post-operative haemorrhage Haemorrhage immediately after surgery is usually due to poor operative haemostasis
or a technical problem e.g. slipped ligature or damage to blood vessel. Where large volumes of blood have been transfused
may be exacerbated by consumption coagulopathy. Also may be due to preoperative anticoagulants or unrecognised bleeding diathesis.
Patients most at risk include those who have undergone:
- Major surgery involving highly vascular tissues e.g. liver
- Major arterial surgery where patient is heparinised
- Surgery leaving a large raw surface, e.g. abdomino-perineal
resection of the rectum.
Management - perform clotting screen including platelet count,
ensure good IV access and insert CVP catheter. Give protamine if heparin used. Order cross-matched blood. If clotting screen
abnormal, give FFP or platelet concentrates. Consider re-exploration at all times.
haemorrhage Where haemorrhage occurs several days after surgery it is usually due to infection damaging vessels
at the operation site.
Management - treat infection and consider exploratory surgery
to ligate the bleeding vessels.
Commonest form is superficial wound infection occurring within first week presenting as localised pain, redness and slight
discharge usually caused by skin Staph. Usually require no treatment except in patients receiving a prosthesis e.g. arterial
graft or joint.
Cellulitis and abscesses usually occur after bowel
related surgery. Most present within first week but can be seen as late as third postoperative week, even after leaving hospital.
First symptom is pyrexia and examination reveals spreading cellulitis or abscess. Cellulitis is treated with antibiotics.
Abscess requires suture removal and probing of wound but deeper abscess may require re-exploration. Wound is left open in
both cases to heal by secondary intention.
Gas gangrene is uncommon and life threatening.
Wound sinus is a late infectious complication from a deep
chronic abscess that can occur after apparently normal healing. Usually needs re-exploration to remove non-absorbable suture
or mesh, which is often the underlying cause.
Most wounds heal without complication and rate is unaffected in the elderly unless there are specific adverse factors
or complications. Factors which can affect healing rate are:
- Poor blood supply
- Excess suture tension
- Long term steroids
- Immunosuppresive therapy
- Severe rheumatoid disease
- Malnutrition and vitamin deficiency.
Wound dehiscence Total
wound breakdown or 'burst abdomen' occurs in approximately 1% of abdominal wounds.
Usually presents approximately one week following profuse
discharge of sero-sanguinous fluid. Although alarming in appearance, wound is relatively painless. Usual cause is poor abdominal
Management - cover with sterile swab soaked in saline and
return to surgery for repair.
Incisional hernia Occur
in 10-15% of abdominal wounds usually appearing within first year but can be delayed by up to 15 years after surgery. They
are caused by breakdown of repair performed on abdominal wall muscle and fascia. Risk factors include obesity, distension
and poor muscle tone, wound infection and multiple use of same incision site. Usually presents as bulge in abdominal wall
close to previous wound. Usually asymptomatic but may be pain or strangulation and tends to enlarge over time and become a
Management - surgical repair where there is pain, strangulation
Unavoidable tissue damage to nerves can occur during many types of surgery e.g. facial nerve damage during total parotidectomy.
In other forms of surgery there is a significant risk of nerve damage e.g. impotence following prostate surgery. Patients
need to be warned of this before giving consent. In other cases there is accidental damage, e.g. recurrent laryngeal nerve
damage during thyroidectomy. This may be simply due to surgical inexperience or complicated by anatomical anomalies. There
is also a risk of injury while being transported and handled in the theatre under general anaesthetic. These include injuries
due to falls from trolley, damage to diseased bones and joints during positioning, nerve palsies, diathermy burns.
These occur in up to 15% of general anaesthetic and major surgery. They include:
- Atelectasis (alveolar collapse) - caused when airways become
obstructed usually by bronchial secretions. Most cases are mild and may go unnoticed. Symptoms are slow recovery from operations,
poor colour, mild tachypnoea,
and low-grade fever. Prevention is from pre-and postoperative physiotherapy. In severe cases, positive pressure ventilation.
- Pneumonia - usually bronchial pneumonia with fever, tachypnoea,
tachycardia and mucopurulent sputum requires antibiotics, physiotherapy and encouragement to cough.
- Aspiration pneumonitis - sterile inflammation of the lungs
from inhaling gastric contents. Presents with history of vomiting or regurgitation with rapid onset of breathlessness and
wheezing. Non-starved patient undergoing emergency surgery is particularly at risk. May help avoid this by crash induction
technique and use of oral antacids or metoclopromide. Mortality is nearly 50% and requires urgent treatment with bronchial
suction, positive pressure ventilation, prophylactic antibiotics and IV steroids.
- Acute respiratory distress syndrome - rapid, shallow breathing,
with scattered crepitations but no cough, chest pains or haemoptysis, appearing 24-48 hours after surgery. Occurs in many
conditions where there is direct or systemic insult to the lung e.g. multiple trauma with shock. Requires intensive care with
mechanical ventilation with positive-end pressure.
Major cause of complications and death after surgery. DVT is very commonly related to grade of surgery. Many cases are silent
but present as swelling of leg, tenderness of calf muscle and increased warmth with calf pain on passive dorsiflexion of foot.
Diagnosis is by venography or Doppler ultrasound.
Pulmonary embolism classically presents with sudden dyspnoea
and cardiovascular collapse with pleuritic chest pain, pleural rub and haemoptysis. However, smaller PEs are more common and
present with confusion, breathlessness and chest pain. Diagnosis is by ventilation/perfusion scanning and /or pulmonary angiography
or dynamic CT.
Management - IV heparin or SC low molecular weight heparin
for 5 days plus oral warfarin.
problems Urinary retention - common immediate postoperative complication that can often be dealt with conservatively
with adequate analgesia. If this fails may need catheterisation.
UTI - very common especially in women, may not be typical
symptoms. Treat with antibiotics and adequate fluid intake.
Acute renal failure - may be caused by antibiotics, obstructive
jaundice and surgery to the aorta. Often due to episode of severe or prolonged hypotension.
Presents as low urine output with adequate hydration. Mild cases may be treated with fluid restriction until tubular function
recovers. In severe cases may need haemofiltration or dialysis while function gradually recovers over weeks or months.
of bowel surgery
Delayed return of function Temporary disruption of peristalsis
- may complain of nausea, anorexia and vomiting and usually appears with the re-introduction of fluids. Often described as
ileus. More prolonged extensive form with vomiting and intolerance to oral intake called adynamic obstruction and needs to
be distinguished from mechanical obstruction. If involves large bowel usually described as pseudo-obstruction. Diagnosed by
instant barium enema.
Early mechanical obstruction - may be caused by twisted or
trapped loop of bowel or adhesions
occurring approximately 1 week after surgery. May settle with nasogastric aspiration plus IV fluids or progress to requiring
Late mechanical obstruction - adhesions can organise and persist commonly causing isolated episodes of small bowel obstruction months or years after surgery.
Treat as for early form.
Anastomotic leakage or breakdown - small leaks are common
causing small localised abscesses with delayed recovery of bowel function. Usually resolves with IV fluids and delayed oral
intake but may need surgery.
Major breakdown causes generalised peritonitis and progressive
sepsis needing surgery for peritoneal toilet and antibiotics. Local abscess can develop into a fistula.