Complications of Abdominal Surgery

Dr. Ahmed Yousif Abdalla

Intended learning outcomes

• By the end of this interactive lecture every candidate should be able to:
  • Define the complication as a concept.
  • Differentiate between complication, side effect and medical error.
  • Study common post op. abdominal complication.
  • Analyze and interpret lap. Investigation to formulate a list of deferential diagnosis.
  • Approach a patient with post op. complications.

Introduction

Definitions (terminology)

• Complication: unfavorable consequence of a disease, a health condition or a therapy — general term
  • Examples: Diabetics and he developed Renal failure; trauma → compartment syndrome
• Adverse effect: undesired harmful effect resulting from a medication or other intervention such as surgery — specific
  • Examples: NSAID → gastric ulcer; In rectal → drawnell leukar
• An adverse effect may be termed a “side effect”, when judged to be secondary to a main or therapeutic effect
• If it results from an unsuitable therapy, improper procedure, or incorrect dosage this is called a medical error and not a complication
  • malpractice

Examples of medical errors (malpractice)

① trauma case after packing use & stop bleeding, he came with Fever and abdominal Pain, chest x-ray showed good Admixturei abdomen

② Pt undergo Pt nephrectomy for Pt kidney failure but the left kidney was taken.

③ Pt overweight the surgeon did for Pain show gastrectomy then he develop leakage (surgery was not indicated)

④ general surgeon did for his pt Rhinoplasty then pt had wound infection (privilege of surgeon - should be done by plastic surgeon)

⑤ if you don’t instruct your pit after surgery about wound care and taking of antibiotic

⑦ Pit I did for him. CT then he develop Renal failure then you found that he had his protein (no need to fit below)

⑧ pit was taken for removal of lipoma in his thigh, under GA you saw skin tag in his back and you decide to take it (no consent)

• But in case of endoscopy and you saw polyp you can take it because it’s a part of the procedure.
• Or in emergency, pit for laparotomy and you injured the bowel. you have to treat him even without consent

Key principles

• Medical knowledge about a disease, procedure or treatment usually entails a list of the most common complications.
• Complications can be foreseen, prevented or recognized more easily and speedily.
• Depending on the degree of vulnerability, susceptibility, age, health status, immune system condition, etc.
• Complications affect adversely the prognosis.
• Prompt identification of complications can significantly improve outcomes.
• Interdisciplinary approach is essential e.g. IR to help me I and d.
• Non-invasive, & minimally invasive medical procedures usually favor fewer complications in comparison to invasive ones.

Timing of complications

• Early, intermediate, late
• Early + intermediate + increased mortality

Grading of Postoperative complications

α not for your exam

Grading	Grade	Definition/treatment performed
Minor complications (most of complications)	Grade I	Adverse event which alters the standard postoperative course without requiring a specific treatment
Can be treated easily	Grade II	Pharmacologic treatment or minor intervention required
Major complications (when patient needs to be taken for OR or ICU)	Grade IIIa	Surgical, radiologic, endoscopic treatment, or multitherapy required without general anesthesia
Needs intervention	Grade IIIb	Surgical, radiologic, endoscopic treatment, or multitherapy required with general anesthesia
	Grade IVa	Intensive care unit treatment for single organ dysfunction required
	Grade IVb	Intensive care unit treatment for multiple organ dysfunction required (Stroke, MI…)
Mortality	Grade V	Adverse event which leads to death (Brain death in ICU)

Case 1: Generalized peritonitis (perforated appendix)

Presentation

• A 35-year old male presented with a 3 days history of abdominal pain. Examination: features of generalized peritonitis.

What are the features of generalized peritonitis?

• Systemic (general) signs:
  • Unwell patient, swelling
  • Disturbed vital signs (↓BP, tachycardia, fever, tachypnea)
• Specific (abdominal) signs:
  • Guarding, rigidity
  • Generalized tenderness and rebound tenderness
  • Active or decreased bowel sounds (according to case)
  • Fever

What next to do?

• Proper detail Hx, examination, relavent investigations
• Labs: CBC, RFT, LFT, LAC, Control

Differential diagnoses

• Perforated viscus, appendicitis

Management

• Laparotomy — surgical exploration (laparotomy or laparoscopic)
• He was prepared for surgery.

At laparotomy

• Perforated appendix was found
• Intraoperative features of generalized peritonitis:
  • Pus collection + red inflamed peritoneum, pyogenic membrane covering the bowel, maybe blood
• Appendectomy & peritoneal lavage was done.
• Abdomen was closed and a drain placed

Postoperative care

• Postoperatively: NPO, IV fluid & broad spectrum antibiotics
• Then switch after C/S
  • Why? Fear of leak + they will have paralytic ileus as we manipulated the abdomen
  • Until when? they pass flatus or according to the procedure
  • As a pt with cholecystitis, we hear bowel sounds after 6-10h then start feeding

Day 1-4

• Steady improvement.
• Afebrile, drain removed.
• Progressed from fluid to normal diet.
• When we should take out the drain:
  • Amount: amount should be < 3.0 ml/day
  • Content: content or color should be fluid (Haemoserous)

Day 5

• Temp. 38°C, loose motion- twice.
• Why? C-Diff colitis due to B-road spectrum antibiotic — high grade fever
• Possible causes of fever? Collection in the pelvic (abscess), drain removed so recollection; wound infection
• Loose motion?
• Next? Ct contrast
• Will x-ray help? Even if showed air under diaphragm? No, normal post op
• History: chest symptoms, urinary symptoms, abdominal pain, wound site pain, leg pain, nature & number of loose motion.
• Examination: General, IV sites, chest, abdomen (wound, abdomen), P/R, Lower limb (DVT)

Wound infection

Severity ladder:

• Early/ mild
• Moderate/ stitch = sheeth / dehiscence
• Sheeth + muscle + evicceration (burst abdomen)

Severity	Involved (μg/d)	Typical Features	Management
Early, Mild	Skin, subcutaneous tissue	Restless, tenderness, minor discharge	Local site + antibiotics
Moderate, Mild/ Abscess	Subcutaneous, partial hernia	Pre-wound suture, partial dehiscence	Oestrogen, severe removal
Trained/Dehiscence	Traces + muscle	Hemangiomous discharge, wound sparing	Surgical repair
Burst abdomen (Extracerebral)	Skin, hernia, muscle, peritoneum	Wound spares, bowel perforation	Emergency surgery

Postoperative fever

• Day 0 is the day of surgery = stress, anaesthesia = malignant hyperthermia with inhaled anaesthesia

Category	Day	Description
Wind	POD 1-2	the lungs, i.e. atelectasis, aspiration, pneumonia
Water	POD 3-5	urinary tract infection, possibly catheter-associated (if a urinary catheter was inserted during surgery or remains in place currently i.e. Foley catheter)
Wound	POD 5-7	infection of the surgical incision(s), either superficial or deep[4]
(W)abscess	POD 5-7	infection of an organ or space[5]
Waking (or VEINS pronounced like “Weins”) (variant in Almaarefa deck: “Walking”)	POD 5+ (risk may persist for months post-operatively)	deep vein thrombosis or pulmonary embolism
Wonder drugs or “What did we do?”	Anytime	drug fever or reaction to blood products, either a febrile non-hemolytic transfusion reaction or transfusion-related acute lung injury
Wing/Waterway	Anytime	bloodstream infection, phlebitis, or cellulitis related to intravenous lines, either central or peripheral

• Intermediate complications = Until they are out of the hospital/ few days

History & Examination (fever workup)

• History: chest symptoms, urinary symptoms, abdominal pain, wound site pain, leg pain, nature & number of loose motion.
• Examination: General, IV sites, chest, abdomen (wound, abdomen), P/R, Lower limb (DVT)

Standard work up

• Labs: CBC with diff, CRP — Septic work up: CBC
• CV/S risk factors
• EKG, ABG (Resp complications)
• Cultures:
  • Sputum
  • Blood
  • Urine (and UA)
  • Others: (Lines, wound)
• Radiology … To reach diagnosis + guide therapy in some cases:
  • CXR
  • CT scan/ spiral
• Treatment:
  • Pan-culture everything (blood, urin, stool, drain)

Postoperative diarrhea

• Causes: MCA
  • Pelvic collection: Cause irritation
    • Passage of mucous with diarrhea is pathognomonic.
  • Pseudomembranous colitis
  • Food poisoning / gastro-enteritis
  • Others

Case 1 continued: examination findings → pelvic collection

• GE: normal
• Chest clear
• Lower limb: no swelling or tenderness
• Abdomen: wound looks OK,
• P/R- bulging anteriorly, tenderness.
• Significance of this finding? Pelvic abscess
• What to do?

Investigations

• Labs. CBC, renal function, CRP
• Radiology:
  • CXR, ?AXR
  • U/S abdomen & pelvis
  • CT scan

Pelvic collection (Collection in Pelvis)

Management

• Conservative- very small collection may resolve
• Drainage:
  • CT guided drainage: Trans-rectal, Percutaneous suprapubic
  • Surgical

Case 2: Acute cholecystitis & post-cholecystectomy bile leak

Presentation

• A 40-year old female admitted with features of acute cholecystitis
• What are these features? URQ pain radiates to shoulder, increases after food
• CBC & LFT- normal. High total
• Diagnosis confirmed by ultrasound.
• What are US findings? Pericholestite fluid, wall thickness, presence of stone and its echolytic shadow
• Patient progress: Responded well to conservative management
• What is her further management? Stabilise and do cholecystectomy within 72h or wait until 6 weeks

Further management plan

• Cholecystectomy
• Time
• Approach
• Advantages vs disadvantages

Q: What are the preconditions?

• Stabilize the patient comorbidities
• Normal labs
• Anticoagulants

laprascopic: Injury to near by structure

Cholecystectomy on next list

• 2 days after admission.
• Difficult laparoscopic cholecystectomy.
• Left a drain at sub-hepatic area.

1st postoperative day

• Sips of water+ IV fluid
• Temp 38°C, pulse 100/ min.
• Abdomen mildly distended, sluggish bowel sounds. (hypoactive)
• Drain 90 ml darkish fluid. (Volum, Color)
• Most likely bile

2nd postoperative day

• IV fluid + NPO
• Temp 37.8°C, pulse 90/ min.
• Vomited twice in last 24 hours.
• Abdomen mildly distended, non-tender, sluggish bowel sound.
• Drain 175 ml dark green. → bile

What next?

• Bile leak, why? Slip ligation, injury to the CBD or CHD, or anywhere.
• Accessory duct as ducts of Luchka — nothing usually to do as will close spontaneously, but as it is increasing we should manage
• Bismuth classification of injury

Post-cholecystectomy bile leak

• Biliary tract injury.
• Proximal bowel injury- ? Duodenum
• Bowel injury unlikely in this patient.
• Why?

Investigations

• ? CXR, AXR → Case: you saw Air under diaphragm and you took the pt to the OR (this is non-practice because normal to have air under diaphragm post op)
• U/S
• CT
• ERCP (diagnosis + therapy) + MRCP + PTC

Ultrasound vs CT (VS)

• VS: only told me if there’s selection or not [only tells if there is collection or not]
• I Can Know the Source

Management of bile leak

• Establish and maintain adequate drainage.
  • Drain was left in situ at the initial procedure- draining bile.
• Percutaneous guided drainage (USS guided)
• Antibiotics and a daily assessment of drain output.
• Drainage out put:
  • <200 ml/day & reducing daily- likely to stop on its own.
  • Persistent drainage > 200 ml/day – ERCP indicated
• ERCP: cystic duct leak- internal stent (5-7 cm)
• Abdominal drain removed once it stops drainage
• Stent removed in 6-8 weeks
• Other CBD injury- surgical intervention
• If ERCP is not possible – surgery in complicated (bypass hepatosejunostomy)

CBD stent

• Stent for 6 weeks to relife the Prusser [relieve the pressure]
• If it was major leakage sometime you need Recondition & biking free

Cystic duct leakage, post cholecystectomy

• ERCP

Causes of cystic duct leakage

• Clips not properly applied
• Pressure necrosis from too tight application
• Distal obstruction- stone in CBD
• Duct of luschka
• Backward pressure
• Accessory duct

Case 3: RTA victim — blunt abdominal trauma (splenic injury)

Primary & secondary survey

• RTA victim
• Conscious, talking
• Primary, & secondary survey
• A & B – stable
• C - hemodynamically unstable
• Rapid crystalloid infusion
• CBC, U/E, cross match
• FAST - splenic injury, free fluid in peritoneum
• Management ?

Supine patient

FAST views

• Standard views (standerded FAST):
  1. Subxiphoid/Subcostal: Pericardium
  2. RUQ: Morrison’s Pouch
  3. Pelvis: Pelvic Cul-de-sac (Douglas)
     • Transverse
     • Longitudinal
  4. LUQ: Splenorenal & perisplenic spaces
• Extended views (E-FAST): For pleural effusion
• Remember: Probe marker almost ALWAYS facing either patient’s right or patient’s head

Management

• Consent for emergency surgery.
• Urgent laparotomy- midline incision.
• Splenic injury with massive hemoperitoneum.
• Perisplenic packing.
• Blood sucked out.
• Splenectomy.
• No other injury.
• Abdomen closed, drain placed

Day 1-3

• Hemodynamically stable
• Initially: NPO+ IV fluid,
• Later allowed oral feeding
• 2 units of PCV to raise Hb above 10g/dl
• Pneumococcal vaccination
• Vag implant in emergency splenectomy
• Antibiotics

Drain timeline

• Day 1 - bloody, 150 cc.
• Day 2 - serous 120 cc
• Day 3 - turbid fluid 150 cc,
• Day 4 - turbid fluid 230 cc
• Drainage fluid contained very high level of amylase → Pancreatic juice
• What is next?

Pancreatic fistula

• Causes:
  • Don’t do ERCP in acute pancreatitis you will make it worse.
  • ✓ Operative trauma,
  • ✓ Complication of acute/ chronic pancreatitis
• Management:
  • Skin care
  • Management of electrolyte & nutrition:
    • NPO+TPN
  • Specific management:
    • ERCP & pancreatic duct stenting
    • Octreotide
  • Repeated CT scan to rule any other collection
  • PCD- for other collections

Case 4: Laparoscopic sleeve gastrectomy — early leak

• A 45- year male, smoker, complained of weight gain and obesity.
• Past Hx: DM (II), on OHA (in morning, now)
• Underwent laparoscopic sleeve gastrectomy
• Found to have HR : 120/ min — Early sign of leak = tachycardia
• Dx: Lackage [leakage] → to exclude it need Contrast → Reason, swallow, Gaital [Gastrografin] Good-grain
  • Rixew Post of note
  • How to treat? According to the site, size?
• Rx:
  • CT with contrast = leak in peritoneal cavity
  • Seal the leak + cover with omentum
  • If mild = drain
  • Some need bypass
• Bleeding to exclude it by CBC
  • P.E. need CT to be excluded
  • H2O (hematocrit) ↓ Hemoglobin
  • How CT for hemolysis or to determine leakage
  • Radiology
  • The hemoglobin could be false high due to dehydration
  • Or False positive if nurse take sample from arm which is his IV fluid
  • No gain due to taste + loss for hematocrit
• Will leak have in day 07? Unlikely. From Day 2 +3

Case 5: Recurrent inguinal hernia after open mesh repair

• A 53- year male complained of right groin swelling for 3 months
• History of open mesh repair of right inguinal hernia 6 months ago — risk factors of recurrence
• Post operatively: wound infection
• 3 months later, presented with recurrent swelling at surgical site
• Past Hx: Unremarkable
• Clinical findings
• Dx:
  • Open, Now it should be laparoscopic:
    • TAPP (TransAbdominal PrePeritoneal repair)+ TEP (Totally ExtraPeritoneal repair)
  • Mesh infection: do US to confirm you will see collection and inflammatory process
• Rx:
  • When hernia should be laparoscopic? Bilateral + recurrence
  • Take off the mish [mesh]
  • If no response at Antibiotic
  • Hestrocele [hydrocele] US to exclude
  • Lymph node do US to confirm it
  • Recurrence exclude it by US then CT
  • Laparoscopic hernia repair (one of indication at laparoscopic)

Case 6: Post-thyroidectomy progressive neck swelling

• A 45- year female complained of neck swelling for 3 months
• Associated with difficulty in breathing and swallowing
• FNA: Benign
• Past Hx: Unremarkable
• Subtotal thyroidectomy
• Post operatively: Progressive neck swelling
• Rx