Chapter 87: Complications of General Surgical Procedures

Outpatient surgical procedures are common, and with increasing pressure for cost containment, admitted patients are being discharged earlier in their postoperative course. As a result, more patients are coming to the ED with postoperative fever, respiratory complications, GU complaints, wound infections, vascular problems, and complications of drug therapy (Table 87-1). This chapter reviews the complications common to all surgical procedures and those specific to a single procedure.

The operating surgeon should be called when one of his or her patients appears in the ED with a surgical complication. This is not just a courtesy, but provides continuity of care important for the patient's well-being.

Fever is a common presenting complaint (Table 87-2). A mnemonic for the common causes of postoperative fever is the "five Ws": wind (atelectasis or pneumonia), water (urinary tract infection), wound, walking (deep vein thrombosis), and wonder drugs (drug fever or pseudomembranous colitis).¹ Respiratory complications, such as atelectasis, and IV catheter–related problems, such as thrombophlebitis, are the predominant causes of fever in the first 72 hours. Necrotizing streptococcal and clostridial infections also occur in surgical wounds early in the postoperative course.

Urinary tract infections become evident 1 to 5 days postoperatively. Seven to 10 days postoperatively, clinical manifestations of wound infections develop. Deep venous thrombosis can result in fever any time but usually not until the fifth postoperative day. Antibiotic-induced pseudomembranous colitis occurs up to 6 weeks postoperatively. An approach for evaluating and managing fever in postoperative patients is presented in Table 87-3.

ATELECTASIS

Atelectasis, the collapse of pulmonary alveoli, is very common. Contributing factors include inadequate clearance of secretions after general anesthesia, decreased intra-alveolar pressure, and postoperative pain, which results in hypoventilation. Although atelectasis can occur after any procedure, it frequently occurs after upper abdominal and thoracic surgery. The presentation varies from an isolated fever to tachypnea, dyspnea, and tachycardia.

Evaluation includes chest radiography, pulse oximetry, and a CBC. Chest radiographs may show normal findings or exhibit platelike linear densities, triangular densities, or lobar consolidation. Mild hypoxemia from ventilation and perfusion mismatch is common, but hypercarbia is uncommon. Patients with mild atelectasis and no evidence of hypoxemia may be managed as outpatients with pain control and increased deep breathing. Admission is indicated for aggressive pulmonary toilet and supplemental oxygenation in debilitated patients, patients with underlying lung disease, patients with hypoxemia, or those in whom the diagnosis is in question.

PNEUMONIA

Pneumonia usually becomes evident between 24 and 96 hours postoperatively. Predisposing factors include prolonged ventilatory support and atelectasis. Presenting symptoms can include dyspnea, chest pain, productive cough, fever, and tachypnea. Postoperative pneumonia is likely to be polymicrobial. After specimens of sputum and blood are obtained for culture, parenteral antimicrobial therapy is given. There are many options for polymicrobial coverage. One option is levofloxacin, 750 milligrams IV once daily, and vancomycin, 1 gram IV twice daily. Admission to the hospital is generally indicated.

PNEUMOTHORAX

Pneumothorax can occur as a complication of thoracic wall surgery, breast biopsy, laparoscopic abdominal surgery, abdominal paracentesis, nasogastric and feeding tube insertion, thoracic surgery, central venous catheter insertion, endoscopic procedures, shoulder arthroscopy, and tracheostomy. For further discussion, see chapter 68, "Pneumothorax."

PULMONARY EMBOLUS

Pulmonary embolism may present any time during the postoperative period. For further discussion of signs, symptoms, and treatment, see chapter 56, "Venous Thromboembolism."

URINARY TRACT INFECTION

Urinary tract infections can occur after any surgical procedure, but the incidence increases in patients who have undergone instrumentation of the GU tract or bladder catheterization. The cause is direct contamination of the urinary bladder, most commonly with Escherichia coli. Other organisms isolated include Staphylococcus aureus, Staphylococcus epidermidis, Proteus mirabilis, Klebsiella, Pseudomonas, and enterococci. Oral antibiotics (ciprofloxacin, 500 milligrams PO twice daily, or levofloxacin, 750 milligrams PO once daily) are appropriate for most infections, and choice of antibiotic should be based on local susceptibility patterns. Elderly or debilitated patients and those with sepsis require admission for parenteral administration of antibiotics (usually levofloxacin, 750 milligrams IV once daily).

URINARY RETENTION

Postoperative acute urinary retention is a common problem for surgical patients.² Urinary retention occurs as the result of catecholamine stimulation of α-adrenergic receptors in the bladder neck and urethral smooth muscle. Increased incidence of urinary retention is likely to occur in elderly men, patients receiving excessive fluid administration during surgery, those undergoing anorectal surgery, patients undergoing longer procedures (>2 hours), and those for whom spinal or epidural anesthesia was used.^3,4

Patients with urinary retention present with lower abdominal discomfort, urinary urgency, and inability to void. The diagnosis is confirmed by use of a bladder scanner or placement of a Foley catheter. The bladder can be safely drained quickly, and there appears to be no foundation for the fears of hematuria, postobstructive diuresis, and hypotension. For patients with normal renal function and no anatomic obstruction, continued catheter drainage is not necessary. For patients with retention after GU procedures, a urologist should be consulted. Antibiotics can be given if the GU tract has been instrumented, if retention is prolonged, or if the patient is at risk for infection (see "Urinary Tract Infection" section above).

ACUTE RENAL FAILURE

Acute renal failure is classified according to the primary cause: prerenal, intrinsic, or postrenal. Volume depletion is the most common prerenal cause. The patient should be examined for signs of hypovolemia and a urinary catheter placed. Indwelling urinary catheters should be irrigated or replaced. A fluid bolus should be given. Intrinsic causes include acute tubular necrosis and drug nephrotoxicity. Obstructive uropathy is a common cause of postrenal failure. In patients with urinary outlet obstruction, placement of a urinary catheter is diagnostic and therapeutic. Renal US is needed to identify hydronephrosis or hydroureter.

Inform the operative surgeon about all postoperative wound complications.

HEMATOMAS

Wound hematomas result from unrecognized inadequate hemostasis. Patients have pain, pressure, and swelling within the wound. Patients with wound hematomas may be febrile and have sanguineous or serous wound drainage. Differentiating between hematoma and wound infection can be difficult. A few sutures should be removed to allow the hematoma to drain, and culture of wound specimens should be performed. If there is no evidence of infection and hemostasis can be maintained, the patient can be discharged. In patients who have a hematoma of the neck or who have undergone vascular surgery, extreme caution and consultation are appropriate.

SEROMAS

A seroma, a collection of serous fluid, is usually the result of inadequate control of lymphatics during dissection but can occur under split-thickness skin grafts and in areas with large dead spaces (e.g., axilla, groin, neck, or pelvis). Patients have painless swelling below the wound or graft, and needle aspiration yields a serous fluid. Aspiration confirms the diagnosis and alleviates the problem, although aspiration may have to be repeated later.

INFECTION

Systemic factors (e.g., extremes of age, poor nutrition, or diabetes) contribute to wound infections. However, local factors (e.g., necrotic tissue, poor perfusion, foreign bodies, and hematomas) are of greatest significance. In nontraumatic, uninfected operative wounds in which the respiratory, alimentary, and GU tracts were not entered, infection rates are low. In such cases, the infecting organism is usually from the skin but can originate from remote infected sources (e.g., urinary tract infection). If there is a remote infected source, the organism is probably the same in both infections. Wounds associated with entering the respiratory, alimentary, or GU tract or wounds secondary to trauma have a higher risk of infection.

Presenting signs and symptoms of wound infections include increasing pain, erythema, swelling, drainage, and tenderness at the incision site. Wounds not involving the perineum and not associated with entry into the GI or biliary tract are most often infected with S. aureus or streptococci. Such wounds can be safely managed with drainage, culture of a wound sample, irrigation, loose packing with gauze, and outpatient administration of antibiotics. Wounds involving the perineum or associated with the GI or biliary tract are often infected with multiple organisms, including gram-negative bacteria and anaerobes. Parenteral broad-spectrum antibiotics are administered, and hospital admission is necessary.

NECROTIZING FASCIITIS

Necrotizing fasciitis is a feared complication. The usual cause is direct contamination of the wound with group A streptococci or S. aureus. However, mixed aerobic and anaerobic infections have been reported. Risk factors include diabetes mellitus, alcoholism, immunosuppression, and peripheral vascular disease, but necrotizing fasciitis also occurs in young, otherwise healthy individuals. Early clinical differentiation from cellulitis can be difficult. CT may show asymmetric fascial thickening, gas tracking along fascial planes, or focal fluid collections. MRI is sensitive but not totally specific for necrotizing fasciitis and can be a useful adjunct.^5,6 Hallmarks of fasciitis are the presence of marked systemic toxicity and pain out of proportion to local findings. In more advanced cases, there may be deep pain with patchy areas of surface hypesthesia, crepitation, or bullae. Treatment should include antibiotics and immediate surgical debridement. Antibiotic choice is controversial, but triple antibiotic therapy with penicillin or a cephalosporin, an aminoglycoside, and clindamycin probably should be used.⁷ For further discussion, see chapter 152, "Soft Tissue Infections."

WOUND DEHISCENCE

Wound dehiscence can be superficial or can extend into the deeper fascial planes. Dehiscence is caused by inadequate closure or intrinsic host factors, such as malnutrition, glucocorticoid use, or diabetes. Serosanguineous fluid may leak from the wound. Dehiscence of abdominal incisions has the potential for evisceration. If evisceration is not present, conservative management using abdominal binders is appropriate. However, if there is any uncertainty about the extent of dehiscence, operative exploration is indicated.

SUPERFICIAL THROMBOPHLEBITIS

Superficial thrombophlebitis of the lower extremities is most frequently secondary to stasis in varicose veins. It is usually aseptic. There is redness and warmth of the affected vein. If there is no evidence of surrounding cellulitis or lymphangitis and no evidence of deep vein involvement on US, treatment is local heat, elevation, and nonsteroidal anti-inflammatory drugs. Suppurative superficial thrombophlebitis is characterized by erythema, palpable tender cord, lymphangitis, and pain. Suppurative thrombophlebitis requires excision of the affected vein.

DEEP VENOUS THROMBOSIS

When lower extremity superficial thrombophlebitis is seen in a postoperative patient, the possibility of concurrent deep venous thrombosis should be considered. Deep venous thrombosis is typically characterized by leg pain or swelling, or both. For suspected deep venous thrombosis, Doppler US is the preferred diagnostic test. Patients with normal color flow Doppler study results should be treated with elevation and bed rest. Repeat color flow Doppler US studies should be performed in 3 days if symptoms persist, but sooner if symptoms worsen. For further discussion, see chapter 56, "Venous Thromboembolism."

Complications of drug therapy are numerous, but the most commonly encountered problem in the ED is an allergic reaction.⁸ Another common problem is antibiotic-associated diarrhea. Many antibiotics can cause diarrhea, but the greatest concern in postoperative patients is pseudomembranous colitis. Pseudomembranous colitis is due to the toxin produced by the bacterium Clostridium difficile. Pseudomembranous colitis is related to antibiotic use, which destroys the normal enteric bacterial flora, allowing an overgrowth of C. difficile. Even short courses of antibiotics have been associated with pseudomembranous colitis. Patients have watery and sometimes bloody diarrhea, fever, and crampy abdominal pain. There are three common ways to diagnose C. difficile: nucleic acid amplification tests, glutamate dehydrogenase, and enzyme immunoassay. The current recommendation for symptomatic patients is to use a nucleic acid amplification test technology like polymerase chain reaction.⁹ For patients with moderate disease, discontinue the offending antibiotic and prescribe metronidazole. For severe disease, discontinue the offending antibiotic and give vancomycin.⁹ For further discussion, see chapters 71, "Acute Abdominal Pain" and 73, "Disorders Presenting Primarily with Diarrhea."

Many medicines can cause drug fever, but antibiotics are the drug class most commonly implicated. The mechanisms proposed are hypersensitivity reactions, pyogenic effect, and disturbed thermoregulation. In patients in whom no source for fever can be found, it is appropriate to consider stopping medications known to cause drug fever. Most often, the patient will require admission to rule out this diagnosis.

Complications of breast surgery are infrequent, but patients can develop minor wound infections and hematomas. Rarely, pneumothorax has been reported. Wound hematomas frequently require operative control for proper evacuation and hemostasis.

Early complications seen with mastectomies include wound infection, necrosis of skin flaps, and the accumulation of seromas. The incidence of postmastectomy lymphedema ranges from a low of 5.5% to a high of 80%.

In addition to the complications already reviewed, patients who have undergone any GI surgery may have intestinal obstruction, intra-abdominal abscess, pancreatitis, cholecystitis, fistulas, and tetanus. Certain procedures, such as anastomoses, bariatric surgery, placement of gastrostomy tubes, biliary tract surgery, other laparoscopic surgery, stoma creation, colonoscopy, and rectal surgery, are associated with specific complications.

INTESTINAL OBSTRUCTION

Ileus, a functional obstruction of the bowel, is postulated to be the result of stimulation of the splanchnic nerves, leading to neuronal inhibition of coordinated intrinsic bowel wall motor activity. It is expected after any operation in which the peritoneal cavity is violated. After GI surgery, small bowel tone usually returns to normal within 24 hours, and colonic function returns within 3 to 5 days. Ileus can also occur after non-GI procedures and is usually secondary to anesthetic agents; function returns to normal after 24 hours. Prolonged ileus can be caused by peritonitis, intra-abdominal abscess, hemoperitoneum, pneumonia, electrolyte imbalance, sepsis, and medications.

Presenting symptoms of ileus include nausea, vomiting, obstipation, constipation, abdominal distention, and abdominal pain. When these symptoms are present in the first few days after surgery, they are most often due to adynamic ileus. The symptoms of adynamic ileus are most often mild and respond to nasogastric suction, bowel rest, and IV hydration. However, in cases of prolonged ileus, look for an underlying cause. Evaluation includes abdominal radiography to identify air-fluid levels, chest radiography, CBC, measurement of electrolyte levels, and urinalysis to search for secondary causes of ileus.

Mechanical ileus of the bowel is most often secondary to adhesions. Symptoms are abdominal distention and pain. Abdominal radiographs demonstrate multiple air-fluid levels and a paucity of gas in the colon; however, with high obstruction, above the ligament of Treitz, there may be no air-fluid levels. In the ED, differentiating between functional ileus and mechanical bowel obstruction can be difficult. Both disorders result in different degrees of abdominal pain, distention, nausea, vomiting, and failure to pass flatus and/or feces. Abdominal CT scanning is helpful to exclude obstruction due to bowel strangulation.¹⁰ Results may have an impact on the decision to manage the obstruction expectantly or not. Once the diagnosis of mechanical obstruction is suspected or confirmed, surgical consultation is indicated.

INTRA-ABDOMINAL ABSCESS

Intra-abdominal abscess is caused most frequently by preoperative contamination, spillage of bowel contents during surgery, contamination of a hematoma, or postoperative anastomotic leaks. Patients may have abdominal pain, nausea, vomiting, ileus, abdominal distention, fever, chills, anorexia, and abdominal tenderness. If the diagnosis is suspected, obtain CT or US of the abdomen. The patient should receive broad-spectrum antibiotics (see chapter 71, "Acute Abdominal Pain"). Treatment is percutaneous drainage or surgical exploration.

PANCREATITIS

Pancreatitis after abdominal surgery is secondary to direct manipulation or retraction of the pancreatic duct. Pancreatitis most commonly occurs after gastric resection, biliary tract surgery, and endoscopic retrograde cholangiopancreatography. Clinical presentation varies from mild nausea, vomiting, and abdominal discomfort to intracTable vomiting, leukocytosis, and left-sided pleural effusion. Severe hemorrhage can cause lumbar pain accompanied by blue-gray discoloration of the skin in the flank area (Turner sign) or similar changes around the umbilicus (Cullen sign). Although the serum amylase level rises in acute pancreatitis, it is also elevated in patients with severe cholecystitis, renal insufficiency, intestinal obstruction, perforated ulcer, or ischemic bowel. A serum lipase measurement may help to identify those with true pancreatitis, although it may be elevated in a patient with a perforated viscus and other conditions. Abdominal radiographs may show localized ileus in the region of the pancreas (sentinel loop). US and CT are useful in defining pancreatic fluid collections or abscesses. In general, the treatment of postoperative pancreatitis is similar to the treatment of nonoperative pancreatitis (see chapter 79, "Pancreatitis and Cholecystitis").

CHOLECYSTITIS

Postoperative complications related to the gallbladder include biliary colic, acute calculous cholecystitis, or acute acalculous cholecystitis. The cause of these disorders in the postoperative period is not clear. US studies of the gallbladder and pancreas should be performed to aid in the diagnosis.

Acalculous cholecystitis is of particular concern in the postoperative period. The disorder seems to be more common in elderly men, but can occur in any sex and age group. Signs and symptoms are similar to those for calculous cholecystitis. Results of liver function studies and the neutrophil count may be normal. Important findings on US include gallbladder enlargement, wall thickening, and pericholecystic fluid collection, but no gallstones. Hepatobiliary scintigraphy may be helpful. Early diagnosis is critical, because early operative intervention can reduce morbidity and mortality.

FISTULAS

Enterocutaneous fistulas can occur almost anywhere in the GI tract and are usually the result of technical complications or direct bowel injury. High-output fistulas can result in electrolyte abnormalities and volume depletion. Fistulas involving the proximal GI tract are frequently high output and are of the greatest concern. Sepsis is the other major complication. Most patients require admission, although many fistulas ultimately close spontaneously.

TETANUS

Although most cases of tetanus in the United States occur after minor trauma, there have been numerous reports of tetanus after general surgical procedures.¹¹ Clostridium tetani is found in the GI tract of 1% of the population. During GI surgery, there is spillage of C. tetani. Proliferation of the organism is facilitated by the presence of devitalized tissue, blood clots, and surgical suture. Incubation can take from 0 to 73 days, at which time the toxin leads to clinical tetanus. The classic symptoms of tetanus, trismus, and opisthotonos may not be evident initially. Patients may present with nonspecific symptoms of abdominal discomfort, fever, and abdominal wall rigidity. Diagnosis is based on physical examination and a history of inadequate immunization.

ANASTOMOTIC LEAKS

Anastomotic leaks occur most frequently after esophageal and colonic surgeries and least frequently after gastric and small-intestinal anastomoses. The cause of anastomotic leakage is related mainly to surgical technique.

Intrathoracic esophageal anastomotic leaks usually manifest within 10 days of surgery. The presentation is dramatic, with fever, chest pain, tachypnea, tachycardia, and possibly shock. Chest radiograph may reveal a pneumothorax with pleural effusion. Disruption can be confirmed by contrast esophagography using a water-soluble contrast agent. Even with immediate reoperation, morbidity and mortality rates are high.

The signs and symptoms of gastric anastomotic leaks include abdominal pain, fever, leukocytosis, gastric outlet obstruction, hyperamylasemia, hyperbilirubinemia, peritonitis, and shock. Plain radiographs may reveal pneumoperitoneum or air-fluid levels. Provide volume resuscitation, parenteral broad-spectrum antibiotics, and nasogastric tube drainage. Immediate surgery is required.

Small-intestinal anastomoses infrequently leak because of the excellent blood supply and rapid healing of the area. However, if a leak occurs, the patient usually presents with local abscess formation or peritonitis. Treatment is immediate reoperation.

Colorectal anastomoses are prone to disruption because of the large number of pathogenic bacteria found, the propensity for colonic distention, and the presence of only a single thin layer of circular muscle to support sutures. The patients usually present 7 to 14 days postoperatively with fever and abdominal pain. CT confirms the diagnosis. Patients should receive broad-spectrum parenteral antibiotics, nasogastric tube drainage, and adequate fluid resuscitation in preparation for surgery.

BARIATRIC SURGERY COMPLICATIONS

Four main bariatric procedures are currently being performed for morbid obesity: laparoscopic adjusTable gastric banding using the LAP-BAND^® device (Allergan, Inc., Irvine, CA), sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch (see Figure 298-1 in chapter "The Patient With Morbid Obesity"). Overall operative mortality is <2%, but postoperative complications are common and are likely related to the technical skill of the surgeon.¹² Common complications are listed in Table 87-4.^13,14

Nausea, vomiting, and abdominal pain are common symptoms in ED patients with a history of bariatric surgery. In the first few postoperative weeks, consider life-threatening problems like anastomotic leak and intra-abdominal bleeding. In patients with abdominal pain, tachycardia, or abdominal tenderness in the early postoperative period, a CT scan is often required to rule out these diagnoses.

A common complication of the Roux-en-Y gastric bypass is dumping syndrome, which can occur either right after the meal (early) or 2 to 4 hours later (late). Dumping symptoms occur when the pylorus is bypassed or removed. The hyperosmolar chyme contents of the stomach are dumped into the jejunum, causing rapid influx of extracellular fluid and an autonomic response. Patients experience nausea, epigastric discomfort, palpitations, colicky abdominal pain, diaphoresis, and, in some cases, dizziness and syncope. Patients with early dumping symptoms experience diarrhea, whereas those with late dumping symptoms, 2 to 4 hours postprandially, usually do not. The late dumping syndrome is believed to be due to a reactive hypoglycemia. The mainstay of treatment is dietary modification; consumption of small, dry meals; and separation of solids from liquids. In refractory cases, pyloroplasty can be tried. Most patients with dumping syndrome do not require hospital admission.

Patients with gastroesophageal reflux disease present with burning epigastric pain that is aggravated by meals and unrelieved by vomiting. The syndrome is caused by reflux of bile into the stomach. Diagnosis is made clinically, but other potential diagnoses are often ruled out with endoscopic examination.

Wernicke's encephalopathy is a rare, but serious, complication that must be considered in a patient with a history of bariatric surgery who presents with any cerebellar signs, ophthalmoplegia, weakness, and/or memory disturbances. Although vitamin deficiencies are common with both Roux-en-Y gastric bypass and biliopancreatic diversion, vitamin B₁₂ deficiency is the only one that requires emergent intervention.

NONBARIATRIC GASTRIC SURGERY

Patients who have undergone partial or complete gastrectomy for nonbariatric reasons can present with a few distinct syndromes: dumping syndrome, alkaline reflux gastritis, afferent loop syndrome, and postvagotomy diarrhea. Although these complications are rare, the symptoms can be disabling. Dumping syndrome as a result of nonbariatric gastric surgery is treated in the same way as dumping syndrome after bariatric procedures.

Patients with afferent loop syndrome also develop severe epigastric pain 1 to 2 hours after eating, which is relieved by vomiting. The vomitus is bilious, without food. The syndrome occurs in patients who have undergone gastroenterostomy (Billroth II) reconstruction after partial gastrectomy. Diagnosis is made by contrast radiography or endoscopy. Operative reconstruction is required.

Truncal vagotomy usually results in increased bowel movements, but occasionally results in diarrhea. Diarrhea is variable in occurrence and not associated with food intake. It is often unpredicTable and explosive, which can lead to weight loss, malnutrition, and severe social complications. The incidence of the diarrhea decreases with time, and treatment is mostly symptomatic.

Gastrostomy Tubes

Most gastrostomy tubes are now placed by an endoscopist by percutaneous endoscopy or by a radiologist by percutaneous fluoroscopy. If the patient has undergone a laparotomy, the general surgeon may place a gastrostomy tube at the time of surgery. If the tube was placed by the surgeon and has not been replaced, it will have a bumper holding the tube in place. The tube has to be cut and the bumper allowed to pass, or the bumper has to be removed by endoscopic technique. For further discussion, see chapter 86, "Gastrointestinal Procedures and Devices."

BILIARY TRACT SURGERY

More than 90% of all cholecystectomies are now performed laparoscopically. Complications can occur after open and laparoscopic cholecystectomies (Table 87-5); complications can also be related to the laparoscopic technique (Table 87-6).¹⁵

The evaluation of abdominal pain after cholecystectomy depends on the clinical condition of the patient. If there are signs of peritoneal irritation or fever, an injury to the biliary system is likely. Obtain an abdominal CT in addition to a CBC, electrolyte measurements, liver function tests, and serum lipase level. A collection of bile can be seen on CT, but endoscopic retrograde cholangiopancreatography is required to identify the specific site of the injury. Depending on the endoscopic retrograde cholangiopancreatography results, reoperation may be necessary. Small collections of bile may require only observation or percutaneous drainage.

Patients presenting soon after cholecystectomy with pain, pancreatitis, and/or jaundice may have retained common duct stones. If US does not demonstrate a dilated common bile duct, or if CT does not reveal an intra-abdominal collection of fluid, an endoscopic retrograde cholangiopancreatography should be performed. Endoscopic sphincterotomy is usually an effective means of dealing with retained stones. Patients presenting late after cholecystectomy with fever, pain, and jaundice may have bile duct stricture. Diagnosis requires endoscopic retrograde cholangiopancreatography. Insertion of stents is usually tried first, but surgical repair may be necessary. A more recent concern has been the spillage of gallstones into the peritoneal cavity at the time of surgery. Initially, such stones were thought to be innocuous. However, they have been linked to abdominal pain, pelvic pain, dysmenorrhea, intra-abdominal abscess, colocutaneous fistula, and implantation into the ovary with subsequent infertility.

OTHER LAPAROSCOPIC SURGERIES

Laparoscopic techniques are used for cholecystectomy, appendectomy, colon resection, antireflux surgery, herniorrhaphy, fundoplication, and most gynecologic and urologic surgical procedures. As with any laparoscopic procedure, there are risks related to the pneumoperitoneum and insertion of the trocar (Table 87-6). In addition to the potential for bowel injury, major vessel injury, and splenic injury, gynecologic and urologic procedures carry a risk of injury to the urinary bladder and ureters.

The two most commonly placed stomas are the ileostomy and the colostomy. Problems with stomas can be quite debilitating. Most acute complications are related to technical errors of stoma placement. Other complications include the development of Crohn's disease or carcinoma at the stomal site, stomal ischemia and necrosis, peristomal skin irritation, peristomal hernia, and stomal prolapse.

Ischemia and stomal necrosis are manifested very early in the postoperative course. The cause is inadequate blood supply to the stoma. Normally, the stoma is pink, without evidence of cyanosis. Any evidence of compromised blood flow requires surgical evaluation.

Peristomal maceration and skin destruction are most likely secondary to a poor seal of the stomal appliance. Consult an enterostomal therapist for a properly fitting appliance.

Stomal prolapse can occur with ileostomies and colostomies. The cause is usually inadequate fixation of the intra-abdominal portion or too large an abdominal wall opening. Patients present with stoma protrusion, with or without pain. Examine the stoma for viability. It should be pink and painless. If the tissue is viable, attempt reduction and follow with surgical consultation. Definitive therapy requires surgical revision.

Parastomal hernias can develop if the abdominal wall opening is too large. Determine if the hernia is incarcerated, attempt reduction, and consult a surgeon. Definitive therapy requires local reconstruction of the orifice.

Potential complications of colonoscopy include hemorrhage, perforation, retroperitoneal abscess, pneumoscrotum, pneumothorax, volvulus, postcolonoscopy distention, splenic rupture, appendicitis, bacteremia, and infection.¹⁶ Hemorrhage is the most common complication and can be secondary to polypectomy procedures, biopsies, laceration of the mucosa by the instrument, or tearing of the mesentery or spleen. If the bleeding is intraluminal, the patient will develop rectal bleeding. Patients with mesenteric or splenic injury have signs of intra-abdominal bleeding. Treatment of intraluminal bleeding depends on the magnitude of hemorrhage. Intra-abdominal bleeding requires emergency laparotomy. Colon perforation with pneumoperitoneum usually is evident immediately but can take several hours to manifest.¹⁷ Perforation is usually secondary to intrinsic disease of the colon (e.g., diverticulitis) or to vigorous manipulation during the procedure. Most patients require immediate laparotomy, but in some patients presenting late (1 to 2 days later) without signs of peritonitis, hospital observation may be appropriate.

Patients who have undergone hemorrhoidectomy frequently have problems with postoperative urinary retention, the management of which has been discussed previously in the section "Urinary Retention." Three other problems that can occur are constipation, rectal hemorrhage, and rectal prolapse.

The management of constipation in a patient who has undergone rectal surgery is no different from management in any other patient. Perform gentle rectal examination to identify fecal impaction, and if present, remove the impaction. Otherwise, enemas can be used. Posthemorrhoidectomy rectal hemorrhage can occur immediately postoperatively but may be delayed up to weeks after the surgery. Causes of delayed bleeding include sepsis of the pedicle, disruption of a clot, and sloughing of tissue. Bleeding can be scant or massive. Temporary balloon tamponade using a Foley catheter may temporize until surgical ligation of the involved vessel is performed.

Mucosal prolapse occurs when the surgeon has not removed all redundant mucosa during hemorrhoidectomy and is much more common than rectal prolapse. Local treatment by a surgeon is usually corrective. Rectal prolapse can occur after any anorectal surgical procedure and likely is related to injury of the puborectalis muscle. The diagnosis is obvious on examination. The treatment is reduction (see chapter 85, "Anorectal Disorders") and surgical consultation.

Infection after anorectal surgery is surprisingly uncommon. The patient usually complains of increasing pain and fever. Examination of the area is necessary to detect an abscess or cellulitis. Fournier's gangrene may follow anorectal surgery. If this is suspected, give broad-spectrum parenteral antibiotics immediately. The patient must undergo immediate surgical debridement.