Dukes Club Annual Meeting          2012
When Things go WrongHow to Deal with Complications in Surgery      Mr J Graham Williams BSc, FRCS, MCh          Royal Wolv...
SURGICAL DISASTERS    Scope of Talk• Why do complications    occur?•   Identification of    complications•   Management of...
Complications in Abdominal             SurgeryReasons Complications Develop        • The patient        • The surgeon     ...
Reasons Complications Develop The Patient • Shape and size (a growing problem) • Co-morbidity • Previous surgery • Motivat...
Decision Making in Surgery     Rarely One Right Answer
Reasons Complications Develop The Operation • Type of Procedure   –Right hemi colectomy vs Low anterior    resection   –Su...
Reasons Complications Develop The Operation • Complex surgery   –Multiple steps, all of which must be right • Procedure pe...
Reasons Complications Develop The Operation    • Unexpected findings    • Abnormal anatomy    • Intraoperative problems   ...
Complications in SurgeryThe Cascade Effect - 1Post operative bleeding               Hypotension         Poor blood supply ...
Complications in SurgeryThe Cascade Effect - 2    Inadequate analgesia                Poor mobility           Pulmonary at...
COMPLICATIONS IN SURGERYIdentification of complications• Be aware that complications can  and will occur
COMPLICATIONS IN SURGERYIdentification of complications• Be aware that complications will    occur•   Complications presen...
COMPLICATIONS IN SURGERY       Identification of complications       • 379 patients, colorectal resection for           ca...
COMPLICATIONS IN SURGERY       Identification of complications       • 379 patients, colorectal resection for           ca...
COMPLICATIONS IN SURGERYIdentification of complications• Be aware that complications will    occur•   Complications presen...
COMPLICATIONS IN SURGERYIdentification of complications• Be aware that complications will    occur•   Complications presen...
COMPLICATIONS IN SURGERYIdentification of complications• Go and see the patient!• History and examination• Review bed char...
Abdominal Surgery Complications• Bleeding; primary and secondary• Wound infection• Incisional hernia• Intra-abdominal infe...
COMPLICATIONS IN COLORECTAL SURGERY  Intraoperative bleeding  • Torn vein – right hemicolectomy  • Splenic capsular tear –...
COMPLICATIONS IN COLORECTAL SURGERY  Torn Vein (gastro-epiploic – SMV)  • Access, light, assistance   • Clamping  • Blind...
Control of Mesenteric Venous Bleeding
COMPLICATIONS IN COLORECTAL SURGERY  Splenic Capsular Tear    • Avoid!    • Access, light, assistance     • Direct Pressu...
COMPLICATIONS IN COLORECTAL SURGERY  Pelvic bleeding    • Site      –Pelvic side wall      –Back of Prostate      –Vagina ...
COMPLICATIONS IN COLORECTAL SURGERY  Pelvic bleeding    • Access, light, assistance       – “Fisting”    • Direct Pressur...
Control of Pre-sacral Venous Bleeding
COMPLICATIONS IN COLORECTAL SURGERY  Post operative bleeding       • Recognition of the problem          – Epidural analge...
COMPLICATIONS IN COLORECTAL SURGERY  Post operative obstruction      • Adynamic         –Ileus      • Mechanical         –...
COMPLICATIONS IN COLORECTAL SURGERY  Post operative obstruction  • Clinical assessment paramount     –Onset     –Pain     ...
COMPLICATIONS IN COLORECTAL SURGERY  Post operative obstruction - management    • Establish cause    • Nasogastric suction...
COMPLICATIONS IN COLORECTAL SURGERY  Operating on Post operative obstruction      • Clear indication      • 5-10 days    ...
COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – factors important in healing • Blood supply, blood supply, blood sup...
COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – consequences        • None        • Poor function        • Contained...
COMPLICATIONS IN COLORECTAL SURGERY                 Anastomotic LeakLeak rate by operation performed          Operation   ...
COMPLICATIONS IN COLORECTAL SURGERY                   Anastomotic Leak Reported Leak Rates     Author        Number       ...
COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – identification       • High index of suspicion       • Abdominal pre...
COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – identification           •Examination              – Abdominal      ...
Pseudoleak
COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – choice of imaging modality • 36 patients with large bowel anastomoti...
COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – choice of imaging modality  • Question to be answered  • Available t...
COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – Management (1)      • State of the patient      • Nature of the anas...
COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – Management (2)      • Optimise the patient         –Fluid resuscitat...
COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – Management (3)  • Sepsis control    –Percutaneous drainage    –Per-r...
COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – Operative strategy     • Senior staff both ends     • Finger dissect...
Dealing with Complications     Common Techniques
Dealing with ComplicationsYou - The Surgeon:• Accept there is a problem• Understand the nature of the    problem•   Make a...
Dealing with ComplicationsThe Patient:• Pay particular attention to the    patient as a whole•   Listen to their concerns•...
Dealing with ComplicationsThe Relatives: (the hard part!)• Do not hide!• Recognise their emotions, including    anger•   B...
COMPLICATIONS IN SURGERYConcluding Remarks• Complications will occur• Leave the operating table as happy    as you can be•...
Complications in Surgery- Mr G Williams
Complications in Surgery- Mr G Williams
Complications in Surgery- Mr G Williams
Complications in Surgery- Mr G Williams
Complications in Surgery- Mr G Williams
Complications in Surgery- Mr G Williams
Complications in Surgery- Mr G Williams
Complications in Surgery- Mr G Williams
Complications in Surgery- Mr G Williams
Complications in Surgery- Mr G Williams
Complications in Surgery- Mr G Williams
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Complications in Surgery- Mr G Williams

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Presentation given by Mr Graham Williams, Royal Wolverhampton Hospitals, at the Dukes' Club AGM 2012. Why do complications occur, identification and management of complications, management of the situation.

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Complications in Surgery- Mr G Williams

  1. 1. Dukes Club Annual Meeting 2012
  2. 2. When Things go WrongHow to Deal with Complications in Surgery Mr J Graham Williams BSc, FRCS, MCh Royal Wolverhampton Hospitals“When things go wrong, boy can they go wrong”
  3. 3. SURGICAL DISASTERS Scope of Talk• Why do complications occur?• Identification of complications• Management of complications• Management of the situation
  4. 4. Complications in Abdominal SurgeryReasons Complications Develop • The patient • The surgeon • The operation
  5. 5. Reasons Complications Develop The Patient • Shape and size (a growing problem) • Co-morbidity • Previous surgery • Motivation • Immune state and nutritional state
  6. 6. Decision Making in Surgery Rarely One Right Answer
  7. 7. Reasons Complications Develop The Operation • Type of Procedure –Right hemi colectomy vs Low anterior resection –Subtotal colectomy and ileostomy vs restorative proctocolectomy • Nature and incidence of complication
  8. 8. Reasons Complications Develop The Operation • Complex surgery –Multiple steps, all of which must be right • Procedure performed –Colostomy vs anastomosis –Resection vs bypass –Laproscopic vs open surgery
  9. 9. Reasons Complications Develop The Operation • Unexpected findings • Abnormal anatomy • Intraoperative problems • Inadequate help
  10. 10. Complications in SurgeryThe Cascade Effect - 1Post operative bleeding Hypotension Poor blood supply to gut Ischaemia at anastomosis Anastomotic leak Peritonitis Death
  11. 11. Complications in SurgeryThe Cascade Effect - 2 Inadequate analgesia Poor mobility Pulmonary atelectasis Post operative chest infection Hypoxia and confusion Anastomotic leak
  12. 12. COMPLICATIONS IN SURGERYIdentification of complications• Be aware that complications can and will occur
  13. 13. COMPLICATIONS IN SURGERYIdentification of complications• Be aware that complications will occur• Complications present in many guises
  14. 14. COMPLICATIONS IN SURGERY Identification of complications • 379 patients, colorectal resection for cancer, with anastomosis • 22 (6%) clinical leak rate • 7 (1/3) classical presentation • 15 (2/3) initially misdiagnosed – 13 – cardiac symptoms – 1 – post operative obstruction – 1 - ascitesLeicester UK Sutton et al 2004, Colorectal Diseases
  15. 15. COMPLICATIONS IN SURGERY Identification of complications • 379 patients, colorectal resection for cancer, with anastomosis • 30 post operative cardiac symptoms • 3 – myocardial infarctionLeicester UK Sutton et al 2004, Colorectal Diseases
  16. 16. COMPLICATIONS IN SURGERYIdentification of complications• Be aware that complications will occur• Complications present in many guises• “If the patient is not right, the operation is not right”
  17. 17. COMPLICATIONS IN SURGERYIdentification of complications• Be aware that complications will occur• Complications present in many guises• “If the patient is not right, the operation is not right”• Find out why!
  18. 18. COMPLICATIONS IN SURGERYIdentification of complications• Go and see the patient!• History and examination• Review bed charts• Simple investigations• Reassess and consider further investigation• Decision - action / observation
  19. 19. Abdominal Surgery Complications• Bleeding; primary and secondary• Wound infection• Incisional hernia• Intra-abdominal infection (abscess)• Intestinal obstruction• Anastomotic leak• Thromboembolic complications• Cardiac / respiratory complications
  20. 20. COMPLICATIONS IN COLORECTAL SURGERY Intraoperative bleeding • Torn vein – right hemicolectomy • Splenic capsular tear – left colon mobilisation • Pelvic bleeding – Rectal resection
  21. 21. COMPLICATIONS IN COLORECTAL SURGERY Torn Vein (gastro-epiploic – SMV) • Access, light, assistance  • Clamping • Blind suture ligation or ligaclips • Gentle, direct pressure  • Direct suture ligation 
  22. 22. Control of Mesenteric Venous Bleeding
  23. 23. COMPLICATIONS IN COLORECTAL SURGERY Splenic Capsular Tear • Avoid! • Access, light, assistance  • Direct Pressure • Haemostatic swab (Surgicel ) ® • Diathermy (spray, set high) • Suture repair • Splenectomy
  24. 24. COMPLICATIONS IN COLORECTAL SURGERY Pelvic bleeding • Site –Pelvic side wall –Back of Prostate –Vagina –Pre-sacral veins
  25. 25. COMPLICATIONS IN COLORECTAL SURGERY Pelvic bleeding • Access, light, assistance  – “Fisting” • Direct Pressure (pelvic packing) • Haemostatic swab (Surgicel ) ® • Diathermy • Suture ligation • Drawing pin • Tight pack and return
  26. 26. Control of Pre-sacral Venous Bleeding
  27. 27. COMPLICATIONS IN COLORECTAL SURGERY Post operative bleeding • Recognition of the problem – Epidural analgesia – Drains • Decision making • Intraoperative strategy –Usual suspects –Sites of most clot • Haemostatic pause –Packing
  28. 28. COMPLICATIONS IN COLORECTAL SURGERY Post operative obstruction • Adynamic –Ileus • Mechanical –Adhesions –Internal hernia –Infection / leak
  29. 29. COMPLICATIONS IN COLORECTAL SURGERY Post operative obstruction • Clinical assessment paramount –Onset –Pain –Observations & Inflammatory markers –Examination –Bowel sounds? –Investigations
  30. 30. COMPLICATIONS IN COLORECTAL SURGERY Post operative obstruction - management • Establish cause • Nasogastric suction • Careful Fluid & electrolyte balance • TPN • Investigation • Patience • Re-operation
  31. 31. COMPLICATIONS IN COLORECTAL SURGERY Operating on Post operative obstruction • Clear indication • 5-10 days  • >10 days – misery • Dealing with serosal tears • Adhesion preventing strategies
  32. 32. COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – factors important in healing • Blood supply, blood supply, blood supply – Tension on anastomosis – Mobility of bowel – Site of anastomosis • Surgical technique • Patient factors – Arterial disease – Steroids – Radiotherapy
  33. 33. COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – consequences • None • Poor function • Contained abscess • Faecal fistula • Peritonitis –Multiorgan failure –Death • Increased rate of local recurrence
  34. 34. COMPLICATIONS IN COLORECTAL SURGERY Anastomotic LeakLeak rate by operation performed Operation Number Leak Rate Right Hemicolectomy 329 2% Left Hemicolectomy 210 2% Anterior resection 329 5% Ileo-anal pouch 102 2% Colostomy closure 40 5% Ileostomy closure 217 2% Oxford UK, Colorectal Diseases 2007
  35. 35. COMPLICATIONS IN COLORECTAL SURGERY Anastomotic Leak Reported Leak Rates Author Number Operation Leak RateVignali 1997 1014 Ant resect 2.9%Isbister 2001 803 Colorectal 4.2%Killingback 2002 1392 Colorectal –cancer 2.1%Walker 2004 1722 Colorectal –cancer 5.1%Yeh 2005 978 Ant resect 2.8%Peeters 2005 924 TME – cancer 11.6%
  36. 36. COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – identification • High index of suspicion • Abdominal presentations – Increasing pain – Obstruction – Wound discharge – Rectal discharge • Non abdominal presentations – Cardiac – Respiratory – Neurological
  37. 37. COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – identification •Examination – Abdominal – Gentle PR • Plain radiology – Free gas – Retroperitoneal gas • Contrast radiology • CT scanning
  38. 38. Pseudoleak
  39. 39. COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – choice of imaging modality • 36 patients with large bowel anastomotic leak • 28/36 (78%) decision to operate based on imaging • 27 patients CT scan – 4 +ve (extravasation of contrast) – 9 more +ve on review • 18 patients H O soluble enema 2 – 15 (83%) +ve • 10 patients initial scan –ve • 8 +ve on subsequent H O enema 2 Nicksa, Connecticut, DCR 2006
  40. 40. COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – choice of imaging modality • Question to be answered • Available technology • Available radiological skills • Clinical state of the patient • Awareness of limitation of investigations
  41. 41. COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – Management (1) • State of the patient • Nature of the anastomosis • Nature of the leak • Presentation of the leak • Adequate existing drainage • Defunctioning stoma –Pre-operative bowel prep
  42. 42. COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – Management (2) • Optimise the patient –Fluid resuscitation –Antibiotics –Oxygen • HDU / ITU –Ventilation –Inotropic support –Renal support – Wonder drugs
  43. 43. COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – Management (3) • Sepsis control –Percutaneous drainage –Per-rectal drainage –Open drainage –Open drainage and defunctioning –Removal of source of sepsis
  44. 44. COMPLICATIONS IN COLORECTAL SURGERYAnastomotic leak – Operative strategy • Senior staff both ends • Finger dissection • Isolation and lavage • Control sepsis • Never, ever attempt re-anastomosis! • Fuss with the stoma • Laparostomy
  45. 45. Dealing with Complications Common Techniques
  46. 46. Dealing with ComplicationsYou - The Surgeon:• Accept there is a problem• Understand the nature of the problem• Make an appropriate plan• Have a plan b, c & d• Review the situation frequently• Learn from the complication• Work with a supportive team
  47. 47. Dealing with ComplicationsThe Patient:• Pay particular attention to the patient as a whole• Listen to their concerns• Spend time discussing the nature of the problem• Keep them informed at all times
  48. 48. Dealing with ComplicationsThe Relatives: (the hard part!)• Do not hide!• Recognise their emotions, including anger• Be open and honest and spend time• Be realistic, manage expectation
  49. 49. COMPLICATIONS IN SURGERYConcluding Remarks• Complications will occur• Leave the operating table as happy as you can be• Assume the worst and hope for the best• Keep on top of the situation• Discuss complications with colleagues

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