SURGICAL COMPLICATIONS

Dr. Salcedo
September 18, 2013
Group 2
Outline
1. Risk factors
2. Clinical presentation of complications
3. Surgical complication COMMON to any
operation
a. Wound problems
b. Respiratory problems
c. Urinary problems
4. Surgical complication SPECIFIC to a procedure
a. Gastrointestinal surgery complications

Immediate
(1-3 days postop)
Atelectasis
-most common
-collapse of
alveoli

Every surgical procedure has a risk for

complications
- must be anticipiated for early management
Risk Factors
1. Nutritional Status
poor surgical complications; more complications
2. Asepsis/Antisepsis
dirty operation; more complications
3. Immune Status
Diabetes, HIV; more complications
4. Hemodynamic Stability
Shock, hypotension
5. Comorbidities
pneumonia, cardiac problems, etc.
6. Emergency Procedures
Surgical Complications
I. Fever
II. Pulmonary Complications
III. Genitourinary Complications
IV. Wound Complications
FEVER
- Heralds the onset of complications
- Usual presentation of surgical complication
- Significant only if >38C and is persistent for 2 days
post operation day (POD)
Different conditions can be determined
according to the onset of the fever

Early
(3-5 days postop)
Wound infection
Respiratory
infection
Catheter related

Late
(5-12 days postop)
Abscess
formation
Anastomotic
leaks
Wound
dehiscence

a.

Fever within the first 24 hours could be due

to:
1. Atelectasis - most common
2. Necrotizing wound infections (more
severe than surgical site infections)

b.

Fever 24-72 hours after surgery could be due

to:
1. Respiratory complications (ARDS,
pneumonia)
2. Indwelling Catheter - related (most
commonly on the IV site and cause
thrombophlebitis)

Onset of fever after 72 hours (usually of

infectious causes)
1. 3-5 days- UTI
2. 4-7 days Intra abdominal Abscess/ Leaks
3. 7-10 days Surgical Wound Infections
These are merely guides to rule in possible
conditions.
c.

RESPIRATORY COMPLICATIONS
Commonly occur after an upper abdominal
(gastric, gallbladder and liver surgery) and
thoracic surgery
This is because post-op pain alters the
mechanics of respiration of the patient
(patient avoid breathing deeply the alveoli
will not expand)
Patients tend to have shallow breathing
because their surgical wound is painful
Accumulation of secretions

SPLINTING
predisposes to surgical complications; caused by
pain
a. Atelectasis

MOST COMMON CAUSE OF FEVER IN THE 1st

24 HOURS
- Collapse of alveoli
- Accumulation of secretions
- Lungs inflation
o Coughing, deep breathing
o Incentive spirometry
o Chest tapping
Bronchodilators, expectorant
Main problem is collapse of alveoli because of the
accumulation of secretions inside the alveoli due
to shallow breathing of patients (* poor alveolar
inflation)
Atelectasis - usually focal or one sided
Dont give antibiotics because the problem is not
infectious
-

DIRECT PULMONARY INJURY

Aspiration
Inhalation injury
Pulmonary contusion
UNRELATED DISORDERS
Multiple transfusions
Factures
Pancreatitis

Injury
Initiation of inflammatory mediators
Increase microvascular permeability

PREVENTION: deep breathing exercises

Chest Tapping excretion of secretions

Proteinaceous fluid deposition in alveolar/capillary

interface

Treatment:
inflation of the lung
Coughing
Bronchodilators- clear airway
Expectorant- clear airway
Early mobilization of the patient
Sit to breath more easily
Incentive Spirometry
Objective is to make the patient breath
for a long time and keep the balls on top
as long as possible
At least 10x per hour

c.

Acute Respiratory Distress Syndrome (ARDS)

- Fluid in the alveoli
b.

Can happen to patient after any surgical

procedure even unrelated procedures
(whether direct or indirect)
Due to a direct pulmonary injury such as
aspiration, inhalation injury, pulmonary
contusion
Blood transfusion, fractures
Basic problem is increase in vascular
permeability due to release of inflammatory
mediators leading to leakage of fluid such as
deoxygenated blood in capillary membrane
and deposited in alveoli
Proteinaceous fluid = no exchange of
gases
End result is abnormal V/Q; ventilation
perfusion mismatch because tissues are not
well- ventilated
Although it is receiving blood resulting to
unrelenting
Hypoxemia
Patchy infiltrates in the lungs
High mortality rate (higher mortality rate
than atelectasis)
Involves both lungs
Opaque on x-ray (usually bilateral) due to
fluid in the lungs

Aspiration Pneumonia

Common in patients with cranial surgery,

comatose with poor gag reflex leading to
aspiration of their fluid
secretions (gastric contents and saliva)
Gastric contents can reflux and enter the
tracheobronchial tree
Common in right lung (shorter, wider, and
more vertical) than left lung due to anatomy

Prevention:
- NPO prior to OR or NGT before surgery (to
decrease risk of aspiration pneumonia
Treatment:
Bronchoscopy
Lavage of upper airway (flushing with
water)
Suction the food in the
tracheophageal tract
Antibiotics
WOUND COMPLICATIONS
1. Hematomas
2. Seromas
3. Wound infections (SSI)
4. Wound dehiscence
Factors that retard wound healing
o Malnutrition
o Uremia
o Sepsis
o Diabetes
o Anemia
o Liver Failure
o Steroid Therapy
1. HEMATOMAS
- collection of blood in a contained space that
can intervene with tissue apposition
- Main cause is inadequate hemostasis
because you fail to ligate a vessel
- If it occurs in the neck, it can cause airway
compression (requires immediate
management) (impingement of the trachea)
so the first thing to do is to remove the
sutures then bring the patient to OR
- Skin Thickness Skin Grafting can lead to graft
failure
- Soft Tissue Flaps can lead to flap necrosis
- Fertile ground for bacterial proliferation

Manifestation
Early:
Pain, Swelling
Serosanguinous wound discharge
(blood and serous fluid)
Late:
Skin Discoloration (bluish)
Management
Early: evacuate hematoma
Late: Expectant management, warm compress
to dissolve the accumulation of blood
Closed Suction Drain
o Jackson Pratt Drainage
To remove serous fluid
Should always be on a negative pressure
15-100ml capacity
Expect 50-70ml in 8 hours
Hemostasis Should ligate a blood vessel
Neck, Graft, Flaps Evacuate immediately
2. SEROMAS
- Accumulation of serous fluid
- Usually due to: Modified Radical Mastectomy,
Axillary Dissection, Inguinal exploration
(*fertile ground for infection)
- Impairs wound healing (same principle with
hematoma)
- Prevents closure of upper and lower layers
Management
- Closed Suction Drains to evacuate seroma
- Compressive Dressings
3. WOUND INFECTION (SURGICAL SITE
INFECTION/SSI)
Three Types
1. Superficial Incisional SSI
skin and subcutaneous tissue
(most common and easy to manage)
2. Deep Incisional SSI
- deep soft tissue (fascia and muscle)
3. Organ/Space SSI
- abscess in peritoneal cavity or peritonitis
(peritoneal cavity)

Open and drain pus

Debridement or remove necrotic tissue
Local Wound Care
Topical antibiotics
Betadine/Alcohol on raw area
Dakin Solution - NSS and zonrox (5-10cc)
More economical; Effective
Drain Intra-abdominal abscess

External evidence of wound sepsis appears on the

third post-op day, (i.e. Reactive, brown, murky
wound drainage)
Usually begins at the subcutaneous and goes
down to involve the muscles and the fascia

Prevention
Prophylactic antibiotic in elective surgery
30 minutes 1 hour before incision so
that antibiotic would be high on tissue
level in time of incision
Type of antibiotic is dependent on the
location of the surgery
Necessary only once for clean wounds
and within 24 hours
Skin Preparation waxing and betadine
o Waxing is a better option because shaving
causes microabrasions
Bowel Preparation in colonic surgery - cleansing
enema to remove fecal contents
Surgical Techniques
Irrigation: NSS(use this) vs Antibiotic
based(same effect)
Sutures: Monofilament (nylon) vs Braided
(higher chance of infection)
Delayed wound closure
- Tertiary for 3 days
- Only skin and subcutaneous layers will be
left open
- Good perfusion, better healing
Duration of Operation
- Good granulation & no purulent discharges
* Common site of SSI: subcutaneous layer (poor
blood supply)
Clinical Manifestations of SSI:
Erythema and Swelling around the incision site
Inordinate Pain-pain out of proportion
Purulent Discharge
Ileus, Abscess formation
Treatment:

4.

NECROTIZING FASCITIS
- Fascia is necrotic
- Remove all necrotic material

5.

FOURNIERES GANGRENE
around perineal area
- Remove all necrotic tissue

6.

WOUND DEHISCENCE
Opening of suture (can happen at
different levels of suture) due to poor
surgical technique - if in the skin, you do
healing with secondary intention
- Separation of fascial layer can lead to
evisceration or extrusion of peritoneal
contents (manage by covering with clean
cloth and place NSS )

Risk Factors:
Wound Hematoma/SSI
Coughing
Malnutrition
Diabetes
Immunocompromised
COPD
Ascites
Clinical Manifestation of evisceration:
Classical: Serosanguinous discharge on the 4th
5th POD
After forceful activity
Complete vs. Partial Dehiscence
Late- Incisional Hernia
o Incisional hernia results from partial
wound dehiscence

Management:
Partial
Non-Operative
Incisional Hernia better than evisceration
Complete
Evisceration
Retention Sutures
- One suture includes full thickness of abdomen
- Plastic tubes(bumpers) to prevent suture from
digging into the skin/ wound
- Wait for 2 weeks before removing the sutures
URINARY COMPLICATIONS
a.

URINARY RETENTION
- Common after anal surgery such as
hemorhoidectomy due to pain that can
constrict anal sphincter with a reflex
constriction of urinary tract
- Prolonged catheterization due to bladder atony

b.

URINARY TRACT INFECTION

- Most common Nosocomial Infection
- Secondary to Indwelling Catheters

c.

ACUTE RENAL FAILURE

- Secondary to inadequate resuscitation
- Secondary to blood transfusion reactions
- Secondary to nephrotoxic drugs
- Temporary dialysis until kidney recovers

CIRCULATORY COMPLICATIONS
1. Hemorrhage
2. Sepsis
3. Myocardial Infarction
4. Pulmonary Embolism
Hemorrhage
Recognition:
1. Overt bleeding on incision site
2. Bloody drain output
3. Distended abdomen
4. Hypovolemia/ Hemorrhagic Shock
- Tachycardia
- Hypotension
- Tachypnea
- urine output
- Cold clammy skin

Management:
1. Control the source of bleeding
- Re-op may be necessary
2. Correction of coagulopathy
3. Fluid resuscitation/ Blood transfusion
Sepsis/ Septic Shock
- OR carried out in the presence of sepsis
- Technical failure
- Spread from a focus
- Bloodstream contamination
(Infected CVP line, IV catheter)
Manifestations:
1. Warm periphery
2. Fever
3. Hypotension
4. Tachycardia
5. Tachypnea
6. Changes in sensorium
Management:
1. Look for the focus
- Undrained abscess, catheters
- Re-exploration
- GS, C/S
2. Fluid resuscitation
3. Star empiric antibiotic treatment
MI/ Pulmonary Embolism
Risk Factors:
- Ischemic Heart Disease
- Arrythmia
- Prolonged immobilization
- Malignancy
- Elderly
- Lower limb fracture
GASTRIC SURGERY COMPLICATIONS
Acute
Duodenal Stump Blowout
requires immediate surgical intervention
Rebleeding
Gastroparesis
Failure of stomach to contract
Anastomotic leak

Long term
Dumping syndrome
Afferent and Efferent loop syndrome
Reflux gastritis
Gastric Stump carcinoma
Anemia
AFFERENT LOOP SYNDROME
Proximal to anastomosis
Present as intestinal obstruction obstruction at junction of afferent limb and
gastric remant
- Postparandial abdominal pain and
nonbillous vomiting (accumulation of
secretions; bile is obstructed)
- Kinking and angulation
- Internal herniation behind efferent limb
- Stenosis of gastrojejunal anastomosis
- Redundant twisted afferent limb (volvulus)
- adhesions involving afferent limb

a.

Clinical Manifestations
Abdominal Pain
o SBO- colicky; more painful
o Ileus- constant
Abdmominal Distention
Obstipation failure to pass out flatus and
fecal material
Bowel Sounds
o SBO- hyperactive with metallic sound
o Ileus- hypoactive bowel sounds
o SBO- Air-fluid level on X-ray;
Stepladder sign
C.

EFFERENT LOOP SYNDROME

- Epigastric pain and bilious vomiting

b.

DUMPING SYNDROME
- Rapid Movement of hypertonic food bolus
to small intestine
- Inc. ECF, diarrhea (distention)
GI: Nausea, Vomiting, Epigastric fullness,
crampy abdominal pain, explosive diarrhea
CVS : Palpitation, tachycardia, diaphoresis,
fainting, dizziness, flushing, blurred vision

c.

INTESTINAL SURGERY COMPLICATIONS

A.
-

B.

ILEUS
Non-mechanical obstruction; temporary
Hypomotility problem
Very common complication of abdominal
surgery
Passage of flatus or regaining function after
surgery:
Small bowel: within 24 hours
Stomach: 24 48 hours
Colon: 3-5 days
SBO
-

Mechanical Problem
Post op adhesions- most common cause

(* kinking and twisting)

Bands

ANASTOMOTIC LEAKS
POORLY PREPARED PATIENT
Inadequate resuscitation
Emergency OR
Inadequate proximal decompression
(-)Bowel Prep
Malnutrition
POOR SURGICAL TECHNIQUE
Adequate Blood Supply
Tension Free
Meticulous Hemostasis
No Contamination

Sequelae of Leaks
1. Peritonitis/Acute Abdomen
2. Abscess Formation
3. Fistula Formation
Complications of Intestinal Anastomosis

Leakage: Peritonitis, Intra-Abdominal Abscess,

Fistula

Stricture: Intestinal Obstruction, Obstructive

jaundice, Dysphagia

Bleeding: Hypovolemic Shock

ENTEROCUTANEOUS FISTULA

FISTULA - Anastomotic leak that has developed a

pathway to the skin
- 4th 5th POD
- Manifest like SSI except that there is leakage
of intestinal obstruction
- Increased wound pain and redness
- Purulent discharge

Leakage of intestinal contents

Path of least resistance

Fistula causes: FRIEND

F - Foreign Body
R - Radiation
I - Inflammation, Ischemia, Infection
E - Epithelialization of tract
N - Neoplasia
D - Distal Obstruction

LOW OUTPUT FISTULA: <200cc

MODERATE OUTPUT FISTULA: 500cc
HIGH OUTPUT FISTULA: >500cc
The lower the output, the higher the
chance of spontaneous closure

Unlikely to close spontaneously:

After 4-5 weeks
Sepsisfree
Adequate Nutrition
Management:
OPERATIVE
Resect and Anastomose
GOAL: Resuscitate
Predictive Factors of Spontaneous Closure

Anatomic
Location

Nutritional
Status
Sepsis

Appendicitis,
Diverticulitis,
Postop

Crohns Dse.,
Cancer, Radiation,
Foreign Body

Bowel
Condition

Healthy Adjacent
Tissue, No
abscess,
Small Leak
Tract > 2cm
Defect <1cm

Total Disruption,
Distal Obstruction,
Abscess, Active
Dse.
Epithelialization,
Foreign Body

Others

Management
GOAL: Spontaneous Closure
- 70% chance of spontaneous closure
- Closure occurs within 4-6 weeks
- >3mons will not close anymore
1. Resuscitate: Fluid and Electrolytes
2. Nutritional Support
3. Sepsis Control
4. Wound Care - discharges can excoriate the skin
5. Assessment of anatomy: Fistulogram

Factor

Etiology

Likely to close

Unlikely to close

Edophageal,
Duodenal Stump,
Jejunal,
Pancreaticobiliary
Well nourished

Gastric, Lateral
Duodenal, Lig of
Treitz,
Ileal

Absent

Present

Malnourished

COMPLEX FISTULA
D.

ABDOMINAL COMPARTMENT SYNDROME

Result of those with multiple injuries;
edematous or distended bowel
- Multi-system trauma, peritonitis, massive fluid
resuscitation
- Intraabdominal Hypertension
- Decrease in venous return to the heart so
hypotension - (impingement of vena cava)
- Decrease renal output leading to renal
failure
- Pulmonary dysfunction due to pressure of
increased size of peritoneal organs
(diaphragm goes up, decreased space for
lung expansion)
- Can cause increased ICP

Management
Open the incision and apply Bogota Bag
Incisional Hernia
Pressure-induced Dysfunction
Decreased Venous Return, Decreased Cardiac
Output
Decreased Renal Flow
Decreased Intestinal Perfusion
Pulmonary Dysfunction
Diagnosis
Intrabdominal pressure > 25-30
mmHg With any of the following:
Compromised respiration,
Oliguria or anuria
Increased Intracranial Pressure
Treatment: Open the incision
Bogota Bags
Attempt closure every 2-3 days

A.

B.

Skin Closure may lead to incisional

hernia

STOMA COMPLICATIONS
NOT on incision site
NOT near bony prominence
Protruded Stoma
RETRACTION
Inadequate length of intestine
- Skin Irritation, peristomal infection and intraab
infection
- As a rule, all retracted stoma should be revised
Adequate length, good blood supply

Pyloroplasty
J.
Gastric Reconstruction
Billroth II
Roux-en-y Anastomosis
K.
Skin Irritation
Allergic reaction to adhesive
Abrasive effects of effluents
Peristomal Infection SQ infection around Stoma
Fecal contamination especially in retracted
stoma
L.
Gangrene
Compromised blood
supply
Treatment is by resection
M. Prolapse and Intussusception
Bowel Distention
Abdominal wall opening larger than
the normal caliber
Prevention: not too large an
abdominal wall opening
I.

A wise surgeon learns from his mistakes. A

wiser surgeon learns from the mistakes of
others.

C.

D.
E.
F.
G.
H.

PERISTOMAL EVISCERATION AND PARASTOMAL

HERNIATION
Large Fascial and/or Skin defect
Poor Anchoring
Repair of Fascial Defect

Postgastrectomy Syndromes
Alkaline Reflux gastritis
Small Remnant Syndrome
Gastric Stump Carcinoma
Anemia
Iron Deficiency
Megaloblastic - Vit. B12, intrinsic factor