All surgery involves a delicate balance of risk management, from the benefits and disadvantages of when a surgical option is appropriate, to the immediate post-operative care.

1. Avoiding and managing
complications with
gynaecological surgery
Joanne Morrison
Alexander Swanton
Ian Z MacKenzie
Abstract
All surgery involves a delicate balance of risk management, from the
benefits and disadvantages of when a surgical option is appropriate, to
the immediate post-operative care. Recognizing areas of high risk and
understanding how these may be minimized, is central to the practice
of safe surgery. All surgeons may encounter complications at some
point, but recognizing when these occur and the most appropriate initial
management is essential to prevent or minimize immediate and long-term
complications. In addition, as some complications will involve areas in
which the surgeon has relatively little expertise, it is important to
acknowledge that limitation and enlist help from an appropriate specialist
at an early stage. This review focuses on general advice on avoiding and
managing complications in gynaecological surgery, excluding radical
cancer surgery.
Keywords bladder injuries; bowel injuries; laparoscopy complications;
ureteric damage; uterine perforation; vascular damage
Introduction
No surgery is without risk and safe surgery aims to recognize and
minimize these risks, whether due to patient or surgical factors.
The previous version of this review concentrated on complica-
tions encountered with specific procedures (see further reading).
In this review, we will concentrate on general surgical principles,
with a greater emphasis on endoscopic surgery.
Factors which predispose to complications during or after
surgery will be considered, followed by pre-operative strategies
to identify these factors, with recommendations for reducing
their occurrence. Techniques to minimize intra-operative
complications will then be discussed, followed by methods for
recognizing these complications during the surgery and the post-
operative period. Finally strategies for managing complications
will be presented.
Complications may be more likely to occur with laparoscopic
surgery than conventional open surgery, due to relative operator
inexperience, the introduction of new instruments and more
frequent use of energy sources. Electrocoagulation and laser
vapourization can cause inadvertent thermal damage, which
may be recognized or suspected intra-operatively, or present as
delayed injuries. The incidence of complications during endo-
scopic surgery is much more likely with therapeutic than diag-
nostic surgery, and the complexity of the surgery significantly
influences the complication rate. The likelihood of injury
depends on a number of factors, and in order to minimize the
chance of complications, it is important to understand which
factors increase the risk and what can be done to minimize them.
Pre-disposing factors
Several conditions including endometriosis, cancer, disturbed
coagulation, previous surgery in the operative field with subse-
quent adhesion formation and obesity can complicate surgery
and increase the chance of injury. Surgical competence is a major
factor and complication rates decline with increasing operative
practice. Appropriate training is therefore essential, but with the
imposed reduction in trainees’ working hours, opportunities will
diminish and inventive teaching techniques, probably using
simulators, will be required to replace that void.
Avoiding and preventing complications
Pre-operative strategies
A thorough pre-operative assessment is crucial to identify
potential anaesthetic and surgical risk factors. A comprehensive
history and relevant clinical examination are vital when surgery
is considered. When a pre-disposing risk factor is identified,
appropriate investigations should be considered (e.g. CT scan or
MRI, lung function tests, ECHO cardiogram, clotting studies).
Pre-operative imaging can inform counselling of the patient and
planning of the procedure for the surgeon. Appropriate equip-
ment and personnel can be selected in advance of the surgery.
Pre- and peri-operative measures to reduce risks in susceptible
cases will include intra-operative antibiotics and thrombopro-
hylaxis (TEDS, low molecular weight heparin and intermittent
pneumatic compression calf devices depending on level of risk).
Full bowel preparation is no longer recommended although
phosphate enemas will help to decompress a loaded rectum, if
rectovaginal dissection is anticipated. If stoma formation is
a possibility, referral to the stoma team for patient counselling
and marking of potential stoma sites, is advisable. Patients with
a body mass index >35 kg/m2
are at increased risk of anaes-
thetic, surgical and post-operative complications and should be
advised to lose weight prior to elective surgery. Serious medical
co-morbidities should prompt seeking senior anaesthetic advice
prior to planned surgery.
Informed consent for any procedure needs to be taken care-
fully by a doctor who understands the operation and the risks
involved. These risks should be explained clearly to the patient,
Joanne Morrison BM BCh MA MRCOG DPhil is a Macmillan Subspecialist
Trainee and Clinical Lecturer in Gynaecological Oncology at the Oxford
Cancer and Haematology Centre, Churchill Hospital, Oxford, UK.
Conflicts of interest: none.
Alexander Swanton MBBS MRCOG is a Consultant Gynaecologist at the
Royal Berkshire Hospital, Reading, UK. Conflicts of interest: none.
Ian Z MacKenzie FRCOG DSc is a Reader and Honorary Consultant in
Obstetrics and Gynaecology at the Nuffield Department of Obstetrics
and Gynaecology, John Radcliffe Hospital, Oxford, UK. Conflicts of
interest: none.
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2. avoiding medical jargon, with careful documentation of this
discussion.
Confirmation of ‘right patient, right operation’, is ultimately
the responsibility of the surgeon. The concept of ‘‘site and side’’
skin marking is often not applicable to gynaecological surgery,
but it can be very important when dealing with vulval lesions
and ovarian or tubal pathology. Ensuring the documentation is in
order and that imaging studies and all necessary equipment are
available, is part of good surgical practice. These checks should
be formalized as part of a pre-operative check-list, which should
involve surgeons, anaesthetists and theatre staff, aimed at pre-
venting complications due to communication or equipment
problems.
Intra-operative strategies
All surgeons should be familiar with the anatomy of the relevant
surgical area. Basic principles are required to avoid major
complications during both open and endoscopic surgery. Specific
risks for open and vaginal surgery are discussed in the previous
version of this review (see further reading).
Patient positioning in theatre can reduce nerve damage, back
and pelvic problems and pressure sores during long procedures.
Steep Trendelenberg positioning is sometimes required during
complex laparoscopic procedures and shoulder supports, with
padding to reduce the risk of brachial plexus injuries and close
anaesthetic monitoring, may be necessary. Lithotomy poles
should be avoided, since these increase the risk of peroneal nerve
injury compared with cushioned foot/calf support devices. Skin
preparation with antiseptic (e.g. betadine or chlorhexidine) and
attention to good sterile techniques will help to reduce the risk of
wound infection. Before most gynaecological procedures, the
bladder should be emptied to reduce the risk of injury. Whether
an in-dwelling catheter is left in place will depend on the nature
and anticipated length of surgery.
Gentle tissue handling and attention to haemostasis should be
applied to all procedures, irrespective of route. Prophylactic
ureteric stenting should be considered if a difficult dissection is
anticipated, which can aid ureteric identification in addition to
allowing conservative management of minor ureteric injuries.
To reduce the chance of complications when introducing the
pneumoperitoneum during laparoscopy, one of the more
frequent occasions when complications occur, the ideal entry
point is at the umbilicus where the aponeurosis is adherent to the
peritoneum. This is also the ideal site to introduce the primary
trocar in the majority of patients, unless significant adhesions
from previous surgery are anticipated, or the patient is markedly
obese or very thin. In these instances, Palmer’s point (3 cm
below the left costal margin in the mid-clavicular line) should be
considered or an open entry technique (Hasson) utilized.
Trendelenburg position is best avoided when introducing the
pneumoperitoneum and during primary trocar insertion, as this
distorts the insertion angle, increasing the risk of vascular injury,
and brings the bowel up out of the pelvis and towards the
umbilicus. Most gynaecologists favour the closed technique with
a Veress needle and rely on tactile sensation when penetrating
the abdominal cavity. Insufflation carbon dioxide pressure
should initially be low on initial entry into the peritoneal cavity,
after which pressure may increase to 20e25 mmHg prior to
inserting the primary trocar. An alternative method to enter the
peritoneal cavity is an open, or Hasson technique, where the
skin, rectus sheath and peritoneum are incised under direct
vision and a blunt cannula inserted to achieve the pneumo-
peritoneum. Although there remains controversy over which is
the safer method, there is no evidence to favour one technique
over the other. Recently developed visual access trocars and
Veress needles may help reduce injury, but evidence at present is
lacking.
Once the primary trocar and laparoscope have been inserted,
a full inspection of the entry site and a 360
assessment of the
peritoneal cavity is made to assess pathology and identify any
damage. The Trendelenburg position can then be employed, to
move bowel out of the pelvis and secondary ports inserted
perpendicular to the skin under direct vision, while maintaining
the pneumoperitoneum at 20e25 mmHg. The intra-abdominal
pressure can then be reduced to 15 mmHg to avoid anaesthetic
complications. Pelvic vessels are more at risk from insertion of
secondary ports, although direct visualization to control entry
should reduce this happening. The inferior epigastric vessels are
at risk with insertion of lateral ports; visualizing the vessels with
the laparoscope and placing insertion sites lateral to the vessels is
advisable. If these vessels are damaged, they may bleed during
the laparoscopy and limit visualization; a sustained slow blood
loss may be underestimated. Alternatively the port cannula may
tamponade the vessels, so that significant bleeding occurs only
after it is removed. Port sites should be inspected after gas release
and instrument removal to check for delayed bleeding at the end
of the procedure. The final port should be removed with the
laparoscope in place, having first released the pneumo-
peritoneum, to prevent a loop of bowel or omentum herniating
into the wound.
Recognizing and managing complications
Uterine injury
Trauma to the uterine cervix or body can occur with any intra-
uterine surgery, but is more likely during therapeutic than
diagnostic procedures. Initial cervical dilatation is usually
required, but if forceful, creation of a false passage or uterine
perforation can occur. This is more common with nulliparity,
previous cervical surgery and in post-menopausal women.
Hormonal changes during pregnancy relax smooth muscle,
which also increases the risk of uterine trauma. Perforation with
a blunt instrument is less likely to cause intraperitoneal visceral
or vascular injury, although suspicion of injury to surrounding
structures should be considered. If the patient remains haemo-
dynamically stable, in-patient observation and antibiotic
prophylaxis is all that is usually required. Perforation with
suction, sharp curettage or an operating hysteroscope is more
likely to result in visceral or vascular injury. Laparoscopy may be
performed if the patient is stable, to inspect for damage and
examine the bowel, adnexa and pelvic side walls. If the intra-
uterine procedure cannot be abandoned, proceeding under
laparoscopic vision is advisable. A laparotomy may be indicated
if the patient is unstable, or the extent of the injury cannot be
adequately assessed or repaired laparoscopically. Lateral perfo-
rations through the cervix or into the broad ligament may be
difficult to recognize, since the injury can be retroperitoneal, but
should be suspected in the presence of a broad ligament hae-
matoma. These can be observed directly for enlargement and
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3. most can be managed conservatively. However, if the haema-
toma does enlarge, or the patient becomes unstable, exploration,
preferably by a surgeon with experience in pelvic side wall and
ureteric dissection, may be required to ligate damaged vessels.
During monopolar operative hysteroscopic procedures,
hypotonic, electrolyte-free distension media, such as 1.5%
glycine, are used. These carry an increased risk of fluid overload,
leading to rare complications such as pulmonary or cardiac
failure. Bipolar instruments can be used with isotonic media, and
although fluid overload can still occur, the relatively high sodium
content of isotonic media makes hyponatraemia and hypo-
osmolality much less likely. Excessively high intra-uterine
pressures (usually 60e75 mm Hg is adequate for good vision)
and long procedures (90 min) should be avoided. Recognition
of fluid overload is paramount and careful monitoring in theatre
of fluid deficit is vital. A fluid deficit of 1000 ml should be
a guide to terminate the procedure and/or expedite the end of an
operation. Fluid overload is a complication which can rarely
result in permanent cerebral injury due to hypo-osmolality.
Post-operative symptoms of hyponatraemia include headache,
nausea, vomiting, restlessness, muscle cramps and agitation. The
management of hyponatraemia is multidisciplinary, involving
critical care and anaesthetic staff. Treatment is generally
supportive, by decreasing fluid overload and normalizing the
serum sodium level. A slow increase back to normal is optimal,
as a too rapid increase has been associated with complications
including central pontine myelinolysis. If the sodium level is
120 mmol/L, intensive care support may be indicated. Air
embolism during hysteroscopic surgery is extremely unlikely, but
can be fatal. It can occur when air is introduced into the cavity,
for example with repeated removal and replacement of the hys-
teroscope during an operative procedure. Air can then be
compressed into small venous channels that are disrupted during
the procedure.
Urinary tract injuries
Although bladder injuries are more common than ureteric
injuries during gynaecological surgery, the latter are usually
more serious, especially if not recognized at the time of surgery.
Because of this, assistance from a urologist should be considered
when dealing with ureteric injuries.
Bladder injury: Full-thickness damage to the bladder wall
should be recognized at the time of surgery. If there is a suspicion
of damage during laparotomy or laparoscopy, a 100e200 ml
solution of diluted methylene blue can be instilled into the
bladder, using a urethral catheter, to identify the site of damage.
Small extra-peritoneal defects will usually heal spontane-
ously, if the bladder is drained with a catheter for 7e10 days. If
the defect requires suturing, the ureters should be identified to
avoid damage during the bladder repair. If in doubt, the bladder
can be opened, ureteric orifices identified and stents placed
under direct vision. Partial thickness defects are usually closed as
a single layer with 2/0 absorbable interrupted or continuous
sutures through the muscle and serosal layers. Full-thickness
injuries are usually closed in two layers, the first involving the
mucosa and muscle and the second the muscle and serosa,
burying the first layer. The bladder should be left catheterized for
7e10 days to allow healing, with a check cystography to confirm
integrity before catheter removal. Larger defects may also need
an intra-abdominal drain for 2e3 days and supra-pubic cathe-
terization, in addition to a urethral catheter. A cystogram should
be performed at about 10 days, via the urethral catheter, to check
bladder integrity before removal of the urethral catheter. The
supra-pubic catheter can then be clamped intermittently to check
voiding function. If a penetrating injury of the bladder is sus-
pected during a trans-vaginal (TVT) or trans-obturator (TOT)
tension-free tape procedure, the bladder should be inspected by
cystoscopy with the needles still in-situ (Figure 1). If confirmed,
these needles create a small hole and can be managed conser-
vatively by withdrawing the needles and draining the bladder
with an in-dwelling catheter over-night.
If bladder injury goes unrecognized at the time of surgery, or the
mechanism of injury means that there is delayed perforation, the
patient may present with anuria, urinary incontinence, metabolic
disturbance due to urinary ascites (hyperkalaemia, hyper-
natraemia, uraemia, metabolic acidosis), a distended, tender
abdomen, paralytic ileus or haematuria. In the post-operative
setting, the best investigation is a cystogram, when a radio-opaque
solution is instilled into the bladder via a urinary catheter. This
should demonstrate if there is urinary leakage, unless the bladder
is insufficiently distended, when overlying bowel may occlude
a small defect. If a urethral injury is suspected, a cystogram should
not be performed via a urethral catheter, since the catheter may
pass through the defect and cause further injury. If a urethral injury
is suspected (rare unless radical cancer surgery is performed) then
a retrograde urethrogram should be performed.
Ureteric injury: Injury to the ureter includes: obstruction by
inadvertent ligation (most commonly in the ureteric canal);
obstruction due to distortion of the ureter by an adjacently
positioned suture; direct surgical incision of the ureteric wall;
inadvertent crushing with a clamp; or ischaemic damage with
subsequent necrosis secondary to diathermy or laser damage. If
the damage is unrecognized, it may lead to chronic ureteral
obstruction or fistula formation. Delayed repair of injury is more
likely to result in long-term sequelae and so recognition of
damage at the time of surgery is essential and requires a good
Figure 1 TVT needle perforating the bladder at cystoscopy. Image courtesy
of Miss N Price and Mr S Jackson.
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4. understanding of the anatomical course of the ureter with
systematic checking of ureteric function (peristalsis) and integ-
rity at the time of surgery.
If a misplaced suture or clamp is noted at the time of surgery,
this should be removed immediately. If ureteric peristalsis is
preserved, no further management is required. However, if there
are concerns about ureteric function or possible ischaemia, or if
there is a partial ureteric transaction, a ureteric stent can be
inserted. This will allow drainage of the kidney into the bladder
and also help to prevent stricture formation. Stents are normally
inserted cystoscopically with fluoroscopic guidance and should
be removed 6e12 weeks following insertion.
If damage to the ureteric wall is suspected at the time of
surgery, retrograde ureteropyelography is performed by cystos-
copy: a ureteric catheter is placed through the ureteral orifice and
contrast injected with fluoroscopic screening, to identify any
obstruction or defect in the wall. Alternatively diluted methylene
blue dye can be injected proximally into the ureter and directly
observed for extravasation of dye. If the ureter is intact, then
management can either be conservative, or a ureteric stent can
be placed, depending on the nature of injury.
For more extensive ureteric damage (for example, transection,
loss of a segment or significant thermal injury), treatment
depends on the location of injury. Above the pelvic brim, a short
segment of ureter (2 cm) can be resected to healthy tissue and
joined as an end-to-end ureteroureterostomy. The cut ends of the
ureter are spatulated and sutured with a 4/0 absorbable suture
over a ureteric catheter, to maintain patency. The anastomosis
should be water-tight, but not so tight as to cause ischaemic
necrosis, and a drain should be inserted adjacent to the anasto-
mosis for 3e4 days. More extensive damage will require
implantation of the damaged ureter into the contra-lateral normal
ureter, with an end-to-side anastomosis. Below the pelvic brim
the ureter can be re-implanted into the bladder: if the injury is
close to the bladder (4 cm), the ureter can be carefully mobi-
lized (with preservation of the adventitial blood supply) and
re-implanted into the bladder. Securing the cut end of the ureter
with a 3/0 absorbable stay suture, the dome of the bladder is
entered, ureteric orifices identified and a site for re-implantation
identified near the dome of the bladder to prevent traction on the
ureter. An entry is made through the bladder wall, either directly
or through a sub-mucosal tunnel in the bladder wall, to prevent
reflux of urine and the ureter is drawn into the bladder, using the
stay suture. The ureteric end is spatulated and sutured to the
inside of the bladder with four 3/0 absorbable sutures and
several 3/0 absorbable sutures placed to anchor the ureter to the
outside of the bladder. A psoas hitch is recommended to prevent
excessive tension on the anastomosis. This is performed by
mobilizing the bladder and placing several 2/0 absorbable
sutures between the muscle layer of the bladder and the fascial
covering over the psoas muscle. A Boari flap is often performed
in such situations, to further reduce the tension on the ureteric
re-implantation, especially if a portion of ureter is lost or requires
resection. To do this, a psoas hitch is performed and a full-
thickness flap is cut from the anterior bladder wall and the distal
ureter (spatulated) is re-implanted directly (or via a sub-mucosal
tunnel) into the upper end of the bladder flap using 4/0 absorb-
able sutures. The edges of the flap are closed with one layer of
interrupted 3/0 absorbable sutures. A ureteric catheter is left
in-situ to maintain patency and the bladder drained with
a urethral or supra-pubic catheter for 10 days.
In more than 70% of cases ureteric injury is recognized post-
operatively. A chronically occluded ureter will lead to the
development of hydronephrosis and loss of renal function in the
affected kidney. Hydronephrosis may be asymptomatic or
present with loin pain. If pyelonephritis develops symptoms
include loin pain, fever and rigours. Necrosis of a ureter may
result from unrecognized ligation, crush injury or devasculari-
zation from excessive stripping of the ureter from the
surrounding tissues, from which it derives its blood supply. This
may lead to stenosis and hydronephrosis with loss of renal
function, or fistula formation and leakage of urine into the
peritoneal cavity, or a uroma in the retroperitoneal space. Either
urinary ascites or a uroma may become infected, presenting with
signs of sepsis and urinary ascites may cause a paralytic ileus.
However, if the vaginal vault has been opened at the time of
surgery, urinary ascites is likely to drain out of the vagina and
present with profuse watery vaginal discharge. In the case of
bilateral ureteric damage, or damage to a solitary functioning
kidney, the patient will present with anuria and rapidly develop
uraemia, which must be urgently investigated and treated,
possibly requiring percutaneous nephrostomies to preserve renal
function, as a matter of considerable urgency.
Investigations will depend on the presenting symptoms, but
will generally include measuring serum electrolytes and creati-
nine levels, blood gases (reabsorption of urine can lead to
metabolic acidosis) and full blood count; C reactive protein and
blood and urine cultures should be sent for microbiology, if the
patient is pyrexial. If excessive drain or vaginal fluid is present,
fluid should be sent for measurement of creatinine and electro-
lytes and compared to serum levels; normal exudates should
have levels similar to serum while raised creatinine levels would
suggest urine. However, as urinary ascites will be mixed with
peritoneal exudates to a variable degree, levels may not be as
high as those in urine and should be interpreted with caution.
Post-operative imaging will depend on the clinical presenta-
tion and can assess hydronephrosis, renal function and ureteric
continuity. Ultrasound will detect hydronephrosis, ascites or
a pelvic mass. Retrograde ureteropylography can be performed
using a flexible cystoscope, and will determine the continuity of
the ureter and allow for stent placement. A CT scan in excretion
phase can be used to image kidneys, ureters and bladder. It also
can demonstrate renal function (a non-functioning kidney will
not excrete contrast medium), hydronephrosis and presence of
ascites or cystic collections, but may not be as useful as retro-
grade ureteropylography or intravenous urography (IVU) for
examining the continuity of the ureter or determining the level of
urinary leak.
Bowel injuries
Bowel injury can lead to considerable morbidity and mortality
and experienced surgical assistance should be sought at an early
stage. Ideally, bowel injury should be noted at the time of
surgery, although diathermy, laser damage and crush injuries
may lead to ischaemic necrosis and breakdown of the bowel wall
within a few days following surgery.
Damage bowel should be isolated with betadine-soaked swabs,
to avoid generalized leakage of contents into the abdominal cavity.
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5. The bowel wall is repaired with interrupted 3/0 absorbable sutures
on a non-traumatic needle and sutures are hand-tied to oppose and
create an air-proof seal, but not so tight as to cause ischaemia,
increasing the risk of dehiscence of the repair. Longitudinal
injuries can be closed horizontally, to help avoid stricture forma-
tion. Sutures should include w5 mm of serosa and muscle layers,
and either sub-mucosa or 1 mm of mucosa, to invert the mucosa
and reduce the risk of fistula formation (Figure 2). If the damage is
superficial and the mucosa not breached, sutures should include
only muscle and serosal layers with the aim of burying the defect.
Occasionally, a damaged section may need to be removed
because of a major laceration, or if vessels in the bowel mesen-
tery have been damaged resulting in ischaemia of the bowel wall.
This will require a primary anastomosis, which can be end-to-
end, end-to-side, or side-to-side. There are a variety of techniques
and suture materials used for bowel repairs and there is little
evidence that one approach is superior to another. An interrupted
suturing approach is described here, as recommended by the
Royal College of Surgeons Basic Surgical Skills Course.
Bowel is clamped with soft bowel clamps, to prevent escape of
bowel contents. 3/0 absorbable stay sutures on an atraumatic
round-bodied needle are placed at the ante-mesenteric and
mesenteric borders, including w5 mm of serosa, muscle and sub-
mucosa and either emerging between the mucosa and sub-
mucosa or involving w1 mm of mucosa. The sub-mucosa is the
strongest layer and it is essential to include this in the suture.
These sutures are not tied at this stage, but the ends are left long
and clipped to help stabilize and manipulate the bowel. Starting
at the mesenteric border, sutures are placed (as described above)
at w5 mm intervals and tied. The bowel is then turned over by
passing the mesenteric stay suture through the defect in the
mesentery and moving the ante-mesenteric suture to display the
posterior aspect of the anastomosis and further sutures are
placed at 5 mm intervals, as before. The bowel is returned to its
original position, by passing the mesenteric stay suture back
through the defect, before the stay sutures are tied and cut. Any
defect in the mesentery should then be repaired with interrupted
sutures, to prevent bowel loops becoming incarcerated.
Following repair, the bowel should be checked for haemostasis,
adequacy of circulation and air leaks and the abdominal cavity
washed-out with warm saline. The patient will require intra-
operative antibiotics according to local antibiotic policy, which
may be continued post-operatively, depending on the degree of
contamination of the abdominal cavity. Increasingly anasto-
moses are repaired with staples and frequently a side-to-side
anastomosis is created using a GIA and TA stapler (Figure 3).
If bowel injury is not noted at the time of surgery or there is
a subsequent leak from a primary repair, presenting symptoms
include abdominal pain, vomiting, fever and rigours. There may
be signs of sepsis (fever, tachycardia, hypotension), and the
abdomen may be tender, with guarding and rebound tenderness;
bowel sounds are normally absent, if peritonitis is present. If the
leak is localized to the pelvic area, vaginal or rectal examination
may be useful to feel for masses, tenderness or cervical excita-
tion. General surgical assistance should be sought, since faecal
peritonitis carries a high mortality rate and dehiscence of
subsequent bowel repair is more common.
In patients diagnosed with post-operative bowel perforation,
the degree of pre-operative investigations will depend on the
clinical condition of the patient with resuscitation instigated
without delay. Immediate investigations should include full
blood count, urea and electrolytes, blood and urine culture,
following which antibiotics can be started. Liver function tests,
amylase, lipase, calcium and glucose may help to rule out other
causes for the acute presentation. Imaging may include an erect
chest X-ray to check for sub-diaphragmatic air, supine and erect
abdominal X-rays to look for dilated loops of bowel, fluid/gas
levels and a visible falciform ligament (which can be seen as an
oblique line in the right upper quadrant down to the umbilicus
and is visible if there is significant free air in the abdomen).
However, free air in the abdominal cavity is not a reliable sign in
patients within 24e48 h of abdominal surgery. Ultrasound
examination may detect signs of bowel perforation (localized
collections of gas or free fluid). A CT scan may detect inflam-
matory changes and evidence of localized perforation. Diagnostic
laparoscopy may be used, although the open approach is prob-
ably safer than blind entry in this situation to reduce the risk of
further trauma. Surgical repair will involve a laparotomy with
careful washout of the abdominal cavity and post-operative
antibiotics.
Following repair of a bowel injury a temporary defunctioning
stoma, to reduce the risk of faecal peritonitis from anastomotic
dehiscence, should be considered. In the case of a primary repair
of healthy small bowel, without abdominal contamination,
a covering ileostomy is not normally required. Use of a loop
stoma (either ileostomy or colostomy) is a matter for debate
amongst colorectal surgeons in other situations. However,
a defunctioning stoma is normally recommended, if there is
faecal contamination or the bowel is not healthy. Recent
randomized control trial evidence suggests that a covering stoma
should be used following a low anterior resection for rectal
cancer since anastomotic leak rates were nearly three times
higher without a covering stoma (10.3% vs. 28%), as were
Figure 2 Placement of bowel sutures. 3/0 Absorbable stay sutures on an
atraumatic round-bodied needle include w5 mm of serosa, muscle and
sub-mucosa and either emerge between the mucosa and sub-mucosa or
involve w1 mm of mucosa. The sub-mucosa is the strongest layer and it
is essential to include this in the suture. Image from the Royal College of
Surgeons Basic Surgical Skills Course Handbook. Copyright: The Royal
College of Surgeons of England. Reproduced with permission.
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6. urgent re-operation rates (8.6% vs. 25.4%). These data support
the use of a covering stoma following significant injury to large
bowel.
Vascular injury
Vascular injury should be noted at the time of surgery and
routine checking for haemostasis examining all pedicles or
secondary port sites following removal, is recommended prior to
closure or withdrawal of the laparoscope.
Despite precautions to avoid injury to superior epigastric
vessels at the time of secondary port insertion during laparos-
copy, damage can still occur. Options for achieving haemostasis
of epigastric vessels include: (a) opening the skin and fascia with
direct ligation of the vessels; (b) ligation with a through-and-
through suture or laparoscopically-placed suture; (c) use of
laparoscopic electrocautery; (d) tamponade from an inflated
Foley balloon catheter secured under traction with a clamp at the
skin surface.
During open surgery, vessel ends should be identified, clam-
ped with non-toothed forceps and re-ligated, taking care of
surrounding structures. It may be necessary to dissect out or
skeletalize the vessel to identify it, especially if the end of the
ovarian artery has retracted into the retroperitoneal tissues.
Defects in larger vessels require expert repair by a vascular
surgeon, to prevent stenosis, dissection or thrombus formation
and embolization. Repair of larger vessels requires dissection to
display anatomy and gain control of the up-stream and down-
stream flow with vascular clamps or slings (avoiding damage to
the intima) and repair the wall with prolene sutures (6e7 throws
for secure knot-tying). Handling of vessels should be limited to
avoid damage and the intima should never be handled. Sutures
are placed from inside to out (intimaeadventitia) wherever
possible, to prevent formation of a flap and dissection of the
intima from the adventitia. Since not all sutures can be placed
like this, down-stream sutures are placed inside-out as a priority.
Transverse arteriotomies can be closed by primary closure, but
longitudinal arteriotomies will require patching to prevent
stenosis.
Occasionally a suture may slip following surgery, leading to
significant haemorrhage. This will normally happen within the
first few hours following surgery. Signs may include pallor, an
increased respiratory rate, which may be the first sign, reduced
urine output, tachycardia and hypotension; beware, because
young fit patients can lose a significant blood volume before
displaying significant haemodynamic changes. Because of this,
careful, frequent post-operative observations should be taken
and the modified early warning score (MEWS) (Table 1) helps to
highlight concerning trends; patients should be reviewed by
a doctor if the MEWS is 4 or more.
Nerve injury
Neuropraxia is a recognized complication of prolonged surgery.
Problems may arise in the lower limb, secondary to extended
lithotomy position in either femoral or peroneal nerves, espe-
cially if lithotomy poles are used (where rates of 20% have
been reported). Problems will be noted post-operatively, when
there is unexpected motor or sensory block. Most cases will
resolve over time, but may require specialist neurological
Figure 3 a Mesenteric vessels are identified, secured with Robert’s clamps, transected and ligated with 2/0 absorbable ties. The damaged section is
cleaned of mesenteric fat and excised with a GIA stapler. b Ante-mesenteric borders are aligned and a 2/0 absorbable suture placed w10 cm away from
the stapled ends between the two ante-mesenteric borders, with soft bowel clamps placed further away from the stapled ends to prevent leakage of
bowel contents when the bowel is opened. Small diagonal cuts are made across the ante-mesenteric stapled ends, to allow placement of the arms of the
GIA stapling device into the bowel. The device is closed, but not fired until each side has been checked to ensure that mesentery is not caught in the
stapling device. c The small defect in the end closed with further staples (TA stapler), ensuring that the staple intersection is slightly off-set. The
mesenteric defect is closed with interrupted sutures. Images reproduced with permission courtesy of Covidien (www.autosuture.com).
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OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:3 80 Ó 2009 Elsevier Ltd. All rights reserved.

7. investigation and physiotherapy to aid recovery and prevent
further complications, such as contractures. Brachial plexus
injuries, due to shoulder restraints to aid the Trendelenburg
position, or arms abducted above the shoulders on arm boards,
have been reported. These will normally resolve over time with
physiotherapy, but may be very disabling in the short term.
Post-traumatic neuropathy can result from damage to nerves
during surgery or at injection sites. Symptoms are usually felt
locally, at the site of injury and radiate to the involved nerve
distribution area. Symptoms of damage include neuralgic pain
(burning, shooting) and possibly hypersensitivity, numbness,
tingling, and muscle weakness depending on the functions of the
nerve involved. There may be changes in the sympathetic
nervous system to that area (excessive sweating, temperature
and colour changes) and allodynia (experiencing normal stimuli
as painful). If the nerve is damaged within the skin, there may be
point tenderness over the site of the injury, which will reproduce
the abnormal symptoms.
Investigations to consider include nerve conduction studies
and cross-sectional imaging to identify sites of nerve compres-
sion. Treatment will normally be in conjunction with a chronic
pain service. Oral medications for neuralgic pain include tricyclic
antidepressants and anti-epileptics, e.g. amitriptyline and gaba-
pentin. Doses should be increased gradually to reduce side
effects. Desensitization injections with dilute local anaesthetic
and steroid can reduce scar hypersensitivity and nerve blocks can
be used with long-acting local anaesthetic and steroid in some
anatomical locations. Permanent blocks e.g. with phenol may
help initially, but may cause deafferentation pain afterwards.
Surgery may be appropriate to decompress a nerve, remove
suture materials, or excise a neuroma, but may exacerbate
symptoms in the long term. All scars are capable of causing
neuralgic pain, and although the mechanism is not completely
understood, may involve entrapment of nerves within scar tissue.
Conclusions
No surgery is without risk and complications are inevitable.
However, correct training and mindful surgery, with a thorough
knowledge of the anatomy will help reduce avoidable compli-
cations. Appropriate pre-operative counselling of women is
crucial in gynaecological surgery, as many procedures are for
symptom control of non-life threatening conditions. Many
complications are relatively minor and appropriate immediate
management will avert long-term sequelae. It is therefore vital to
be able to recognize when complications have occurred, institute
‘first-aid’, and enlist senior and experienced assistance when
necessary. Last, but by no means least, the patient should be
made aware of any complication as soon as possible following
surgery. Thorough explanation of events and likely conse-
quences is essential and follow up for further debriefing may be
required depending on the circumstances. Patients accept that
complications may occur and are sometimes unavoidable.
However, failing to communicate adverse events and answer
questions appropriately is not. A
FURTHER READING
http://www.autosuture.com/autosuture/pageBuilder.
aspx?topicID¼31271;breadcrumbs¼0:122497.
http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance/
index.asp.
Morrison J, MacKenzie IZ. Avoiding and managing complications during
gynaecological surgery. Obst Gyn Repro Med 2007; 17: 105e11.
Preventing entry-related laparoscopic injuries (Green-top guideline 49).
London: The Royal College of Obstetricians and Gynaecologists, May
2008.
Thomas WEG. The Intercollegiate Basic Surgical Skills Course: Participant
handbook. 3rd Edn. London: The Royal College of Surgeons of
England, 2002.
Modified early warning score for post-operative observations
Score 3 2 1 0 1 2 3
Respiratory rate (minÀ1
) 8 9e14 15e20 21e29 29
Heart rate (minÀ1
) 40 41e50 51e100 101e110 111e129 129
Systolic BP (mm Hg) 70 71e80 81e100 101e199 !200
Urine output (ml/kg/h) Nil 0.5
Temperature (
C) 35 35.1e36 36.1e38 38.1e38.5 !38.6
Neurological Alert Reacting to voice Reacting to pain Unresponsive
Table 1
Practice points
C Pre-surgical preparation of patient, surgeon and operating
team is central to avoiding complications.
C Careful explanation of procedure and risks to the patient is
required for consent to be valid.
C Sequelae of a complication can be minimized by prompt
recognition and initial management.
C Prompt recourse to appropriately experienced assistance is
advised.
C Careful explanation and counselling of the patient following
complications is essential.
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OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:3 81 Ó 2009 Elsevier Ltd. All rights reserved.