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11/24/2015 OB/GYN POST-OPERATIVE CARE AND COMPLICATIONS MICHAEL TING MD, FACOG MAINEGENERAL OBSTETRICS AND GYNECOLOGY MESPAN CONFERENCE NOVEMBER 2015 I HAVE NO DISCLOSURES TO REPORT 1 11/24/2015 ESTIMATES OF COMPLICATIONS • ABDOMINAL HYSTERECTOMY - 9% • VAGINAL HYSTERECTOMY - 4.2% • LAPAROSCOPIC HYSTERECTOMY (LAVH AND TLH) 5.3% • ROBOTIC HYSTERECTOMY - 5.5% • LAPAROSCOPIC PROCEDURES - 8% • PELVIC SUPPORT PROCEDURES - 5%-10% • OFFICE BASED PROCEDURES - 10X MORE ADVERSE EVENTS COMPARED TO HOSPITAL BASED PROCEDURES OFFICE BASED PROCEDURES • THIS IS THE NEW TREND (30% OF GYNECOLOGICAL SURGERIES) • TRANSCERVICAL STERILIZATION - ESSURE • LEEP • IUD • ENDOMETRIAL ABLATION • SUBURETHRAL VAGINAL SLINGS • SAME INFORMED CONSENT PROCESS / TIMEOUT • APPROPRIATE EQUIPMENT, STAFF ASSISTANCE, AND GOOD TECHNIQUE 2 11/24/2015 TYPES OF COMPLICATIONS • ORGAN INJURY • VASCULAR • BOWEL • BLADDER • URETERAL • INFECTIOUS MORBIDITIES • SEPSIS • Neuropathies • Other • Thromboembolic • Adhesions • Fistulas • Lymphedema • Incisional Hernias • WOUND INFECTION • PNEUMONIA • URINARY TRACT INFECTION PERI-OPERATIVE STRATEGIES • CONSENT PROCESS • DESIGNATED APPOINTMENT FOR PREOPERATIVE DISCUSSION • WRITTEN MATERIALS • FAMILY INVOLVEMENT, POWER OF ATTORNEY • BLOOD TRANSFUSION 3 11/24/2015 PERI-OPERATIVE STRATEGIES • MEDICAL EVALUATION • FOCUSED CARDIAC AND RESPIRATORY HISTORY (CARDIOVASCULAR DISEASE IS LEADING CAUSE OF DEATH) • SMOKING CESSATION • RISK ASSESSMENT FOR DVT PROPHYLAXIS • DISCUSSION OF CONTRACEPTIVES AND HORMONE REPLACEMENT PERI-OPERATIVE STRATEGIES • BOWEL, SKIN, AND VAGINAL PREPARATION • LOW RESIDUE DIET, ORAL ANTIBIOTIC AND/OR MECHANICAL BOWEL PREPARATION • PERIOPERATIVE ANTIBIOTICS (ACOG PRACTICE BULLETIN # 74) • TOPICAL ESTROGEN FOR ATROPHIC TISSUES (UNDERUTILIZED) 4 11/24/2015 BLEEDING • “EXCESSIVE” BLEEDING IN 1-3% OF HYSTERECTOMIES GENERALLY RECOGNIZED INTRAOPERATIVELY • • POST OPERATIVE RECOGNITION • VITAL SIGN CHANGES • DECREASED • VAGINAL • FLANK • MONS PUBIS PAIN AND SPACE OF RETZIUS • DECREASED HEMOGLOBIN/HEMATOCRIT URINARY OUTPUT BLEEDING PAIN WITH RETROPERITONEAL BLEEDING LABIAL SWELLING WITH BLEEDING INTO POST OPERATIVE MANAGEMENT • PHYSICAL EXAM • RETURN TO OR BOWEL INJURY AND ILEUS • 4-5% INCIDENCE OF ILEUS AND 0.3% INCIDENCE OF BOWEL INJURY WITH HYSTERECTOMY • RECOGNITION AND MANAGEMENT OF ILEUS • NAUSEA, VOMITING, AND DISTENDED ABDOMEN • ADEQUATE HYDRATION AND ELECTROLYTE MANAGEMENT • BOWEL REST AND CONSIDER USE OF NASOGASTRIC TUBE • RECOGNITION AND MANAGEMENT OF INJURY • VISUALLY WITH IMMEDIATE REPAIR • NAUSEA, EMESIS, FEVER, PERITONITIS • DIFFICULT AT TIMES TO DISCERN INJURY VS. ILEUS • DELAYED RECOGNITION REQUIRES RETURN TO OR 5 11/24/2015 VAGINAL CUFF DEHISCENSE • OVERALL RATE- 0.39% • TLH/ROBOTIC 1.5%, LAVH 0.28%, TAH 0.15%, TVH 0.08% • RELATED TO ENERGY USE, OBESITY, VAGINAL ATROPHY, PELVIC ACTIVITY • SYMPTOMS • EXCESSIVE VAGINAL BLEEDING, WATERY DISCHARGE, PELVIC PRESSURE • BOWEL EVISCERATION IN 66% • TREATMENT • SURGICAL EMERGENCY, RETURN TO OR FOR CUFF REVISION AND REPAIR, POSSIBLE BOWEL RESECTION BLADDER INJURIES • 0.1 TO 0.5% INCIDENCE • RECOGNITION • VISUAL INSPECTION • RETROFILLING (INFANT FORMULA, DILUTED METHYLENE BLUE) • CYSTOSCOPY • CT CYSTOGRAM (URINOMA) • MANAGEMENT • SURGICAL REPAIR IMMEDIATELY • POSTOPERATIVE DRAINAGE (FOLEY CATHETER FOR 7-14 DAYS) • FISTULA REPAIR - COLOVESICAL / ENTEROVESICAL (POPPY SEED TEST1.25 OZ MIXED WITH YOGURT AND VISUALIZE URINE IN 48 HOURS. 100% SENSITIVE AND SPECIFIC) 6 11/24/2015 URETERAL INJURIES • 0.2%-1.3% INCIDENCE • LOWEST WITH VAGINAL APPROACH • HIGHEST WITH LAPAROSCOPIC APPROACH • RECOGNITION AND MANAGEMENT • VISUALIZE AND PALPATE URETERS • STENTS NOT PROVEN TO BE HELPFUL • CYSTOSCOPY WITH INDIGO CARMINE, ORAL PYRIDIUM • SURGICAL REPAIR (DEPENDS ON LOCATION OF INJURY) INFECTIOUS MORBIDITIES • COMBINED 9% INCIDENCE OF WOUND INFECTION, PELVIC CELLULITIS, VAGINAL CUFF ABSCESS, AND PELVIC ABSCESSES AMONG WOMEN WHO RECEIVED PROPHYLACTIC ANTIBIOTICS WITH HYSTERECTOMY (VAGINAL FLORA) • 1-5% RATE OF SYMPTOMATIC URINARY TRACT INFECTION • 30-50% OF WOMEN UNDERGOING HYSTERECTOMY DEVELOP A FEVER POST OPERATIVELY • RECOGNITION AND MANAGEMENT • REMEMBER 6WS (WIND, WOUND, WATER, WALK, WONDER DRUGS, WHOPPERS) • HISTORY, PHYSICAL EXAM, AND LABS/RADIOLOGICAL STUDIES • TREAT WITH INCENTIVE SPIROMETRY, AMBULATION, AND ANTIBIOTICS 7 11/24/2015 THROMBOEMBOLIC COMPLICATIONS • DEEP VENOUS THROMBOSIS • 7-45% INCIDENCE IN GENERAL AND MALIGNANT GYNECOLOGIC SURGERIES • ASYMMETRIC EDEMA, WARMTH, TENDERNESS • ULTRASOUND (90% SENSITIVE FOR PROXIMAL LEG VEINS) • ANTICOAGULATION • PULMONARY EMBOLUS • 0.1-5% INCIDENCE • TACHYCARDIA, TACHYPNEA, DECREASED OXYGEN SATURATION • SPIRAL CT, VQ SCAN, EKG (SINUS TACHYCARDIA, S1Q3T3 PROMINENT S WAVE, Q WAVE AND INVERTED T WAVE) • ANTICOAGULATION NEUROPATHIES AND NERVE ENTRAPMENT • 1.9% INCIDENCE IN ONE UNIVERSITY OF FLORIDA STUDY • GENERALLY RELATED TO POSITIONING AND RETRACTOR PLACEMENT • PRESENTS WITH MOTOR WEAKNESS AND SENSORY DEFECTS, PHYSICAL EXAM IS KEY • COMPARTMENT SYNDROME • TREATMENT WITH PHYSICAL THERAPY OR SOMETIMES EXPLORATION FOR PAINFUL NERVE ENTRAPMENT 8 11/24/2015 COMPLICATIONS OF HYSTEROSCOPY • PERFORATION OF THE UTERUS • COMPLICATIONS RELATED TO DISTENDING MEDIA (NORMAL SALINE FLUID OVERLOAD TERMINATE PROCEDURE IF FLUID DEFICIT > 1.5 L) • HIGH O2 • HOSPITALIZATION • IV LASIX • THERMAL • HEMORRHAGE FOR MONITORING INJURY • INTRACERVICAL • INSERTION OF FOLEY WITH 13-30CC SALINE VASOPRESSIN FOR 6-8 HOUR AND SLOW DEFLATION • INFECTIOUS • HEMATOMETRA OBSTETRICAL COMPLICATIONS • POSTPARTUM HEMORRHAGE • UTERINE ATONY • LACERATIONS • RETAINED PRODUCTS • UTERINE INVERSION • PLACENTA ACCRETA • HEMATOMA • EPIDURAL ANESTHESIA • POSTDURAL PUNCTURE HEADACHE • TRANSIENT BACK PAIN • MENINGITIS 9 11/24/2015 CASE #1 • 24 YO FEMALE PRESENTS WITH NAUSEA, ANOREXIA, AND ABDOMINAL PAIN. SHE IS NOW DAY # 3 FROM A LAPAROSCOPIC LEFT OOPHORECTOMY AND A LYSIS OF ADHESIONS FOR A DERMOID CYST. • CYST RUPTURED DURING THE CASE • BOWEL RESECTED FROM THE CYST AND PELVIC SIDE WALL • DISCHARGED 2 HOURS AFTER SURGERY WITHOUT COMPLICATIONS THANK YOU Questions? 10