6
Postoperative care and
complications
The postoperative period is a time when the surgeon
must not let down his guard. Patients recovering from
complex surgical procedures need to be monitored
closely, and those recovering from routine surgery
may develop unexpected problems.
It is often the culmination of the preoperative
assessment, counselling, consent and preparation fol-
lowed by the eventual surgery that determines a suc-
cessful outcome or not. Any deficiency in the preceding
activities will become evident now. It is during this
time that the surgeon’s experience often counts and,
for this reason, it is imperative that each surgeon
keeps a record of his outcomes. It is the surgeon in
whom the patient entrusted her own well-being; it is
the surgeon who accepted that trust and the respon-
sibilities beholding it; and it is the surgeon who must
ensure a satisfactory outcome at all times.
Pain relief
Epidural anaesthesia has been shown to be most
effective for postoperative pain relief. Not only does
it provide relaxation of muscles during surgery and
less blood loss through a reduction in venous and
arterial pressure, continuation of the epidural anaes-
thesia reduces the risk of postoperative thromboem-
bolic events and provides an excellent form of pain
relief. In many institutions, the epidural can be
Bonney’s Gynaecological Surgery, 11th edition.
© Tito Lopes, Nick Spirtos, Raj Naik, John Monaghan.
Published 2010 by Blackwell Publishing Ltd.
1 1
managed in the comfort of a standard ward rather
than a high-dependency unit, where the possibility
of peaceful recovery and relaxation is undermined
by the constant activity of the nursing and medical
staff and the increased risk of hospital-acquired
infections.
An alternative analgesic option is patient-controlled
analgesia, in which a controlled infusion of opiates
can be administered based upon the patient’s require-
ments. This can be combined with the use of local
injection of the wound with local anaesthetic agents
immediately before or after the surgery. Early recourse
to non-opioid analgesics allows minimization of the
associated side-effects such as drowsiness, nausea and
vomiting, confusion and hallucinations.
Thromboprophylaxis
The role of thromboprophylaxis has been described
in detail in Chapter 2. This section is simply to
emphasize the need to continue prophylaxis until the
patient is fully ambulatory or is ready for discharge.
Following major surgery, the subcutaneous injection
of low-molecular-weight heparin commenced imme-
diately before or after surgery should be continued
for at least 5 days or until the patient is mobile. The
patient should be strongly advised to continue using
the compression stockings postoperatively for at least
4–6 weeks until fully mobile.
It is always important not to overlook complaints
of shortness of breath, and one should respond with
the appropriate work-up to rule out pulmonary
embolism including arterial blood gas and spiral CT.

Antibiotics
Other than prescribing intraoperative antibiotics, the
editors do not recommend the routine use of postop-
erative antibiotics unless, as rarely occurs, there has
clearly been considerable faecal soiling during the
surgery or a confirmed infection has been identified
preoperatively.
Catheterization
The editors’ current practice relating to bladder cath-
eterization is to use transurethral catheterization
inserted immediately prior to major surgery and to
remove the catheter on the second postoperative
day when the patient can be expected to have
recovered reasonably from the surgery and patient
mobilization is to be encouraged. Radical abdominal
hysterectomies, radical abdominal trachelectomies
and urinary incontinence procedures are best managed
by suprapubic catheters which are clamped on day 5,
and the patient taught intermittent self-catheterization
in the presence of high residual volumes.
Mobilization and physiotherapy
The need for early mobilization cannot be overem-
phasized and requires the nursing staff to ’bully’ the
patients out from their beds. Physiotherapists who
concentrate more on motivating patients with breath-
ing and lower limb exercises and early mobilization
rather than vigorous documentation in notes are to
be encouraged.
Outreach teams
Critical care outreach teams are to be congratulated
for their expertise and manner in which they ensure
adequate postoperative pain relief and identification
of patients who are deteriorating through develop-
ment of complications. Complete reliance on their
activities, however, serves to de-skill the remaining
nursing and junior medical teams and they should be
seen as a useful educational resource rather than a
replacement of an already established service.
PO S TO P ER ATI V E CA RE A ND CO MP LI C ATI ON S
Wound monitoring
There can be no excuse for the surgeon not monitor-
ing the surgical wounds of his own patients during
the postoperative period. Much can be learnt from
this simple practice. Nursing staff, despite significant
experience at managing wounds, often still require
the need for support from their medical colleagues to
ensure that difficulties do not arise and that optimal
methods are being utilized.
Although the editors currently cover all abdominal
and groin wounds with self-adhesive dressings imme-
diately after the surgery is completed, these are gener-
ally removed on the second or third postoperative day
when the wound is allowed to air and can be cleaned
and dried with a shower-head and a dryer.
Stoma therapists
This service provides a valuable adjunct to the surgi-
cal team in terms of both patient education and
proper placement and management of the stoma in
the immediate postoperative period. This function is
facilitated by a preoperative evaluation in patients in
whom diversion of the urinary or gastrointestinal
tract is being considered.
Complications
Infection
Postoperative infections are all too common in
today’s surgical practice. Pyrexia in the early postop-
erative period (less than 24 hours) is usually due to
atelectasis rather than infection, and the trainee
should resist the commencement of antibiotics unnec-
essarily. Thereafter, urinary, wound, chest, intra-
abdominal, skin and line infections (including
peripheral and central) as well as bowel infections
including Clostridium difficile need to be diagnosed
and treated early. Full blown sepsis/bacteraemia sec-
ondary to antibiotic-resistant organisms requires
close cooperation from the antimicrobiological team,
whose advice can often be invaluable. These events
are all quite distinct from cellulitis, which may or
may not require Gram-positive antibiotic coverage
given parenterally or orally based on severity of the
infection.
BO NNE Y’ S GYNAE C OLO GICA L S UR GE R Y
Wound breakdown
Occasionally, input from the tissue viability nurse
provides useful advice regarding the need for vacuum-
assisted closure (VAC) therapy and dressings which
have been shown to provide speedier recovery of large
wounds. Close liaison with the community nurses
ensures that these patients are discharged in a timely
manner and that their care is not interrupted or
disadvantaged.
It is often the editors’ practice, especially with peri-
neal wounds, which have a tremendous blood supply,
to leave the wound open to heal by secondary inten-
tion. The results with good nursing care, which can
be witnessed and documented postoperatively, can be
astounding.
In all cases, the surgeon should have a low thresh-
old to return the postoperative patient to the operat-
ing theatre in order to evaluate and possibly debride
necrotic tissue surrounding the surgical incision. This
is particularly true in cases of suspected necrotizing
fasciitis. The need for early and regular debridement
is an often overlooked part of the management of the
postoperative wound.
Wound dehiscence
Superficial dehiscence
This occurs more commonly in obese patients. They
are easily managed through regular cleansing. Taking
of culture swabs ensures the early detection of signifi-
cant infections and the appropriate use of antibiotics.
Complete dehiscence
This is often masked during the early postoperative
period as the skin staples or subcutaneous sutures are
still in situ. Often, the only sign is the occurrence of
profuse serous fluid emanating from the suture line for
no apparent reason. It is only when the staples are
finally removed that evidence of a complete dehiscence
become obvious. Immediate application of large, wet,
sterile packs over the open wound and preparation for
urgent recourse to the operating theatre should be
made. The sheath should be repaired with continuous
or interrupted non-absorbable sutures, taking large
bites of the sheath, and separate deep tension sutures
can be added depending on the surgeon’s preference.
Antibiotics should be given intraoperatively and con-
tinued if there is any evidence of infection. Patients
particularly prone include the obese, malnourished,
those on long-term steroids and those with chronic
cough and severe constipation.
Urinary tract
Infection
Urinary infections occur more commonly following
catheterization, ureteric stenting or bladder injury. The
routine collection of a catheter specimen/midstream
specimen of urine during the postoperative period
should be mandatory to ensure that asymptomatic
cases are identified and treated appropriately.
Fistulae
Vesicovaginal fistulae The women complain of being
continuously wet. The fistula can be confirmed by
the injection of methylene blue into the bladder
through a urethral catheter and seeing whether
a tampon inserted into the vagina turns blue.
Confirmation can also be made by a cystogram or
cystoscopy. Most cases will heal spontaneously if
managed conservatively with long-term indwelling
catheterization. Only occasionally is further surgical
repair required.
Ureteric fistulae As with a vesicovaginal fistula, the
patient may complain of being continuously wet. If
the patient has enough fluid leaking out of the vagina,
it can be collected and sent for a creatinine level. If it
is significantly elevated above the patient’s serum
creatinine, the diagnosis can be suspected after a
vesicovaginal fistula has been ruled out as above. An
intravenous urogram (IVU) or CT urogram may also
be useful in making a diagnosis, but a definitive diag-
nosis may be made only with a bilateral retrograde
ureteropyelography (to exclude bilateral fistulae).
Referral to a urologist should be made for further
management. Conservative management with inser-
tion of a retrograde ureteric stent may be possible.
Surgical options are described in Chapter 26.
Gastrointestinal
Ileus
Ileus is usually a result of excessive bowel handling
during surgery. It is managed by minimizing oral
intake and ensuring adequate hydration and electro-
lyte maintenance with intravenous fluids and supple-

mentation. There is no value in routinely starving
patients postoperatively after straightforward cases,
even after bowel surgery, and this practice in general
should be discouraged. Most, if not all, motility issues
following surgery are related to improper emptying
of the stomach and routine use of metoclopramide
may facilitate emptying and reduce complaints of
nausea. There is a significant body of literature on
immediate feeding of patients in the recovery room
using needle-catheter jejunostomy, making it clear
that feeding immediately after surgery is almost
always limited by gastric emptying.
Obstruction
Obstruction during the postoperative period usually
occurs some weeks after surgery and is usually the
result of surgically induced adhesions. Initial man-
agement should be conservative as most cases will
recover spontaneously after a period of rest. Rarely
will further surgery be required and often a band of
tissue or adhesion of the small bowel to the pelvis
or anterior abdominal wall is identified as the source
of the obstruction. A simple excision of the band
resolves the problem without the need for bowel
surgery.
Leaks and fistulae
Gynaecological oncology procedures may often
require the need for bowel surgery and, in some cases,
the large bowel is anastomosed without a defunction-
ing stoma. The commonly accepted rate of anasto-
motic leaks or fistulae is less than 10%.
An attentive mind is therefore required during the
postoperative period to ensure that any disturbance
to expected recovery is not the result of an anasto-
motic leak, which often presents between the 7th
and 10th postoperative day. A proactive approach, a
thorough examination and early use of investigations
including radiographs and CT scan for immediate
PO S TO P ER ATI V E CA RE A ND CO MP LI C ATI ON S
detection are imperative to recover the situation
whether the further management is to be conservative
with drainage and antibiotics or surgical repair. Close
relationships with colorectal colleagues ensure that an
accepted approach is adopted.
Sepsis
Overwhelming postoperative sepsis is a rare event. All
possible sites need to be inspected, examined and
investigated to ensure adequate diagnosis and treat-
ment. Blood culture investigation is mandatory and
regular communication with the antimicrobiological
department imperative. Broad-spectrum antibiotics
are the mainstay of treatment. Detailed abdominal
investigation to exclude anastomotic leaks, unidenti-
fied bowel injury and localized collections which may
require drainage are also required.
Prolonged surgical times, hypotension, dissemi-
nated intravascular coagulopathy and excessive blood
loss are all associated with the development of acute
respiratory distress syndrome. As a result, every effort
should be made to avoid these problems from
occurring.
Co-morbidities
Often, it is the association of co-morbidities that
determines the overall outcome. Many such patients
succumb to cardiovascular or cerebrovascular events
which to a large degree are unavoidable despite the
best of surgical interventions. Maintenance of a con-
sistent blood pressure and an adequate urine output
with appropriate fluid resuscitation throughout the
intraoperative and immediate postoperative period
play a large role in ensuring that these complications
are reduced to an absolute minimum. The rest is
dependent upon adequate preoperative assessment
and luck!