Post Operative Complications

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Post Operative Complications
Dr. Khalid Jamal Hamdi
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POST-OPERATIVE COMPLICATIONS
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• Classification
• Anaesthetic Surgical
• Local General
• (Operation site) (Other systems)
• respiratory
• cardiovascular
• urological

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Surgical Immediate
(within first 24 hs.) Early
(2nd day- 3 weeks)
Late (after discharge)
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• Other Post-op. Complications
• Post.op. pancreatitis ( 10 of all cases of acute
  pancreatitis) Operations in vicinity of pancreas
  e.g. 1 after cholecystectomy and 8 after CBD
  exploration.
• Post-op. Parotitis.
• C.V.A. ( 1-3 after carotid endarterectomy)
• Post-op. cholecystitis.
• Complications of I.V. Therapy ( air embolism,
  phlebitis.)

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Post-op. jaundice.
I. Pre-hepatic jaundice (bilirubin
overload) Haemolysis (drugs, Transfusion, sickle
cell crisis) Reabsorption of haematomas. II.
Hepatocellular insufficiency Viral
hepatitis. Drug-induced (anesthesia,
others) Ischemia (shock, hypoxemia, low-output
states) Sepsis Liver resection (loss of
parenchyma) III. Post-hepatic obstruction to
bile flow Retained stones Injury to
ducts Tumour (unrecognized or
untreated) Cholecystitis Pancreatitis
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Wound Infection After
After open surgery laparoscopic
surgery 10 lt2 ? large wound size
? small ? open to atmosphere ? not ?
more manipulation ? less ? poor blood
supply ? better
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Aetiology Pre-operative
Operative Post-operative (exist
before surgery) (during operation)
(after patients return to ward) ? perforated
organ. ? inadequate sterilization ?
cross ? compound of instruments,
surgeons infection fracture
hands or dressings between ?
skin infection patients
(boils) ? nasal carriers of
? contamination Staphylococci among
during dressing nurses and
surgeons. ? operations
on alimentary, biliary or urinary tracts
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• Clinical Picture
• Occurs a few days or even weeks after surgery.
• Pain and swelling of site of operation.
• General manifestations e.g. malaise, vomiting or
  anorexia.
• Swinging temperature (hic tic).
• Wound is also red and tender.
• Pus may be expressed out on pressure.

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Treatment Prophylactic Therapeutic
? good sterilization. ? drainage of pus
? scrupulous O.R. and ? antibiotics if
dressing techniques. associated ?
isolation of infected cases. with spreading
? elimination of carriers with
cellulitis cold or septic lesions among
nurses and surgical teams
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Burst Abdomen Total (early)
Partial (late) ? all layers gape ? Skin
is intact which leads to including skin, so
weak scar leading to viscera comes out
incisional hernia
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• Clinical Picture
• Usually occurs on the 10th post-operative day.
• Pinkish discharge (pink fluid sign).
• Viscera may come out after a strain e.g. coughing
  or sneezing.

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• Treatment
• Sedation to alleviate fear.
• Cover contents with sterile saline packs
• Re-suturing of wound using strong nylon through
  all layers of abdominal wall (tension sutures).
• Usually heals rapidly and soundly.

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Post-operative sinus or fistula Gastrointest
inal Biliary Pancreatic
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• Causes
• Poor surgical technique.
• Poor blood supply at anastomotic site.
• Sepsis leading to suture line break-down.
• Poor patients condition e.g. uraemia, anaemia,
  protein deficiency or cachexia.
• Distal obstruction e.g. missed CBD stone.

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• Clinical Picture
• Usually obvious due to escape of bowel contents
  or bile.
• Oral methylene blue test.
• Testing fistula fluid for bile or pancreatic
  enzymes e.g. amylase.
• Injection of contrast to delineate the tract.
• Sinogram / Fistulogram

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Management ? protect skin ? replace
fluid and ? reduce sepsis by from
ulceration electrolytes
judicious ? vitamins and drainage
of nutrients pus ?
antibiotic therapy
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Post-operative Pyrexia (high temperature for more
than 48 hours)

• Causes
• Wound haematoma.
• Pelvic abscess.
• D. V. T.
• Chest infection (collapse, pneumonia, infarction
  or sub-phrenic abscess).
• U. T. I.
• Enterocolitis.
• Possible drug sensitivity.

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Pulmonary Collapse

• It is a common post-operative complication after
  abdominal or thoracic surgery.
• Due to mucous retention blocking fine bronchi.
• Usually involves basal lung segments.
• May become secondarily infected by inhaled
  organisms or blood born.

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Aetiology Pre-operative Operative
Post-operative ? pre-existing ? irritant
? pain acute or anaesthetic ?
immobilization chronic lung agents
infection. ? atropine which ? emphysema.
Makes secretions viscid ? heavy Smoking
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• Clinical Picture
• Occurs within first 48 hours post-operative
• Dyspnea, tachycardia and fever.
• May be cyanosis.
• Fruity cough.
• Impaired chest movement particularly on the
  affected side.
• Basal dullness and crepitations with diminished
  air entry.
• CxR opacity of involved segments.

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Treatment Pre-operative
Post-operative ? breathing ? breathing
exercises exercises. ? encourage
coughing. ? stop smoking. ? small doses
of ? antibiotics for sedatives for
pain infection. ? antibiotics if
sputum is infected
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• Deep Vein Thrombosis
• (D. V. T.)
• Usually occurs at time of operation.
• Manifest itself during the second post-operative
  week.
• Involves the deep veins of lower limbs and
  pelvis.
• Pain and swelling of the leg and calf muscles.
• Skin temperature is increased with dilated
  superficial veins.
• May be mild pyrexia.
• Homans sign may be positive.

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Investigations Venogram I125 labeled
Doppler fibrinogen
ultrasound ? very valuable ? very sensitive
? simple and sensitive. ? can be
repeated at ? non-invasive ? can not be
short intervals. ? can detect loss
repeated frequently ? only useful for
of doppler detection of veins
effect on the below knee
occluded (excreted in urine
veins and held in bladder).
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Treatment

• Prophylactic
• active and early mobilization
• post-operatively.
• elevation of legs.
• elastic graded compression
• stocking.
• use of inflatable bags.
• electrical stimulation of leg
• muscles.
• prophylactic S.C. doses of
• heparin.

• Therapeutic
• heparinization.
• oral anticoagulants.
• ligation of I.V.C.
• I.V.C. umbrella.

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• Pulmonary Embolism
• Due to dislodgement of a clot from deep veins of
  lower limbs or pelvis.
• A massive embolus can obstruct the right heart
  out put and causes death.
• Less severe cases give rise to shock,
  breathlessness and cyanosis with severe
  retro-sternal pain and discomfort.
• Mild cases present with pleural pain, dyspnea and
  haemoptesis in 50 of cases.
• Might lead to lung infarction if patient has
  cardiac failure due to lung congestion.

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• Clinical Picture
• Difficult to diagnose clinically.
• Helpful signs are
• pleural rub
• crepitations
• diminished air entry
• May be silent.

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• Investigations
• CxR ? normal in early stage, but shows patchy
  shadowing later-on.
• E.C.G. ? Changes of right heart strain.
• Perfusion lung scan ? uneven circulation through
  the lungs with multiple perfusion defects.
• Ventilation scan ? normal in absence of
  pre-existing pulmonary diseases.
• Arteriogram (diagnostic) ? shows filling defect
  due to embolus in pulmonary artery.

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• Treatment
• Morphia for pain.
• Oxygen.
• Lysis of embolus with streptokinase if seen
  early.
• Heparinization.
• Embolectomy in critically ill patients using the
  cardio-pulmonary by-pass machine

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