COMMON SURGICAL COMPLICATIONS

Objectives:

 Discuss the commonly encountered surgical complications

 Discuss the predisposing/risk factors of the various
complications
 Discuss the diagnostic parameters for such complications
 Discuss the management of the complications, preventive
and therapeutic

GENERAL POST-OPERATIVE COMPLICATIONS

IMMEDIATE

 Primary hemorrhage:
o either starting intra-op or following post-operative
increase in blood pressure
o large vessel injury, failure/inadequate hemostasis,
bleeding diathesis, coagulopathy
o replace blood loss/component, prompt return to OR to
re-explore
 Atelectasis:
o loss in functional residual capacity
o poor pain control, poor inspiratory effort – collapse of
lower lobes
o predispose to pneumonia
o sit patients up >45*, adequate analgesia
 Shock
o blood loss, acute myocardial infarction, pulmonary
embolism, ARDS or septicemia
 Low urine output
o inadequate fluid replacement intra- and post-
operatively

EARLY
 Acute confusion: dehydration, sepsis, neurologic

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  Nausea and vomiting: analgesia or anesthetic-related;
paralytic ileus
 Fever of various origins
 Secondary hemorrhage: such as resulting from infection
 Pneumonia
 Wound or anastomosis dehiscence
 Deep vein thrombosis (DVT)
 Acute urinary retention
 Urinary tract infection (UTI)
 Post-operative wound infection
 Bowel obstruction due to fibrinous adhesions
 Paralytic ileus

LATE
 Bowel obstruction due to fibrous adhesions
 Bowel resection related complications
 Persistent sinus/fistula
 Incisional hernia
 Recurrence of reason for surgery, e.g. malignancy

POST-OPERATIVE FEVER

DAYS 0-2:
 Mild fever (<38*C) – common
o Tissue damage and necrosis at operation site
o Hematoma
 Persistent fever (>38*C)
o Atelectasis: the collapsed lung may become
secondarily infected
o Specific infections related to the surgery, e.g. biliary
infection post biliary surgery, UTI post-urological
surgery
 Blood transfusion or drug reaction

DAYS 3-5:
 Bronchopneumonia
 Sepsis

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  Wound infection
 Drip site infection or phlebitis
 Abscess formation, e.g. subphrenic or pelvic, depending on
the surgery involved

AFTER 5 DAYS:
 Specific complications related to surgery, e.g. bowel
anastomosis breakdown, fistula formation

AFTER THE 1 ST WEEK:

 Wound infection
 Distant sites of infection, e.g. UTI
 DVT, pulmonary embolus (PE)

HEMORRHAGE

 Large volumes blood transfusion, may exacerbate

hemorrhage by consumption coagulopathy
 Use of pre-operative anticoagulants – give protamine if
heparin has been used
 Unrecognized bleeding diathesis
 Perform clotting screen and platelet count
 Ensure good intravenous access and insert (CVP) catheter
 Cross-match blood
 Clotting screen – abnormal – fresh frozen plasma (FFP) or
platelet concentrates
 Consider surgical re-exploration
 Late post-operative hemorrhage several days after surgery –
usually due to infection damaging vessels at the operation
site.
o Treat infection and consider exploratory surgery

INFECTION

 Infectious complications – main cause of post-operative

morbidity in abdominal surgery
 Wound infection
o Superficial would infection – most common – occurring
within the 1st week

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  Localized pain, redness & slight discharge
usually caused by Staphylococci
o Cellulitis and abscesses
 Usually occur after bowel-related surgery
 Present within 1st to 3rd week – pyrexia &
spreading cellulitis or abscess
 Antibiotics, abscess – drainage. Deeper
abscess may require surgical re-exploration –
healing by secondary intention
 Gas gangrene is uncommon but life-threatening
 Wound sinus – late infectious complication from a deep
chronic abscess that can occur after apparently normal
healing
o Usually needs re-exploration to remove the underlying
cause like non-absorbable suture or mesh

IMPAIRED WOULD HEALING

Factors which may affect healing rate are:

 Poor blood supply

 Excess suture tension
 Long term steroids
 Immunosuppressive therapy
 Radiotherapy
 Severe connective tissue diseases
 Malnutrition and vitamin deficiency

WOUND DEHISCENCE

 Affects about 2% of mid-line laparotomy wounds

 Serious complication with a mortality of up to 30%
 Due to failure of wound closure technique
 Usually occurs between 7 and 10 days post-operatively
 Heralded by serosanguinous discharge from wound
 Assumed that the defect involves the whole of the wound
 Initial management includes opiate analgesia, sterile dressing
to wound, fluid resuscitation and early return to OR for
resuture under general anesthesia

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INCISIONAL HERNIA

 Occurs in 10-15% of abdominal wounds usually appearing

within first year
 Can be delayed by up to 15 years after surgery
 Risk factors include obesity, distention and poor muscle tone,
wound infection and multiple use of same incision site
 Presents as bulge in abdominal wall close to previous wound.
Usually asymptomatic but there may be pain, especially if
strangulation occurs. Tends to enlarge over time and become
a nuisance.
 Management: surgical repair where there is pain,
strangulation or nuisance.

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SURGICAL INJURY

 Unavoidable tissue damage to nerves during surgery

o Facial nerve damage during total parotidectomy
o Recurrent laryngeal nerve damage during
thyroidectomy
o Impotence following prostate surgery (nervi erigentes)
o Inguinal herniorrhaphy – ilioinguinal nerve
 Risk of injury during transport to and handling of patients in
the OR under general anesthetic.
o Injuries due to falls from OR table, stretcher
o Damage to diseased bones and joints during
positioning
o Nerve palsies
o Diathermy burns

RESPIRATORY COMPLICATIONS

 Occur in up to 15% of general anesthetic and major surgery

 Causes:
o Malnutrition
o Inadequate analgesia
o Inadequate mechanical ventilation

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 o Inadequate pulmonary toilet – risk for bronchial
plugging and lobar collapse
o Aspiration
o Injury – pneumothorax, hemothorax
 Atelectasis (alveolar collapse):
o Caused when airways become obstructed, usually by
bronchial secretions.
o Most cases are mild and may go unnoticed
o 15-40% of ventilated patients
o Symptoms – slow recovery from operations, poor
color, mild tachypnea, tachycardia and low-grade
fever
o Prevention – pre- and post-operative physiotherapy
o Severe cases, positive pressure ventilation may be
required
 Pneumonia – VAP, requires antibiotics, C&S physiotherapy
 Aspiration pneumonitis:
o Sterile inflammation of the lungs from inhaling gastric
contents
o History of vomiting or regurgitation with rapid onset of
breathlessness and wheezing
o Non-starved patient undergoing emergency surgery is
at risk
o Mortality is nearly 50%
o Requires urgent treatment with bronchial suction,
positive pressure ventilation, prophylactic antibiotics
and IV steroids

ACUTE RESPIRATORY DISTRESS SYNDROME

 Rapid, shallow breathing, severe hypoxemia with scattered

crepitations
 Chest pains or hemoptysis, appearing 24-48 hours after
surgery/trauma
 Occurs in many conditions – direct or systemic insult to the
lung, e.g. multiple trauma with shock
 Requires intensive care with mechanical ventilation with
positive-end pressure

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THROMBO-EMBOLISM

 Major cause of complications and death after surgery

 DVT – many cases are silent
o Swelling of leg, tenderness of calf muscle and
increased warmth
o Calf pain on passive dorsiflexion of foot
o Diagnosis: Venography or Doppler ultrasound
 Pulmonary embolism:
o Classic – sudden dyspnea and cardiovascular collapse
with pleuritic chest pain, pleural rub and hemoptysis.
o Smaller Pes are more common and present with
confusion, breathlessness and chest pain
o Diagnosis is by ventilation/perfusion scanning and/or
pulmonary angiography or dynamic CT
 Management: intravenous heparin or subcutaneous low
molecular weight heparin for 5 days plus oral warfarin.

COMMON URINARY PROBLEMS

 Urinary retention: common immediate post-op complication

o Adequate analgesia, catheterization
 UTI: very common, especially in women: may not present
with symptoms
o Antibiotics and adequate fluid intake
 Acute renal failure:

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 o Often due to episode of severe or prolonged
hypotension
o Other causes: antibiotics, surgery to the aorta
o Presents as low urine output with adequate hydration
o Mild cases may be treated with fluid restriction until
tubular function recovers
o Differentiate from pre-renal failure due to
hypovolemia which requires rehydration
o In severe cases may need hemofiltration or dialysis
while function gradually recovers over weeks or
months

COMPLICATIONS OF BOWEL SURGERY

 Delayed return of function: Ileus

o Temporary disruption of peristalsis: nausea, anorexia
and vomiting and usually appears with the re-
introduction of fluids
o More prolonged extensive form with vomiting and
intolerance to oral intake – distinguish from
mechanical obstruction
o If involves large bowel usually described as pseudo-
obstruction
o Diagnosis – PE, plain abdominal x-ray, barium enema
 Early mechanical obstruction: twisted or trapped loop of
bowel or adhesions occurring approximately 1 week after
surgery
o NGT plus IV fluids or progress and require surgery
 Late mechanical obstruction: adhesions can organize and
persist
o Causing isolated episodes of small bowel obstruction
months or years after surgery
o Treat as for early form
 Anastomotic leakage or breakdown: small leaks are common
causing small localized abscesses with delayed recovery of
bowel function
o Usually resolves with IV fluids, delayed oral intake,
antibiotics but may need surgery

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  Major breakdown causes generalized peritonitis and
progressive sepsis
o Surgery for peritoneal toilet, and antibiotics
o Local abscess can develop into a fistula

HEAD & NECK

 Thyroid and Parathyroid

o Bleeding/hematoma

 Diagnosis: enlarging neck, copious drainage, dyspnea

 Treatment: reopen/surgical revision-hemostasis
 Preventions: meticulous hemostasis; pre-op bleeding
parameter, control HPN
 Recurrent Laryngeal Nerve (RLN) Injury
o <5% of pts.
o Of those with injury, 10% permanent
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 o Dissection near the inferior thyroid artery – common
area
o Diagnosis: direct laryngoscopy – vocal cord
apposition; stridor, labored breathing.
o Treatment: intra-op transection – primary
reapproximation of perineurium with non-absorbable
sutures.
 Temporary palsy – function returns in 1-2
months
 Permanent palsy – stenting techniques
o Prevention: identify the RLN
 Electrolyte abnormalities
o Hypocalcemia – inadvertent removal, injury or
devascularization of parathyroids
 Transient – in up to 50%
 Permanent – <2%
 Diagnosis: circumoral, fingertip numbness,
anxiety, confusion, Chvostek’s & Trousseau’s
sign, Tetany
 Treatment: Calcium – IV or oral
 Preventive – meticulous dissection
 Seroma
 Wound infection
 Completion thyroidectomy – rate of complications higher due
to scarring & inflammation
 Thyroid storm – extreme hyperthyroid state
o <10%; mortality 20-30%
o Precipitating factors: intercurrent illness or infection,
surgery, radioiodine treatment, withdrawal of
antithyroid, vigorous thyroid palpation, iodinated
contrast dye, thyroid hormone ingestion, stress,
trauma
o Diagnosis: hyperpyrexia, dehydration, HR >140,
dysrhythmias, CHF, confusion, agitation, delirium,
coma, seizures, nausea, vomiting, diarrhea; lab-
elevated T3, T4, 24 hr radioiodine uptake, suppressed
TSH

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 o Treatment: start when clinically suspected; defer
surgery
 Block thyroid hormone synthesis – PTU,
Methimazole
 Block thyroid hormone secretion – Logul’s
solution or saturated solution of potassium
iodide, lithium, plasmapheresis, peritoneal
dialysis
 Block peripheral action of thyroid hormone –
Propanolol, Esmolol or Guanethidine or
Reserpine
 Supportive – Fluid & electrolyte, Pressors,
Paracetamol, cooling blankets, Glucocorticoids,
Digitalis, etc.
o Preventive:
 Meticulous search for the precipitating factor
 Vigilant monitoring of signs & symptoms of
hyperthyroidism (pre-op)
 Adequate control of the thyrotoxic state –
euthyroid.
 Neck Dissection
o Hemorrhage/Hematoma – internal jugular, subclavian
vein, carotid artery – immediate repair
o Pneumothorax – dissection near the apex; aspiration
or chest tube
o Air embolism – large volume of air enters internal
jugular vein – cyanosis, hypotension, loud churning
noise over precordial area – pack or clamp vein, turn
patient to left side, head down, aspiration of air from
the heart.
o Nerve damage – marginal mandibular branch of facial
nerve; cervical sympathetic chain, spinal accessory
nerve, hypoglossal nerve, vagus nerve, brachial
plexus

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 Chylous fistula – thoracic duct
 Wound infection, skin flap loss
 Salivary fistula – small & large leak – local care, TPN
 Facial edema – bilateral internal jugular vein
 Carotid rupture – 3-7%
o Predisposing factors:
 Radiation therapy, infection, salivary fistula,
suction catheters eroding the vessel,
exposure/dehiscence
 Parotidectomy
o Bleeding
o Seroma
o Facial nerve paralysis/paresis – immediate grafting
using the g. auricular or sural nerve
o Greater auricular nerve
o Frey syndrome – erythema & sweating on the cheek
related to eating
o Salivary fistula

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BREAST

 Modified Radical Mastectomy

o Seroma beneath skin flaps & axilla
 30% - most common complication
 Prevented by closed system drainage
 Catheter drains removed if <30ml/d
o Skin flap necrosis/infections
 tension, aerobic & anaerobic bacteria
 debridement/antibiotics
o hemorrhage
 moderate to severe
 rare
o significant lymphedema
 10-20%
 Factors: Extensive axillary dissection, radiation
therapy, presence of pathologic lymph nodes,
obesity
 Treatment: compressive sleeves
o 2010 – Iram Bokhari et al. evaluated Early
Complications of Mastectomy with Axillary Clearance
in Patients with Stage II & III Carcinoma Breast – 100
patients
 Seroma formation was the most common
complication despite the use of suction drains
 Edema of arm was observed in only two
patients
 Wound infection – 12 patients
 Hematoma – 4 – evacuated
 Skin flap necrosis was observed in 6 patients
 Necrosis of rotation flap was observed in 2
patients

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COMPLICATIONS IN THE GIT SURGERY

ANASTOMOTIC COMPLICATIONS
 Result of ischemia or suboptimal surgical technique, including
staple gun failure
 Stenosis – symptomatic anastomotic stenosis
o Upper gastrointestinal contrast series show delayed
passage of contrast material. On CT, a spherical pouch
or air – contrast level is suggestive of this diagnosis
 Ulcers – anastomotic ulcers after gastric bypass procedures
are common – 12-16%
o An upper gastrointestinal double-contrast barium
series may show these ulcers
 Leak and perforation – most serious complication
o Evident in the first postoperative week
o Some anastomotic leaks are complicated by an
enteroenteric, enterovesical, or enterocutaneous
fistula
 Afferent loop obstruction
o Possible causes of obstruction are adhesions, internal
hernia, anastomotic stenosis, stomal ulcer, recurrent
tumor, and obturation from bezoar

ENTERIC CONNECTION
 Enteric-related complications – rare

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 o Result from improper anatomic connection of bowel
loops & are distinct from anastomosis-related
complications
o Blind pouch syndrome
 Side-to-side anastomosis performed in Roux-
en-Y gastric bypass surgery and after intestinal
resection can result in an enlarged aperistaltic
loop of the small bowel. This enlarged loop is
termed “blind pouch”
 The blind pouches do not form until
approximately 4 months after surgery. These
structures do not usually increase significantly
in size after 12 months.
 Although often an incidental finding, blind
pouch can lead to malabsorption,
gastrointestinal bleeding, and bowel
perforation.
 If symptoms are ascribed to the pouch, the
pouch can be laparoscopically removed.

SHORT GUT SYNDROME

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  Malabsorption – caused by inadequate length of functioning
small bowel after widespread small bowel resection
 The minimal length of small bowel (excluding the duodenum)
required to cope without parenteral nutrition or small-bowel
transplantation is estimated to be 100 cm.
 Patients with a longer small bowel may also have digestive
problems if with an altered residual mucosa or a resected
distal ileum
 Short gut syndrome – by inadvertent surgery when the ileum
is mistaken for the jejunum and a gastroileostomy rather
than a gastrojejunostomy is created.
 UGIS, CT examination may show multiple loops of
nondistended jejunum that are not opacified with oral
contrast, while there is oral contrast in the stomach, ileum,
and right colon.

ALTERED BOWEL POSITION

 Small bowel may become trapped in undesirable positions
postoperatively
 Transmesenteric internal hernia
o Can occur in any procedure, including liver
transplantation and gastric bariatric surgery, in which
a Roux loop is fashioned.
o Are more common after laparoscopic bariatric surgery
than after open surgery
o Occur through the tear in the mesocolon through
which the Roux loop is brought during a retrocolic
anastomosis
o The reported incidence of internal hernia is about
2.5% and it generally involves the Roux loop.
o UGIS could show the degree and location of small
bowel obstruction but is less useful in determining the
cause of obstruction.
o The finding of dilated proximal jejunum that remains
fixed in a high position on erect views suggests
internal hernia.
o CT – more helpful in differentiating transmesenteric
hernia from mesocolic tunnel stenosis, stenosis at the

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 jejunojejunostomy, or adhesion-related simple bowel
obnstruction.
 External hernia
o Ventral hernia is a major source of morbidity after any
major abdominal procedure
o A Richter hernia can occur at the site of the trocar
after laparoscopic procedures
o Parastomal and lumbar are the other external hernias
commonly associated with abdominal surgery
 Intussusception
o Accounts for 5% of small-bowel obstruction in adults
and is more common in post-operative patients.
o Possible causes include the presence of foreign
material, such as sutures and feeding tubes, and
hyperperistalsis of bowel that has been extensively
handled

ADHESIONS
 Most common cause of bowel obstruction after surgery
 Can be symptomatic and non-obstructive
 Adhesive small-bowel obstruction is classified as simple,
closed loop, or strangulating
 Symptomatic, without Overt Obstruction
o More than 90% of patients who have had abdominal
surgery have enteric adhesions
 Adhesive Small-Bowel Obstruction
o The diagnosis of adhesion-related small bowel
obstruction is presumed on CT if there is a narrow
zone of transition without an identifiable obstructive
lesion.
o Although these patients rarely require surgery, those
with complete, closed-loop, or strangulating
obstruction require emergent surgery.

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  Biliary surgery
o Bile leak/bile duct injury – recognition, repair; T-tube;
ERCP stenting
o Abscess
o Bleeding
o Wound infection
o Retained stone – choledochoscopy, ERCP, MRCP, re-
open

COMPLICATIONS OF LAPAROSCOPIC SURGERY

COMPLICATIONS OF LAPAROSCOPIC ACCESS

 Jansen et al. found that of the 145 complications reported in
25,764 laparoscopic gynecological cases, 57% were caused
while obtaining access.
 Complications associated with Veress needle or trocar
insertion include
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 o Injuries to major retroperitoneal vessels & to bowel,
with significant morbidity and mortality.
o Abdominal wall hematoma, wound infection, fascial
dehiscence and herniation
 Mayol et al. carried out a prospective trial of 403 patients to
assess which factors were predictive of a complication with
the placement of trocars.
o Complication rate related to access of the abdominal
cavity was 5%
o Abdominal wall hematoma (2%), umbilical hernia
(1.5%), and umbilical wound infection (1.2%). Rate of
penetrating injuries was 0.2%.

PHYSIOLOGIC COMPLICATIONS OF THE PNEUMOPERITONEUM

 Carbon dioxide pneumoperitoneum causes respiratory
acidosis, presumably from absorption of the gas.
 Patel et al. found that patients undergoing laparoscopic
cholecystectomy were at high risk for developing deep
venous thrombosis (DVT), with 40% having calf DVT and 15%
having axial vein DCT on follow-up screening.
 The pneumoperitoneum required for laparoscopic surgery
leads to several important hemodynamic alterations
 Cardiac output decreases by up to 30% due to a decrease in
stroke volume
 Increase in systemic vascular resistance. Mean arterial
pressure remains unchanged or increase up to 16%.
 Patients with marginal cardiac performance may warrant
invasive cardiac monitoring to assure they tolerate
pneumoperitoneum.
 Joris et al. demonstrated that these hemodynamic changes
were at least in part due to intravascular volume status, and
could be ameliorated by preloading patients with isotonic
fluid and achieving pneumoperitoneum in the supine position
rather than the reverse-trendelenburg

COMPLICATIONS OF THE OPERATIVE PROCEDURE

CHOLECYSTECTOMY

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  Major bile duct injury during laparoscopic cholecystectomy is
associated with local factors (e.g. acute cholecystitis,
gallstone pancreatitis, and aberrant anatomy) and
experience of surgeon
 Overall rate of CBD injury – 0.31%
 The rate decreased in a statistically significant manner with
the number of procedures performed – from 0.49% during the
first 10 cases to 0.04% after 100 cases

 The classic mechanism for major bile duct injury as presented

by Lee et al.:
o Misidentification of the common bile duct or common
hepatic duct for the cystic duct.
o Delayed stricture related to thermal injury
o The first attempt at a repair for a major biliary injury
offers the best chance for the patient.
o Experienced hepatobiliary surgeon

LAPAROSCOPIC ANTIREFLUX SURGERY

 Complications, perioperative and postoperative, occur in 4%
to 16%.
 Most commonly reported intraoperative complications:
o Perforation of either the esophagus or stomach,
splenectomy, and pneumothorax.
o The rate of splenectomy is much lower in laparoscopic
than in open antireflux procedures
 Dysphagia – common post-op complication
o 22% to 57% of patients, with 4% to 32% requiring
dilatation
 Other postoperative complications include paraesophageal
herniation, atelectasis and pneumonia.

LAPAROSCOPIC INGUINAL HERNIA REPAIR

 Complications occur during and after TAPP at a rate of 6% to
31%

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  Excluding laparoscopic access associated injuries,
intraoperative complications include bladder injury, injury to
the epigastric vessels and to the spermatic cord.
 Recurrence of the inguinal hernia – most relevant
postoperative complication – 1.0% to 2.9% (minimum follow-
up of 26 months) after TAPP.
 Mesh infection – rare.
o Litwin et al. reported one out of 535 patients & Leibl
et al. 3 of 2700 patients.
 Port site herniation – infrequent.
o Litwin et al. 3 port site hernias in 535 patients who
underwent TAPP.
 Urinary retention – 3% to 7% of patients postoperatively
 Others: hematoma/seroma and neuralgia.
 Wellwood et al. conducted a large (200 patients in each arm)
randomized prospective trial comparing TAPP to Lichtenstein
tension-free mesh repair.
o Conclusion: TAPP had lower rate of wound infection,
groin/thigh pain, genital swelling, local numbness, and
constipation.
o Urinary retention did occur in a greater percentage of
the patients undergoing TAPP.

LAPAROSCOPIC APPENDECTOMY
 Complication rate of open vs lap appendectomy were similar.
 Slim et al. – most common complication
o Open appendectomy – wound infection
o Lap appendectomy – intraabdominal abscess
 Garbutt et al. – no difference in the rate of intraabdominal
abscess.
 Recent studies have found a trend toward increased intra-
abdominal infection in the laparoscopic group.

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