Complications of Hysterectomy and Laparotomy

Intra-operative Complications

Bleeding

Bladder injury

Ureteric injury

Bowel injury

Post-operative complications

Haemorrhage

Postoperative collapse

Management of postoperative collapse

Postoperative infection

Management of postoperative infection

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Intra-operative complications

Bleeding

• Minimize blood loss by good technique, by use of bloodless planes and by cautery
• Look for bleeders at regular intervals, keep track of blood loss
• For sudden severe bleeding apply firm pressure and call for help
  • The consultant may employ packing or ligation of major arteries
• Consider blood transfusion, with platelets and/or FFP if there are clotting problems
• Arrange close postoperative care – recovery area, ICU
• Always keep the anaesthetist well informed of bleeding

Bladder injury

• It is better to recognize the bladder injury at operation
• Routinely check for bladder injury at hysterectomy. If in doubt pass dye (or milk) through the urinary catherter
• Simple bladder defects may be closed in 2 layers with polyglycolic suture (Vicryl)
• Bladder base defects require attention to the position of the ureters, at times with stenting. Call for help from a consultant or urologist. Bladder suturing at or near the trigone may accidentally close the ureter

Ureteric injury

• Always check both ureters for damage or dilatation at the end of a hysterectomy
• If a ureter is dilated, follow its course distally. If ureteric ligation or injury is suspected, call a consultant or urologist. Re-implantation may be required

Bowel injury

• Very small defects can be closed with a simple Vicryl sutures
• Diathermy burns are often more severe than they first appear
• If in doubt, or with significant injury, call a consultant or general surgeon

Post-operative complications

Haemorrhage

1. Assess for shock – pallor, hypotension, tachycardia
2. If still in theatre/recovery, get help from an anaesthetist
3. Order emergency blood
4. If there is no rapid improvement, take the patient back to theatre 
5. Call for a consultant
6. Vaginal bleeding from the vault can sometimes be tackled from below
7. Suspected intra-abdominal bleeding would require relook laparotomy

Postoperative collapse

Causes are:

• Anaemia worsened by intraoperative bleeding
• Internal haemorrhage
• Pulmonary embolism
• Sepsis (not immediately after clean surgery)
• Myocardial infarction or a medical condition e.g. cardiac failure.

 Management of postoperative collapse

1. Call for assistance
2. Attend to the ABC of resuscitation
3. Ensure venous access
4. Take FBC, U&E & ABG
5. Look for a cause – read the notes for underlying problems
6. Treat the cause, & manage in a high care / intensive care area

Postoperative infection

Sources may be:

• Chest – cough, lung crackles, chest X-ray
• Urine – symptoms, urinalysis, urine culture
• Wound – Painful oozing red hot wound
• Vault – Offensive discharge, bogginess & heat in vagina

Management of postoperative infection

1. Treat with appropriate antibiotics
2. Check HIV status & CD4 count if HIV positive
3. Observe for signs of severe sepsis
4. Do blood cultures, FBC, U&E, ABG if necessary
5. Vault infection or haematoma:
   • Try to push a finger through to drain pus or blood
   • If necessary, drain under general or spinal anaesthetic (cut the vault suture)
6. Wound sepsis:
   • Remove as many sutures as is necessary to expose all infected surfaces
   • Clean the wound with saline
   • Explore the length and depth of the wound
   • Debride necrotic tissue under general or spinal anaesthetic if necessary
   • Dress with saline at first, then special wound dressing