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Operative complications

Operative complications. Introduction. Litigation Indemnity cover: MPS. Urologic complications. Important to know the normal urinary tract anatomy and various anomalies (3.3-11.1% of the population) encountered in clinical practice To prevent injury and complications and medicolegal problems.

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Operative complications

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  1. Operative complications

  2. Introduction • Litigation • Indemnity cover: MPS

  3. Urologic complications • Important to know the normal urinary tract anatomy and various anomalies (3.3-11.1% of the population) encountered in clinical practice • To prevent injury and complications and medicolegal problems

  4. Causes of oliguria • Prerenal • Decreased volume • Dehydration • Blood loss • Third space sequestration • Circulatory • Septic shock • Cardiogenic shock • Postrenal • Acute obstructive uropathy • Ureteral obstruction • Urethral obstruction • Urinary extravasation • Intrinsic renal disease

  5. Ureteric injury • Low incidence (0.4-2.5%) but serious implications of morbidity and litigation • 75% occur during gynaecologic surgery • Thought to be higher with laparoscopic surgery • Only 1/3 detected during surgery • Intraop recognition is critical for prompt repair before renal compromise occurs • Prevented by routine identification and dissection of the ureter

  6. Risk factors for ureteric injury • Enlarged uterus • Previous pelvic surgery • Ovarian neoplasms • Endometriosis • Pelvic adhesions • Distorted anatomy • Massive bleeding

  7. Types of ureteric injury • Ligation • Angulation • Transection • Laceration • Crush • Ischaemia • Resection

  8. Sites of ureteric injury • Most common site during abdominal hysterectomy or adnexectomy is the pelvic brim where it lies beneath the IFP ligament • Over the iliac arteries • In the cardinal ligament at the level of the internal cervical os where the uterine artery crosses the ureter • At the anterolateral vaginal fornix as the ureter enters the bladder

  9. Sites of injury 5. In vaginal hysterectomy: near the internal cervical os and vaginal fornices as it enters the trigone of the bladder 6. At laparoscopy near the USL esp. with endometriosis 7. Trying to control bleeding in broad ligament at caesarean hysterectomy 8. Hypogastric artery ligation

  10. Prevention of ureteral injuries • Ureteric stenting for difficult cases e.g. Ca ovary • Adequate exposure during surgery. Identify the ureter • Avoid blind clamping of vessels • Caution when using diathermy (laparoscopy)

  11. Diagnosing ureteric injury • 70% diagnosed postop in gynaecologic procedures

  12. Intraoperative diagnosis • If ureters can’t be identified, use of IV methylthioninium chloride or indigo carmine can demonstrate patency • Intraop transurethral cystoscopy or abdominal telescopy may be used to show ejaculation of dye stained urine from both ureteric orifices • Cystoscopy should be considered for complex cases

  13. Postoperative diagnosis • Symptoms are variable: Flank pain, fever, haematuria, retroperitoneal urinoma (sonar) • IVP, CT with IV contrast, retrograde ureterogram, renal u/s, cystoscopy, contrast dye tests

  14. Treatment of ureteral injuries: principles • Tension free anastomosis • Minimal use of fine absorbable suture • Use of peritoneum or omentum to surround the anastomosis • Drain site with passive drain to prevent urine accumulation • Stent with ureteric catheter

  15. Case • Prolonged labour • C section done • Post-op abd distension • ? Diagnosis

  16. Bladder injury • 2 layer repair • Catheter for 10 days

  17. Cardiovascular complications • Perioperative cardiac morbidity is the leading cause of death after anaesthesia and surgery • Includes: MI, unstable angina, CCF, dysrhythmia • Risk factors: Age, previous MI, hypertension, Diabetes • Prevention: good preop care, lab tests, ECG, CXR, cardiologist review

  18. Haematological complications: risk factors • Alcohol abuse • Liver disease • Family h/o bleeding tendency • Prior need for transfusion • Severe menorrhagia • Frequent nosebleeds • Easy bruising • Von Willebrand’s disease • Chronic renal disease • SLE • Anticoagulant use • Antiplatelet drugs

  19. Intraoperative bleeding: risk factors • Surgical technique: blood vessels in retroperitoneal space • Obesity • Large pelvic mass • Adhesions • Cancer • Prior radiotherapy

  20. Blood product replacement • Red cell transfusion: whole blood, red blood cells, leukocyte-poor red cells, washed red cells • Platelet transfusion • Plasma derivatives: Cryoprecipitate-rich in Factor VIII and fibrinogen

  21. GIT • Approached with trepidation by the gynaecologist • Important in complicated surgery like Ca ovary • Bowel injury during surgery • Postop complications: Perforation, ileus, obstruction, reexploration for bowel complications, fistulae

  22. Others • Retained foreign bodies • Lymphoedema • Sexual dysfunction • Death

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