General Surgery Sheet #9 By Suhaib Attieh

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General Surgery Sheet #9 By Suhaib Attieh

Post by Sura on 24/4/2012, 2:26 am

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Re: General Surgery Sheet #9 By Suhaib Attieh

Post by Shadi Jarrar on 4/5/2012, 10:56 pm

بسم الله الرحمن الرحيم

General surgery lecture no. 10
17\4\2012
Surgical complications

• Most surgical complications develop in relation to operation room but not all of them, so we can limit many of these complications by considering some measures we will mention them later in this lecture.
• Surgical complications can occur regardless the experience of the surgeon, wither he is senior or junior.
• Surgical complications are of high concern in legal issues, as it could be due to a surgeon’s fault but also it could be due to environmental or host factors. Some complications are expected in some cases to some degree either due to the patient status or the operation room environment. But also many unexpected complications occur, so it’s referred to the investigation staff to decide the cause and punish the one who did the mistake.
• A surgery can be performed in a technically perfect operation for a severely ill patient. Complications in these cases are more likely to be due to health status of the patient.
• Surgical complications:
1- Wound complications.
2- Temperature changes. Hypo or hyper- thermia.
3- Post operative fever.
4- Pulmonary complications.
5- Cardiac complications.
6- Renal complications.
7- GI complications.
8- Metabolic and neurologic complications.
9- Other complications: like bleeding that may lead to hypovolemia & hypotension which may result in MI.
• A full medical history would give the surgeon an idea about the possible complications and what risk factors are present.

• Surgeries could be divided into:
1- Minor surgeries. Complications are less likely to happen in this type of surgeries, but still there’s a chance for complications to happen.
2- Major surgeries. Major surgeries, when there’s general anesthesia, have higher risk of complications. General anesthesia by itself is considered a major procedure and has many side effects so it is preferred to be avoided whenever possible. Again, if the procedure can be done under local anesthesia, general anesthesia must be avoided.
• During the surgery especially if the patient is at risk of MI:
1- Blood pressure should be monitored.
2- Continuous administration of IV fluids. This also should be under monitoring to avoid fluid overload.
3- Adequate analgesia.
• Rules that must be followed to prevent or reduce surgical complications (preventive measures):
1- Prevent bleeding.
2- Sterile procedure to prevent wound infection.
3- Follow certain measures to reduce the risk of possible complications. For example, if the patient is at risk of DVT (deep vein thrombosis) we put the patient under heparin therapy “prophylactic heparin” to prevent DVT.

• Some unrelated factors might also complicate the operation. For example, patient with diverticulosis (Diverticulosis is a condition that develops when pouches (diverticula ) form in the wall of the colon (large intestine ). These pouches are usually very small (5 to 10 millimeters) in diameter but can be larger.) came with another chief complaint that needed a surgery, while performing the surgery, the patient is at risk of certain complications due to diverticulosis which is unrelated to the chief complaint. Also patient with upper respiratory tract infection came to perform a GI surgery; this patient is at higher risk to develop aspiration pneumonia.
• Details about surgical complications:
1- Wound complications:
a- Dehiscence: is separation of facial layer (opening of the wound). The facial layer is the strongest layer in the wound. Early after operation. Serous drainage from the edge of the wound. I may feel a bulge under the wound. Hard to be diagnosed, so any discharge from the wound we have to consider a wound problem i.e. infection or dehiscence.
- Risk factors of dehiscence(also increase the risk of wound infection):
a) Type of surgery and the technique used in it. For example, if the wound was closed under tension, this will increase the risk of dehiscence. Also regarding the type, wither it’s a clean wound or dirty wound, which affects the suture line.
b) Malnutrition: affects the protein synthesis in the body, thus affecting the healing process.
c) Radiotherapy: before the surgery or even during healing of the wound.
d) Chemotherapy:
e) Steroid use: causes improper wound healing, that increase the risk of dehiscence.
f) Increase intra-abdominal pressure: this increase in pressure causes edema which makes it harder for the wound to be closed. In these cases we might close the wound in another procedure (apply gauze and wait till the edema is relived and then close the wound) and this is better than having dehiscence and fighting to treat it.
g) DM: poor healing that increase the risk of dehiscence.
- Mortality from wound dehiscence could reach up to 30%. This high mortality may be due to bowel incarceration (intestinal obstruction) or misdiagnosis. This point is very important, the patient might come complaining of abdominal pain and the medical stuff misdiagnose a dehiscence and just prescribe analgesics. After that, the dehiscence is complicated and might cause death.
Evisceration: the skin is opened completely and the content under it is leaking out.
So to differentiate between dehiscence and evisceration, in evisceration the wound is completely opened and the content might be leaking out of it.
The evisceration is an emergency situation and I have to deal with it as fast as possible. First of all I put a sterile strips on the bowel (I don’t put it back to avoid intra-abdominal infection) after that, I send the patient again to the operation room. Some cases of wound dehiscence could be treated conservatively with antibiotic and wound care without being sent to the operation room, but the patient should be monitored especially if he has other systemic complications like hypotension. In some cases, I can’t take the patient back to the operation room due to his medical situation, in this case I try to treat him as conservative as possible.



b- Seroma: is a collection of liquefied fat, serum, fluids & lymphatics under the site of incision. It’s a common post-operative complication mostly found in the fat tissue, so any increase in the percentage of the fat around the wound will increase the risk of seroma. It’s a benign pathology (not malignant) appears as a swelling around the wound area after 3 -7 days.
- It’s not tender and there’s no erythema. This is a very important point to differentiate it from wound infection which is associated with tenderness and erythema.
- Seromas are different from hematomas, which contain red blood cells, and form abscesses, which contain pus and result from an infection. (If the swelling contains fat, it’s called seroma. If it contains blood, it’s called hematoma. And if it contains pus, it’s called abscess).
- Seroma is usually associated with dissection, so to prevent it, the surgeon must avoid dissection. But if dissection is a must, then, proper suction must be applied to prevent this accumulation of fat, serum and lymphatics.
- Seroma could be super imposed with infection, so when the doctor suspect a seroma, he must perform aspiration or evacuation to eliminate infection. It’s preferred to take a sample from the seroma even if the patient isn’t complaining of pain or tenderness and there’re no signs of infection. We have to roll out infection by making culture of the sample. And till getting the result of the culture, we give a course of anti-biotics, and we stop it if the result was negative.
- Note: if we have a prosthesis (valve or artery or anything) and there was a discharge near it, we should worry about that, because infection with a prosthesis is a disaster.

c- Hematoma: it’s an abnormal collection of blood, appear as a swollen blue-purple skin discoloration at the site of incision, with time it changes into yellowish discoloration until it disappears.
- It’s also a common complication at the site of surgery.
- It’s due to inadequate homeostasis. Sometimes we do a proper control of homeostasis during the surgery but after we finish, the blood pressure might rise so the small vessels start bleeding and eventually the hematoma formation. Patients on anti-coagulants or anti-platelets are at higher risk of hematoma formation.
- Hematoma might be super imposed with infection (like seroma) so I have to investigate if I suspect infection. Large hematomas might be associated with a low grade fever (fever is associated with the absorption of hematoma).
- In neural surgeries, hematoma must be avoided as much as possible. Neural surgeons would never do a neural surgery to a patient on anti-coagulant or anti-platelets. Hematoma is dangerous also in the neck, in thyroid surgery for example; as it affects the breathing (soft tissue edema in the neck will compress on the larynx and might cause suffocation). Hematoma in the neck is an emergent situation; the surgeon might need to re-open the wound so it’s preferred to put two drains to avoid the formation of hematoma.

d- Wound infection: now it’s called surgical site infection (SSI).
- It’s a major problem. Could be superficial (skin and subcutaneous) or deep (affecting intra-abdominal organs).
- It occurs usually at 4th to 6th day. Usually I don’t uncover the surgical site at the first or second and I wait to the third one to keep it as sterile as possible. Another reason that the surgeon don’t uncover the surgical site is that he doesn’t expect to see wound infection before 3 days.
- Signs of infection:
a) Erythema
b) Tenderness: the patient can’t tolerate the pain when any one touches the wound. Pain usually expected at the surgical site, but in case of infection, it’s much more than the expected.
c) Edema
d) Some Latin words indicate that there’s SSI (4 markers of SSI):
Rabor ------- erythema
Tumor ------ swelling
Calor ------- hotness
Dolor ----- pain
- Mostly caused by staph. Aureus.

- Type of wound play a role:
a) Clean wound
b) Clean contaminated
c) Contaminated
d) Dirty
As the contamination increase (dirty is the most contaminated), the risk of developing SSI will increase.
Mortality could reach up to 40% in dirty cases
- Necrotizing fasciitis: is a bacterial infection of underlying fascia (the fascia soft tissue and muscles). It’s a severe infection. The infection might not be obvious on the skin. Mostly streptococcus, rarely anaerobes and gram negative, are the causative agents. Usually needs surgical debridement consistent with anti-biotic therapy as anti-biotic administration alone isn’t efficient.

- Clostridial myositis: very rare. The most important thing about it is the gas gangrene. The causative organism is the clostridia perfringens. Surgical debridement is also required in association with the anti-biotic administration. It’s important to take a biopsy from the muscle and send it to the lab to take a culture (swap isn’t enough).
- The most important IV anti-biotic is the penicillin.
e- Incisional hernia: (An incisional hernia is a type of hernia caused by an incompletely-healed surgical wound)


2- Complications of thermal regulation: *(the second surgical complication, the first was wound complications)
a) Hypothermia: any drop in temperature more than 2 degree c.
- Causes:
a- The operation room temperature is low.
b- Children have more risk to hypothermia than adults, because incision surface area to body surface area is higher in children so they lose heat faster. Regarding that, to perform a surgery for a child, the surgeon has to increase the operation room temperature.
c- Fluids management. When we give the patient IV fluid –for deficit or maintenance- of low temperature _as it was stored in a cold environment- it lowers the body temperature and increases the risk of hypothermia. So it’s preferred to give warm fluid during resuscitation.
d- In cases where trauma results in neural injury, loss of response might happen, which will lead to hypothermia.

- Hypothermia leads to:
a- Platelets dysfunction & coagulopathies that increase the risk of bleeding.
b- Decrease in heart rate and cardiac output which affect inversely the thermal condition.
- Hypothermia is divided into 3 stages according to the severity:
1. Mild hypothermia: 35-32
2. Moderate hypothermia: 32-28
3. Severe hypothermia:28-25
b) Malignant hyperthermia: is a rare condition. The anesthetic is more concerned about it. It’s an AD (autosomal dominant) disorder. It’s a reaction due to hyper-metabolic state results from inhalation of anesthetic gases and muscle relaxants. What happens actually that there’s increase in the metabolic state results in increase of Ca ions that leads to contraction and rigidity which causes hyperthermia.
- (Malignant hyperthermia (MH) or malignant hyperpyrexia[1] is a rare life-threatening condition that is usually triggered by exposure to certain drugs used for general anesthesia; specifically, the volatile anesthetic agents and the neuromuscular blocking agent, succinylcholine. In susceptible individuals, these drugs can induce a drastic and uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms the body's capacity to supplyoxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if not treated quickly.)
- Treatment by intravenous administration of dantrolene (a muscle relaxant).
3- Post-operative fever:
- Any post operative fever from the first day up to two weeks is caused by certain condition – the time of fever onset helps us in the diagnosis of the underlying cause-.

- Causes of post-op fever (the 5 Ws)
Wind ----- pneumonia
Wound ------ infection
Water ---- UTI (urinary tract infection)
Walking ----- DVT (deep vein thrombosis)
Waste ---- abscesses
- Non-infectious causes result in fever in the first 48 hours after the operation, later fever is an indication of infection.
- The most common non-infectious cause of fever (within the first 48 hours) is the atelectasis.
- If the patient has post-op fever, the Dr. must come by himself and start investigations. Investigations include chest X-ray and examination, lower limp examination, urine sample and biopsy or sample from the wound –we send these samples to the lab for culture.

Note: malignant hyperthermia is an intra-operative complication, while fever is a post-op complication.

4- Pulmonary complications:
a- Atelectasis: is defined as the collapse or closure of alveoli resulting in reduced or absent gas exchange. It may affect part or all of one lung.
- The most common cause of non-infectious (in the first48hour) post-op fever.
- The sequence that results in atelectasis:
Pain ---- the patient is not able to aspirate as usual, may be due to decrease movement of the diaphragm --- the loss of aspiration results in collapse of alveoli (atelectasis).
- Treatment: incentive spirometer. We help the patient to talk a deep breath as slow as possible and we measure the capacity of his lungs. By many exercises per day the lung capacity will increase.

b- aspiration pneumonitis:
- It’s important for the patient to be 6-hour fasting prior to any surgery, if not, food aspiration is expected and thus the development of aspiration pneumonitis.
- Certain maneuvers ma by used to reduce the risk of aspiration pneumonitis.
c- nasocomial pneumonia:
d- Pulmonary edema: may be due to over-load of IV fluids. After the surgery, if the patient has tachypnea, the surgeon should auscultate the chest for abnormal sounds.
- For more confirmation, chest X-ray might be taken for the patient.
- Treatment: diuretics decrease the fluids and help in the relief of edema so it’s the choice.
- ARDS (acute respiratory distress syndrome): usually seen in burn patients. Also seen in sepsis patient. It’s a bad pulmonary complication with a mortality rate up to 50%.
e- Pulmonary embolus (PE): the most important pulmonary complication.
- 20 % fatal
- The key management is the prevention.
- The most common cause is DVT. We do our best to prevent DVT not because of its direct effects alone, but also to prevent the effects of the thrombus after dislodgment (PE formation), and this is of more importance.
- The pathway of an embolus:
From the leg to the IVC (inferior vena cava) that drains in the right heart and through the pulmonary artery to the lung.
- Divided into:
a) Major PE: associated with hypotension
b) Small PE: associated with tachycardia
- Treatment: anti-coagulant.

5- Cardiac complications:
a- Hypertension:-
- Causes:
a) Uncontrolled post-op pain.
b) Fluid overload.
c) Improper administration of hypertension medications.
b- Ischemia and infarction:
- It’s very important to avoid or prevent MI formation.
- If MI is diagnosed, I give the patient nitroglycerin, aspirin and I give analgesic.
c- Arrhythmia: tachycardia, bradycardia or irregular rhythm
- Causes:
a) Electrical abnormalities.
b) Medications.
c) Electrolytes abnormalities.
d) Stress
e) Endocrine abnormalities
f) Underlying cardiac disease. Aortic disease, valvular disease or any disease affecting the heart walls.
- Echo test is performed for more diagnosis.
6- Renal complications:
a- Urinary retention:
- Especially in patients who have hernia-repair or peri-anal surgery. It affects the innervation of the pelvis, thus leading to a feeling of pain, and the patient can’t urinate.
- Sometimes we need to put catheter to help in emptying the bladder and prevent bladder complications.
- It’s usually reversible, but it’s important to prevent further depilation of the bladder.




b- Acute renal failure:
- Causes:
a) Pre-renal cause: most commonly is the hypo-volemia (hypo-volemia could result from bleeding for example) and the resultant hypotension.
b) Intrinsic renal cause: due to certain drugs administration that causes nephro-toxicity.
c) Post-renal cause: due to any post-renal obstruction. The surgeon might tie the ureter, some surgical debridement might cause obstruction of the urinary tract.
7- Gastro-Intestinal complications:
a- Post-operative ileus. It is the most common. Usually seen in the first two days.
-causes:
a) Paralyzed bowels.
b) Short bowel injury.
c) Narcotics (originally referred to a variety of substances that dulled the senses and relieved pain) use.
d) Peritonitis (is an inflammation (irritation) of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs).
- It’s a lack of function without obstruction
Air level Auscultation
ileus Air is filling the colon No sounds
small bowel obstruction No air on X-ray (obstructed) Sound of hyper-active bowel

b- GI bleeding: upper or lower GI bleeding. Mainly distress is the cause, so we give the patient H2 blockers or proton pump inhibitors.
c- Pseudomembranous colitis: it’s due to prolonged treatment of IV anti-biotic, Clostridium difficile (c. difficile) bacteria will colonize the colon and the patient will start complaining of diarrhea. Recurrent diarrhea up to 10 times per day is possible. If Pseudomembranous colitis is suspected, IV anti-biotics must be stopped and the patient is given specific therapy for c. difficile. Also we take a sample from the patient for culture to be sure of the diagnosis. Toxic colitis may occur, and that’s emergency situation.
d- Ischemic colitis. When the surgeon ligates the inferior mesenteric artery, ischemic colitis will develop. Colonoscopy is done for diagnosis.
e- Anastomotic leak: An anastomotic leak is a breakdown along an anastomosis which causes fluids to leak. Anastomoses are used when a hollow organ such as the intestine needs to be severed and reconnected to allow fluids to flow through it, most commonly because part of the organ needs to be removed. Any surgery on the bowels is of risk for the development of anastomotic leak. First sign of anastomotic leak is the discharge from the wound. Diagnosis by medical imaging study. It can develop into enterocutaneous fistula.
f- Enterocutaneous fistula. It’s a disastrous complication. Could be chronic fistula in some patients which is difficult to treat, and might cause sepsis and thus increasing the mortality rate.
- Causes of anastomotic leak and fistula formation:
a) Technical problems i.e. the surgeon didn’t ligate the anastomosis very well
b) Patient factors like hypoxia, hypotension and disruption of the anastomosis which leads to leak and thin fistula formation.
c) Radiation
d) Distal obstruction
e) Infection and poor wound healing
8- Metabolic complications:
a- Patients with adrenal insufficiency. These patients might develop hypotension and adrenal crisis in severe cases, so prophylactic steroid therapy is administered.
b- Patients with hyper & hypo-thyroidism. It’s a must to diagnose these patients before any surgery to avoid the complications.
c- Inappropriate secretion of ADH (SIADH): a continuous ADH secretion.
- Causes fluid overload and hyponatremia which may lead to neurological manifestations.
9- Neurological complications:
- Be aware for the prescribed drugs to the patient, as it may be the cause of complications
a- Dementia, delirium and psychosis.
b- Seizures disorders
c- Stroke and TIA (transient ischemic attacks). Patients under open-heart surgery are at higher risk to develop strokes, so continuous monitoring of the carotids is required.

Best wishes
Done by: Suhaib Attieh




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Shadi Jarrar
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