Complications of gynecologic surgery

INTRODUCTION — Extensive gynecologic surgery often entails meticulous dissection near the bladder, rectum, ureters, and great vessels of the pelvis. Complications of gynecologic surgery include hemorrhage, infection, thromboembolism, and visceral damage. The risk of complications depends upon the extent and approach to surgery and patient characteristics. Understandably, the more common complications from this surgery relate to injuries to these viscera and occur during extensive resections for the treatment of cancer or when anatomy is distorted due to infection or endometriosis. Other complications, such as pulmonary embolus, myocardial infarction, pneumonia, or fluid or electrolyte imbalance are common to all surgery. (Refer to individual topic reviews on these subjects).

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

HEMORRHAGE — Hemorrhage in gynecologic surgery is discussed in detail separately. (See "Management of hemorrhage in gynecologic surgery".)

UTERINE PERFORATION — Uterine perforation is a potential complication of all intrauterine procedures and may be associated with injury to surrounding blood vessels or viscera (bladder, bowel). In addition, uterine perforations and associated complications that are not diagnosed at the time of the procedure can result in hemorrhage or sepsis. The risk of uterine perforation is increased by factors that make access to the endometrial cavity difficult (eg, cervical stenosis) or alter the strength of the myometrial wall (eg, pregnancy, menopause).

Uterine perforation is discussed separately. (See "Uterine perforation during gynecologic procedures".)

URINARY TRACT INJURIES — The rates of ureteric and bladder injury vary with the indication for surgery and the procedure. Risk factors for urinary tract injury include surgery for malignant disease and for urinary incontinence or pelvic organ prolapse.

Urinary tract injury in gynecologic surgery is discussed separately. (See "Urinary tract injury in gynecologic surgery: Epidemiology and prevention" and "Urinary tract injury in gynecologic surgery: Identification and management".)

BOWEL INJURY — Serosal abrasions need not be repaired, but injuries involving the muscularis or muscularis and mucosa should be repaired.

Detailed discussions of the evaluation and treatment of patients suspected to have an intestinal injury are presented separately. (See "Traumatic gastrointestinal injury in the adult patient", section on 'Approach to management' and "Overview of gastrointestinal tract perforation", section on 'Risk factors'.)

Intraoperative management

●Small bowel injury – Small defects of the serosal or muscularis may be repaired using continuous or interrupted 3-0 silk or synthetic absorbable suture material. Single layer closure of small bowel is adequate in most cases. Suture lines should be perpendicular to the long axis of the bowel to prevent narrowing of the bowel lumen. Large defects can sometimes by closed with a stapling device, or resection with reanastomosis may be necessary.

●Colonic injury – Repair is similar to that described above for the small bowel. Lack of preoperative bowel prep is not an indication for colostomy. After the bowel is repaired, the abdomen is copiously irrigated. Occasionally, a segment of bowel must be resected, and if reanastomosis is performed, routine care can resume. If bowel reanastomosis cannot be performed due to extensive injury or pathology (ie, dense adhesions or inflammatory changes), a diverting colostomy may be required. Closed-system drains are commonly placed in the pelvis, but are not used by all surgeons.

We do not give additional antibiotics to woman who have already received prophylaxis prior to surgery; if no antibiotics were given, we administer broad spectrum antibiotics if the bowel lumen is entered. Postoperatively, enemas and rectal probe temperatures are proscribed in patients with rectal injuries.

There are no postoperative dietary restrictions unless the bowel injury and repair involved a large area. We do not use nasogastric tubes.

Postoperative diagnosis — Patients with bowel injury, necrosis, and perforation, particularly that results from thermal injury at the time of surgery, often do not present until the postoperative period. These women typically present with abdominal and/or chest pain. However, for women with a perforation resulting from a laparoscopic procedure, fecal contamination of the abdomen may not be associated with peritoneal signs, and patients may actually be eating and drinking and passing flatus. The diagnosis is made by observing increasing free air on CT scan. For older women, bowel necrosis and perforation can present as persistent tachycardia. The clinical presentation and diagnosis of bowel perforation is presented separately. (See "Overview of gastrointestinal tract perforation".)

FISTULA FORMATION

Urinary tract — Most fistulas occur after hysterectomy for benign conditions, since these procedures are far more common than surgery for cancer. However, the risk of fistula formation is higher after radical surgery because of the scope of surgery, the presence of tumor, and, in some cases, radiation induced changes.

Fistulae of the ureter, bladder, or both occur after radical gynecologic surgery in less than one percent of women. The fistula is localized by cystoscopy, intravenous pyelogram, and retrograde studies of the ureter (see "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions"). Simple vesicovaginal fistulae can be managed by prolonged drainage to allow an opportunity for spontaneous healing. Antibiotic prophylaxis, and, if appropriate, postmenopausal hormone therapy, are given. It is unclear how long drainage should be continued, but usually healing occurs in less than four weeks. Although cautery has been advocated for closing small fistulae, no data exist to support this practice.

Surgical correction is necessary when healing fails to occur. An immediate repair may be performed in the absence of infection and excessive granulation tissue, although delayed repairs were recommended in the past. A vaginal approach (eg, Latzko procedure) is the procedure of choice and may be done as an outpatient, with minimal morbidity. If complete closure is not obtained, a second effort may be successful. Otherwise, excision of the fistula, layered closure, and placement of an omental flap to separate bladder and vagina and provide neovascularity can be attempted transabdominally.

Simple ureterovaginal fistulae usually heal after being stented, preferably percutaneously. If this fails, surgical repair will be necessary. Complex ureterovesicovaginal fistulae require stenting and drainage until inflammation and infection have resolved. Although spontaneous healing infrequently occurs, the tissue is in more optimal condition for surgical repair. Fistulae are discussed in greater depth elsewhere. (See "Urogenital tract fistulas in females".)

Gastrointestinal — Gastrointestinal fistulae after gynecologic surgery are rare. They occur 10 to 14 days postoperatively, and may be heralded by spiking temperatures with no clear source, no response to antibiotics, and a tender, but otherwise normal-appearing, incision. The diagnosis and site of the fistula are determined radiographically by injecting dye into the fistula (fistulogram) and subsequently performing a small and large bowel series.

Management consists of resting the gastrointestinal tract by eliminating oral intake, and possibly by using inhibitors of pancreatic and gastric secretion (eg, somatostatin). Healing occurs over weeks. However, the fistula will not heal if there is an obstruction distal to it. Parenteral nutrition is indicated in most cases. If healing fails to occur, laparotomy with resection of the anastomosis and primary repair is appropriate. For low rectovaginal fistulae, the Latzko procedure can be performed. (See "Rectovaginal and anovaginal fistulas".)

POSTOPERATIVE NAUSEA AND VOMITING — Postoperative nausea with or without vomiting (PONV) has been related to a number of factors. Analgesic and anesthetic drugs, especially general anesthesia and opioids, are the most common sources of PONV. Surgical factors for PONV include intraabdominal surgery and procedures of long duration [1]. The most common surgery-specific cause of PONV is postoperative ileus or obstruction. Postoperative ileus is discussed in detail separately. (See "Postoperative ileus".)

Other risk factors include patient factors, such as female sex, nonsmoking status, history of motion sickness, and history of PONV [1]. In contrast, early refeeding of postoperative gynecologic patients, defined as fluid or food within 24 hours of surgery regardless of bowel function, has not been associated with increased nausea, vomiting, or ileus [2].

Patients at moderate to high risk of PONV benefit from preoperative administration of a prophylactic antiemetic agent (eg, serotonin receptor antagonist, dexamethsone, anticholinergic agent) [1,3,4]. If a prophylactic antiemetic was administered, treatment of PONV within six hours of surgery should be with an antiemetic from a different pharmacologic class (ie, acting at a different receptor) [1]. After six hours, PONV can be treated with any antiemetic; sometimes combinations of antiemetics from different classes are needed. Treatment of PONV is discussed in detail elsewhere. (See "Postoperative nausea and vomiting".)

ADHESIONS — One function of the peritoneal surface of pelvic and abdominal structures is to prevent adherence between these structures when they touch. If the peritoneum is injured as a result of surgery, the damaged areas may stick to each other and a permanent adhesion may form. The mainstay of prevention is careful handling of tissue at the time of surgery as tissue trauma and bacterial infection have been linked to adhesion formation [5]. Multiple agents, including liquids, solids, and gels, have been used intraoperatively in attempt to reduce the risk of adhesion formation. However, a systematic review reported no difference in efficacy with liquid barriers compared with no treatment or placebo on the adhesion-related outcomes, such as postoperative pelvic pain, pregnancy rates, and live birth rates [5]. In addition, there was inadequate evidence supporting the efficacy and safety of anti-adhesion solids and gels in gynecologic surgery.

Postoperative adhesions typically occur within the first five days after surgery [6]. They occur in 60 to 90 percent of women undergoing major gynecologic surgery [7]. They are a common cause of small bowel obstruction, although most adhesions do not result in serious sequelae: infertility, chronic pain, intestinal obstruction, or difficult subsequent surgery (possibly resulting in inadvertent enterotomy). The incidence of adhesion-related intestinal obstruction after gynecologic surgery for benign conditions without hysterectomy is approximately 0.3 percent, increasing to 1 to 3 percent among patients who undergo simple hysterectomy, 5 percent after radical hysterectomy, and 20 percent in patients who undergo both radical hysterectomy and pelvic radiation [7-9]. Symptoms may occur weeks to years after the procedure. A multihospital series of 135 cases of small bowel obstruction due to intraabdominal adhesions in nononcologic patients reported that 50 percent were related to abdominal hysterectomy (incidence 49/3597 abdominal hysterectomies or 13.6/1000) [10]. (See "Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in adults" and "Postoperative peritoneal adhesions in adults and their prevention" and "Management of small bowel obstruction in adults".)

LYMPHEDEMA AND LYMPHOCYST — Unilateral or bilateral lymphedema of the lower extremities is uncommon after radical surgery, even when postoperative radiation is given. It is a chronic problem for which there is little effective intervention. Support hose and leg wraps will minimize edema; elevation of the extremities when sitting and elevating the foot of the bed also help to control the problem. Women with lymphedema should be warned to take care of their skin and pay special attention to the development of erythema or tenderness, which may indicate infection and a need for systemic antibiotics. Diuretics do not improve lymphedema, and may lead to electrolyte abnormalities. (See "Clinical features and diagnosis of peripheral lymphedema" and "Clinical staging and conservative management of peripheral lymphedema".)

Lymphocysts are uncommon after pelvic lymphadenectomy, occurring in 1 to 3 percent of women 11 to 12 days after surgery. They are seldom symptomatic and are detected when radiologic studies are performed surveying the woman for recurrent neoplastic disease. Symptoms consist of vague, colicky, lower abdominal pain. Symptomatic lymphocysts and those causing hydronephrosis can be drained percutaneously [11]. Recurrent lymphocysts should be drained again and tetracycline instilled to sclerose the cavity. There is little, if any, role for laparotomy for drainage or marsupialization.

NEUROPATHIES — Neuropathies associated with gynecologic surgery, although relatively rare, are related to malposition of the patient, retraction, hematoma, and operative injury. This subject is discussed in detail separately. (See "Nerve injury associated with pelvic surgery".)

INFECTIOUS MORBIDITY — In one series, approximately 30 percent of women undergoing laparotomy for a gynecologic condition developed a fever of 38.0°C or more (≥100.4°F) [12]. The majority of fever work-ups were of low clinical yield and added moderate cost, except when one or more of the following risk factors were present: surgery for malignancy, bowel resection, several febrile days, higher fever, and moderately increased white blood cell count. Postoperative fever is discussed in detail separately. (See "Fever in the surgical patient".)

Fever within the first 48 hours of surgery is almost always cytokine related. Fever-associated cytokines are released by tissue trauma and do not necessarily signal infection. Fever due to the trauma of surgery usually resolves within two to three days.

Chest radiography, urinalysis, and blood and urine cultures are NOT indicated for all postoperative patients with fever. The need for laboratory testing should be determined by the findings of a careful history and physical examination. The febrile postoperative patient should be evaluated systematically (table 1), taking into account the timing of the onset of fever and the many possible causes (table 2) [13,14].

A useful initial screen for the more common causes of postoperative fever is represented by the four-part mnemonic "Wind, Water, Wound, What did we do?". "Wind" refers to pulmonary causes of fever including pneumonia, aspiration, and pulmonary embolism. "Water" refers to UTI, and "Wound" refers to SSI. "What did we do?" is a reminder to consider treatments as a cause of fever and includes medications, blood product transfusions, and intravascular, urethral, nasal, and abdominal catheters.

Significant febrile morbidity after gynecologic surgery is usually attributable to infection of the urinary tract, wound (including the vaginal cuff and necrotizing fasciitis), or pelvic cellulitis and abscess. (See "Catheter-associated urinary tract infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Complications of abdominal surgical incisions" and "Posthysterectomy pelvic abscess".)

After the first two postoperative days, a thorough inspection of the wound and good rectovaginal examination are the most important components of the fever work-up. Empiric broad spectrum antibiotics may then be started. It is appropriate to obtain an intravenous pyelogram to look for occult ureteral obstruction in women febrile after 24 hours of antibiotics. Ureteral obstruction should be treated by percutaneous stent placement. Persistent fever despite antibiotics can be a sign of septic pelvic thrombophlebitis, which requires heparin therapy. (See "Septic pelvic thrombophlebitis".)

Postoperative fever is discussed in detail separately. (See "Fever in the surgical patient".)

HERNIA — Incisional hernia may occur, as with any abdominal operation [15]. One approach to prevention is use of a bulk running closure with a permanent suture and a suture length-to-wound length ratio of at least 4:1 (ie, attempt to close the incision incorporating a length of suture at least four times the length of the incision) [16,17]. Symptomatic or cosmetically unacceptable hernias are repaired by opening the incision, debriding the edges, and either performing a primary bulk closure or placing a mesh patch. Data suggest that use of a mesh to close incisional hernias, whether large or small, is preferable to simple closure without mesh [18]. (See "Complications of abdominal surgical incisions", section on 'Fascial dehiscence' and "Overview of abdominal wall hernias in adults".)

POSTOPERATIVE THROMBOEMBOLISM — This topic is discussed in detail separately. (See "Perioperative management of patients receiving anticoagulants" and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)

RETAINED FOREIGN OBJECTS — Foreign objects are sometimes inadvertently left in the patient; these retained objects are referred to as gossypibomas [19]. One study of 54 patients with a total of 61 retained foreign bodies observed that 69 percent were sponges and 31 percent were instruments [20]. Risk factors for retention of a foreign body were emergency surgery, unplanned change in the operation, increasing body-mass index, and absence of a sponge and instrument count. (See "Retained surgical sponge (gossypiboma) and other retained surgical items: Prevention and management".)

SEXUAL DYSFUNCTION — A discussion of sexual function should precede and follow gynecologic surgery. If problems are identified with a woman's sex life, then appropriate counseling is warranted as soon as possible since sexual dysfunction may become worse after surgery or radiation therapy. As an example, vaginal fibrosis may result from radical hysterectomy or vaginal irradiation. However, most gynecologic procedures are not associated with subsequent sexual dysfunction [21-23].

Management of the physical problems related to sexual dysfunction is multifaceted. Adequate endogenous hormones or exogenous therapy are required. Vaginal lubrication can be augmented with commercial water-soluble lubricants. Use of a vaginal dilator can both enlarge the caliber of the vagina, and increase length over time. Sexual positions in which the female is on the bottom can be made more comfortable by having the patient keep the thighs slightly closer together to create a "longer" vagina. This will require the patient to guide the penis during entry. Female superior or side-by-side positions will allow the female more control over depth of penile penetration. Oral and anal sex may be reasonable considerations in patients who find this acceptable. Masturbation by the patient or sex partner may allow gradual adjustments to altered perceptions of sexual pleasure. (See "Overview of sexual dysfunction in females: Management".)

MORTALITY — A retrospective study of 1.45 million gynecology inpatients in England reported a mortality rate of 0.2 percent within 30 days of admission, and 0.5 percent within 90 days [24]. The 30-day death rate in patients with cancer was higher than for patients without cancer (5.1 percent versus 0.1 percent).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)

SUMMARY AND RECOMMENDATIONS

●Complications of gynecologic surgery include hemorrhage, infection, thromboembolism, and visceral damage. The risk of complications depends upon the extent and approach to surgery and patient characteristics. (See 'Introduction' above.)

●The mortality rate for gynecologic surgery appears to be 0.2 percent within 30 days of admission and 0.5 percent within 90 days. Death rates are higher for women with malignancy. (See 'Mortality' above.)

●For bowel injuries, serosal abrasions need not be repaired, but injuries involving the muscularis or muscularis and mucosa should be repaired. (See 'Bowel injury' above.)

●Many women undergoing laparotomy for a gynecologic condition develop a postoperative fever of 38.0°C or more (≥100.4°F). The majority of fever work-ups are of low clinical yield and added moderate cost, except when one or more of the following risk factors are present: surgery for malignancy, bowel resection, several febrile days, higher fever, and moderately increased white blood cell count. (See 'Infectious morbidity' above.)

●A discussion of sexual function should precede and follow gynecologic surgery. If problems are identified with a woman's sex life, then appropriate counseling is warranted as soon as possible since sexual dysfunction may become worse after surgery or radiation therapy. (See 'Sexual dysfunction' above.)