfect hemostasis

High risk of wound hematoma:
o Patients on anticoagulants
o Pre-existing coagulopathies

Contributing factors:
o Vigorous coughing or marked arterial hypertension


Clinical signs:
Wound elevation and discoloration of edge
Wound discomfort and swelling
Blood leaking through skin sutures
Airway compromise in certain cases of neck hematomas after thyroid
surgery, parathyroid surgery or carotid artery surgery

Treatment:
o Small hematomas resorb spontaneously but may increase chance of infection
o Wound exploration and evacuation of clots
o Effect hemostasis

II. WOUND SEROMA
Collection of fluid in the wound other than blood or pus
Operations that involves elevation of skin flaps and transection of numerous
lymphatic channels (eg, mastectomy, groin operations)
Delays healing and increased risk of wound infection

Treatment:
o Repeated needle aspiration to evacuate
o Compressive dressings
o Leaking wound seroma may need to be reexplored and lymhpatics ligated
o No treatment


III. WOUND DEHISCENCE
Partial or total disruption of any or all layers of the operative wound closure
In abdominal wound closure, dehiscence may lead to visceral evisceration
1 3%of abdominal surgical procedures

Contributing Factors:
o Systemic Risk Factors
Age rare in less than 30 years; 5%risk in 60 years after laparotomy
Immunocompromised patients
- Diabetes mellitus
- Uremia
- Immunosuppression
- Jaundice
- Sepsis
- Hypoalbuminemia
- Cancer
Obesity
Steroids

Local Risk Factors
o Inadequate closure (technical)
o Increased intra-abdominal pressure
o Deficient wound healing
o Usually combination of above factors
o Type of incision (transverse, midline, etc) NO INFLUENCE to
incidence of dehiscence

Adequacy of closure:
Single most important factor; technical issue
Fascial closure is most crucial (in abdominal wound closure)
Accurate approximation of anatomic layers is essential


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o Prevention:
Neat incision
Avoid tissue devitalization/gentle handling of tissues
Accurate placement and tyingof sutures
Proper suture selection
Often results to placing too few stitches and placing them to close to edge of
fascia
o Ostomies and drains brought out in separate incisions

Intra-abdominal Pressure
o Etiologic agents:
Postoperatiove ileus
- Chronic obstructive pulmonary disease
- Postoperative bowel obstruction
- Obesity
- Cirrhoisis with ascites formation
Extra precautions are necessary in the above conditions

Deficient Wound Healing
o Contributing factors:
Wound infection in 50%of wound rupture
Presence of drains, seromas and hematomas
o Healing Ridge a palpable thickening extending about 0.5 cmin each
side of incision; must appear near end of 1st week after operation; clinical
evidence of adequate healing; absent in deficient healing

Diagnosis and Management:
o Wound dehiscence may occur anytime following closure
o Most commonly observed between 5th 8th postoperative day when
wound strength is at minimum
o May occasionally the 1st sign of intra-abdominal abscess
o First sign: discharge of serosanguinous fluid or sudden evisceration
o Other manifestations depends on wound location
Hematoma formation
Leak of pleural fluid or air with paradoxic breathing (thorcotomy
closure)
Management is individualized
o Delayed closure of evisceration
o Immediate resuturing
o Control of infection
o Control of contributingfactors

Miscellaneous problems
Chronic wound pain
Wound pain usually decreases after 4 -6 days
Stitch abscess
Granuloma
Incisional herni0061
Neuroma
Neuropathic pain

RESPIRATORY COMPLICATIONS

Most common single cause of surgical morbidity after major procedures
Second most common cause of postoperative mortality in patients older than 60 years
old
Common in thoracic and upper abdominal operations
Incidence lower in pelvic surgery; even lower in extremity or head and neck operations
More common in emergency operations

Risk factors:
Pre-existing COPD
Elderly patients
ATELECTASIS...
Most common pulmonary complication; significant lung segment are collapsed
25%of patients who have abdominal surgery
Common in elderly; overweight; smoker; (+)respiratory symptoms
Pathogenesis involves obstructive and non-obstructive factors
Obstructive factors due to secretions brought about by COPD, intubation and
anesthetic agents
Non-obstructive factors due to closure of small bronchioles secondary to
shallow expansion in post-operative patients
Usually manifested by fever, tachyacardia and tachypnea
PE will show an elevated diaphragm, scattered rales and decreased breath
sounds

Prevented by early mobilization, frequent change in position, encouragement to cough,
use of incentive spirometer

Persistent after 72 hours invariable result to pneumonia

Treatment: Good pulmonary toilet

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Pulmonary Complications
PULMONARY ASPIRATION...
Leads to pneumonia
Conditions that may lead to aspiration
Trauma and unconscious patients
Nasogastric intubation
Intestinal obstruction and pregnant women
In 80%of patients with tracheostomies
2/3 of cases follows thoracic and abdominal surgery; 50%of which progress to
pneumonia; mortality rate for aspiration pneumonia is also at 50%

Prevention:
Preoperative fasting; proper positioning of patient; careful intubation during induction
of general anesthesia

Treatment:
Effective pulmonary toilet, Bronchoscopy to remove solid aspirates, Antibiotics

Respiratory Complications
POSTOPERATIVE PNEUMONIA...

The most common pulmonary complication among patients who die after surgery

Highest risk:
Peritoneal or intra-abdominal infection
Prolonged ventilatory support
Clinical manifestations:
Fever, tachypnea, increased secretions and physical changes suggestion pulmonary
consolidation
Radiographic evidence of pulmonary consolidation

Management:
Effective antibiotics
Pulmonary toilet and physiotherapy
Prevention

Respiratory Complications
PLEURAL EFFUSION & PNEUMOTHORAX

Small effusion postoperative is fairly common and requires no treatment esp. after
upper abdominal sugery

In the absence of cardiac condition, effusion late in postoperative period is due to:
Subdiaphragmatic inflammation (subphrenic abscess, pancreatitis)
No compromise of pulmonary function requires NO treatment
With compromise of function requires evacuation either by needle aspiration
(thoracentesis) or tube thoracostomy
Postoperative pneumothorax usually follows subclavian vein catheterization or
in operations that may have violated the pleura (eg, nephrectomy or
adrenalectomy)

Respiratory Complications
FAT EMBOLISM...

Common but rarely causes symptoms
Fat particles in pulmonary vascular bed in 90%of patients who had long bone
fractures or joint replacement
Exogenous sources of fats such as in blood transfusion, IV fat emulsions or
bone marrow transplantation

Fat embolismsyndrome neurologic dysfunction, resp insufficiency, petechiae in the
axilla, chest and
proximal arms; evident 48-72 hours after injury; diagnosis by the presence of fat
droplets in sputum
and urine; management mainly supportive Decreased hematocrit, thrombocytopenia
and coagulation abnormalities are usually seen


CARDIAC COMPLICATIONS

Life-threatening complication
Comprehensive cardiac evaluation preoperatively
Correct existing cardiac conditions (eg valvular heart disease)
Determination of cardiac function and presence of dysrhythmias
General anesthesia depress myocardium; some anesthetic agents predispose the heart
to dysrhythmias

Duration and urgency of surgery; degree of perioperative bleeding
correlates with risk of serious postoperative cardiac complications

Noncardiac complications may induce and increase risk of cardiac complications Eg,
massive bleeding inducing myocardial infarction

Use of electrocautery in patients with cardiac pacemakers
Postoperative sepsis and hypoxemia are common culprits that may induce cardiac
complications
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Fluid overload leads to left ventricular failure
ICU-CCU monitoring post-operatively usually necessary
Cardiac Complicatons...
DYSRHYTHMIAS

Most appear intraoperatively or within the first 3 days postoperatively
Especially likely during intra-thoracic surgery
Intraoperative dysrhythmias
Overall incidence is 20%; higher (35%) in those with pre-existing condition
Mostly self-limited
Usually duringinduction of anesthesia (35%); likely related to anesthetic agents


Postoperative dysrhythmias
Generally related to reversible factors: hypokalemia, alkalosis, digitalis toxicity, and
stress during emergence from anesthesia

Maybe the first sign of myocardial infarction
Mostly asymptomatic; can have chest pain, palpitations and dyspnea
Medical management and ICU monitoring
Postoperative Myocardial Infarction
Incidence of 0.4%of all operations (USdata)
Increased incidence with predisposing factors
Elderly; preoperative CHF
Operations for atherosclerosis (eg, carotid endarterectomy, aortoiliac graft)
Previous ischemia or frank MI (surgery usually delayed 6 months post MI)

Diagnosis: clinical and ECG
CCU monitoring and management
Postoperative Cardiac Failure
Left ventricular failure and pulmonary edema in 4%of patients over 40 years of age
undergoing surgery and anesthesia

Fluid overload in limited myocardial reserve most common cause; others are MI and
dysrhythmias

Clinically will present with dyspnea, hypoxemia with normal CO2 tension and diffuse
congestion by chest x-ray

Management is generally supportive

HEMOPERITONEUM
Bleeding is the most common cause of shock within the first 24 hours post-operatively
in abdominal surgery; a life-threatening and rapidly-evolving complication Technical
problem in hemostasis

Coagulation and bleeding problems
Usually apparent within the first 24 hours post-operatively
High-index of suspicion in diagnosis
Management is frank reoperation after all other differentials are ruled-out

Peritoneal Complications...
COMPLICATIONSOF DRAINS
Postoperative drainage of peritoneal cavity indicated to prevent accumulation of fluids
such as bile or
pancreatic juice; to treat established abscess

Drains may be left to evacuate small amounts of blood; not reliable to assess rate of
bleeding

NOT A ROUTINE for operations not expected to have fluid leaks (eg. Cholecystectomy,
splenectomy,
colectomy)

May increase risk of infection; may also promote anastomotic leaks

Choice of type must be individualized
Penrose rubber drain
Closed suction silastic tube drains
Postoperative Parotitis...
Rare but serious staphylococcal infection of the parotid gland
Limited almost entirely to elderly, debilitated, malnourished patients with poor
oral hygiene
Appears in the 2nd postoperative day; associated with prolonged nasogastric
intubation
Triggering factors are dehydration and poor oral hygiene
Decreased secretory activity of gland and inspissated secretion becomes
infected by staphylococcal bacteria
Clinically as pain and tenderness



Management:
Hydration; Drainage of the duct
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Appropriate antibiotics (vancomycin)
Surgical drainage in progressive disease
Complications of altered gastrointestinal motility...
Effective GI motility is under the control of the enteric nervous system
Anesthesia and surgical manipulation depress effective GI motility resulting to
postoperative ileus

Factors that worsen or prolong ileus:
Opioids
Electrolyte abnormalities
Inflammatory conditions (pancreatitis or peritonitis)
Pain
Degree of ileus related to degree of surgical manipulation
GI peristalsis returns to normal within 24 hours after most non-abdominal
surgery
After laparotomy, gastric peristalsis returns in 48 hours as well as
colonicactivity; small bowel activity affected to lesser extent except with small
bowel resection and anastomosis

Signs of returning bowel function: passage of flatus, mild cramps and return of appetite
No specific treatment for postoperative ileus
Gastric Dilatation...
Rare life-threatening complication
Massive distention of the stomach by gas and fluids
Risk factors:
Asthma
Recent surgery
Gastric outlet obstruction
Absence of the spleen
Forced mechanical ventilation
Progressive dilatation leads to more problem
Gastric outlet obstruction
Ventilatory compromise due to further elevation of the diaphragm
Gastric venous congestion leading to mucosal necrosis and bleeding; may lead to
perforation
Gastric volvulus
Clinically ill patient with abdominal distention, hiccups and electrolyte imbalance
Management is immediate decompression by NGT; late stages may require gastrectomy


Bowel Obstruction...
Failure of prompt return of normal bowel function
May lead to paralytic ileus or mechanical obstruction

Usual cause:
Postoperative adhesions
Internal herniation
About 50%of early postoperative bowel obstruction follows colorectal surgery
Diagnosis requires high index of suspicion
Radiographic demonstration of air-fluid levels in the bowel
High mortality (15%) due to delayed diagnosis; leads to gangrenous changes in the
bowel
Decompression and hydration suffice most cases
Re-operation in established mechanical obstruction

Postoperative Fecal Impaction...

Usually the result of colonic ileus and impaired perception of rectal fullness
Disease of elderly and young patients with megacolon or paraplegia
Anorexia, obstipation and diarrhea; marked distention may lead to colonic perforation
Diagnosis by rectal examination
Manual removal of impacted stool; enemas and repeated digital rectal examination

Postoperative Pancreatitis...
Accounts for 10%of all cases of acute pancreatitis
Usually related to surgery near the pancreas
1%incidence after cholecystecomy
8%incidence after CBDE exploration
Higher incidence in those with pre-existing pancreatitis
Occasionally seem after cardiopulmonary bypass, parathyroid surgery, and renal
transplantation
Frequently of the necrotizing type
Mortality is high: 30 40%
Pathogenesis appears to be related to mechanical trauma to the pancreas and its blood
supply
Diagnosis both clinical and aided by laboratory (hyperamylasemia)
Management depends on severity; medical or surgical
Postoperative Hepatic Dysfunction...
Mild jaundice to life-threatening hepatic failure in 1%of surgical procedures
performed under general anesthesia
High incidence following pancreatectomy, biliary bypass operations and
portacaval shunts
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Postoperative elevation of the bilirubin categorized as:

PREHEPATIC JAUNDICE
Hemolysis (drugs, transfusion, sickle cell crisis)
Reabsorption of hematomas

HEPATOCELLULAR INSUFFICIENCY

Viral hepatitis
Drug-induced (anesthesia, others)
Ischemia (shock, hypoxia, low-output states)
Sepsis
Liver resection (loss of parenchyma)
Others (TPN, malnutrition)

POSTHEPATIC OBSTRUCTION (to bile flow)
Retained stones
Injury to ducts
Tumor (unrecognized or untreated)
Cholecystitis
Pancreatitis
Occlusion of biliary stents
Postoperative Cholecystitis...
May occur in any type of operation
More common in GI surgery
Shortly after endoscopic sphicnterotomy in 3-5%
Chemical cholecystitis after chemotherapy with mitomycin and floxuridine (hence
cholecystectomy are performed prior to givingthese agents)
Fulminant gangrenous cholecystitis following hepatic tumor embolization or for
arteriovenous malformations

Degree of severity:
Frequently acalculous (70-80%)
Common in males (75%)
Progression is rapid to gangrenous changes
Not likely to respond to conservative management
Etiologic factors:
Biliary stasis
Biliary infection
Ischemia
Treatment: prompt cholecystectomy

CLOSTRIDIUM DIFFICILE COLITIS...
Heralded by postoperative diarrhea
Common nosocomial infection in surgical patients
Asymptomatic colonization to rare severe toxic colitis
Diagnosis by identification of specific toxin
produced by the bacteria Clostridium difficile
Prevention is important
Treatment by IV metronidazole and oral vancomycin; supportive

Urinary Complications...
Postoperative urinary retention
Inability to void the urine postoperatively
Especially after pelvic and perineal operations; under spinal anesthesia
Interference in the neural mechanism that controls voiding
When normal bladder capacity of 500 cc is exceeded, it further inhibit ability of the
bladder to contract
Prophylactic catheterization when needed
May lead to hemorrhagic cystitis and frank bacterial cystitis
Length of catheterization must be individualized
Treatment for retention: Catheterization
Urinary Complications...
Urinary tract infection
Most frequently acquired nosocomial infection

Principal cause:
Pre-existing infection
Instrumentation/ catheterization
Bacteriuria is present in 5%of catheterized patient
for less than 48 hours; clinical UTI seen only in 1%


Clinical manifestations:
Dysuria and mild fever for cystitis
High fever if with pyelonephritis; flank tenderness
and occasionally ileus

Treatment:
Judicious catheterization
Antibiotics
Adequate hydration

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CENTRAL NERVOUSSYSTEM COMPLICATIONS...
Postoperative cerebrovascular accident
Almost always results from ischemic neural damage due to poor perfusion
Elderly patients with atherosclerosis who becomes hypotensive during surgery
May be related to the surgery itself inadvertent clamping of the carotid artery during
extensive neck
surgery

Specific procedures at risk:
Carotid endarterectomy (13%)
Open heart surgery (risk of embolism)
Non-cardiac operations (0.2%)
CENTRAL NERVOUSSYSTEM COMPLICATIONS...
Seizures
Epilepsy, metabolic derangements and medications may lead to seizures
postoperatively
Common in ulcerative colitis and Crohns disease for unknown reasons
Management generally supportive to avoid further complications from surgery

PSYCHIATRIC COMPLICATIONS...
Anxiety and fear is normal in patients undergoing Sx
Cultural and psychological factors play role
Postoperative psychosis develops in about 0.5%after abdominal surgery
More common after thoracic surgery; elderly and those with chronic disease
Underlying depression or history of chronic pain may exaggerate problem
Depression to frank delirium
After ruling out metabolic problems related to surgery, prompt psychiatric consult is in
order
May compound or lead to other surgical complications (eg. wound dehiscence)
PSYCHIATRIC COMPLICATIONS...
Delirium Tremens
Related to chronic alcoholism
The ICU syndrome
Related to the environment of pain, fear and sleep deprivation in the ICU
Sexual dysfunction
In certain procedures such as prostatectomy, heart surgery and aortic
reconstruction; abdominoperenial resection. Unclear pathogenesis

Complications of Intravenous Therapy and
Hemodynamic Monitoring
Air embolism
During or after insertion of venous catheter; accidental introduction of air
Air lodges to right atrium preventing adequate filling of heart
Hypotension, jugular vein distention and tachycardia
Prevention is important; Trendelenberg position when central line is being inserted
Treatment by aspiration of air with syringe; patient positioned right side up and head
down

Phlebitis
Inflammation in the venous catheter site

Predisposing factors:
Nature of canula
Solutions infused
Bacterial infection
Venous thrombosis
Symptom triad: induration, edema and tendernessFrequent and periodic change of
tubing for prevention (every 48-72 hours) and rotation of insertion every 4 days

Usual cause of fever after 5 days postoperatively
Treatment is drainage in frank abscess formation
Complications of Intravenous Therapy and Hemodynamic Monitoring

Cadiopulmonary complications
Related to procedure performed
Right atrial perforation and tamponade after insertion of subclavian catheter

Ischemic necrosis of finger
Related to continuous arterial catheterization and monitoring
Complications of Intravenous Therapy and Hemodynamic Monitoring

POSTOPERATIVE FEVER...
Occurs in 40%of patient after major surgery

Causes:
Atelectasis if within the 1st 48 hours
After the 2nd post-operative day
Urinary tract infection
Surgical site or wound infection (on the 3rd 5th day)
Phlebitis
Fever is rare after the 1st week in normally convalescing patient; if persistent, may think
of drug allergy,
transfusion related, septic pelvic thrombosis and intra-abdominal abscess


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