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Complications from major abdominal procedures that lead to ED visits usually occur at least 3 days postoperatively (Table 105-5).
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Hysterectomy remains one of the most common major surgical procedures in the United States, with the abdominal approach composing 60% of cases (14% laparoscopic and 26% vaginal).2,15 A total hysterectomy is removal of the uterus and part or all of the cervix and is unrelated to removal of the ovaries. A subtotal hysterectomy involves removal of the uterus without removal of the cervix. Patients may be unsure of the type of hysterectomy that was performed.
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The risk of postoperative infection after hysterectomy is 3% to 10%, with higher rates in the abdominal versus the vaginal approach.16 Risk factors for postoperative infections include obesity, diabetes, and long operative time.16
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Most wound infections occur within the first 2 postoperative weeks; however, they can present several months after surgery. Symptoms include fever and increased pain at the incision site. Examination reveals wound tenderness, skin erythema, induration, purulent discharge from the incision, and possible dehiscence.
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Empiric antibiotics should provide coverage against staphylococci, including methicillin-resistant S. aureus, and streptococci. If an incisional abscess is diagnosed, first open and drain the wound. Probe the wound with a sterile cotton swab to confirm an intact fascia. Then, irrigate the wound copiously with normal saline and pack with saline-soaked wet-to-dry dressings. If staples have been placed, they should be removed. Obtain aerobic and anaerobic cultures to tailor antibiotic therapy.
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For invasive infections, consult with the operating gynecologist. Give parenteral antibiotics and, usually, admit to the hospital.
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WOUND SEROMA AND HEMATOMA
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Wound seromas and hematomas are characterized by drainage, rather than fever or pain, and can be visualized by bedside US. Small seromas and hematomas can be managed by observation and will usually resolve spontaneously. Large seromas can be aspirated. If there are any signs of infection, the wound should be opened and drained and then packed with wet-to-dry dressings.
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VAGINAL CUFF CELLULITIS AND PELVIC ABSCESS
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The vaginal cuff formed during hysterectomy is composed of the contiguous retroperitoneal space immediately above the vaginal apex and the surrounding soft tissue. Vaginal cuff cellulitis usually occurs early after surgery. Patients complain of fever; purulent vaginal discharge; and pelvic, back, or abdominal pain. Pelvic examination reveals tenderness and induration of the vaginal cuff and purulent discharge.
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Vaginal cuff and pelvic abscesses and infected hematomas are rare and usually present 10 to 14 days postoperatively. Symptoms include fever, chills, tachycardia, pelvic pain, and rectal pressure. Examination findings include lower abdominal and vaginal cuff tenderness, a tender or fluctuant mass near the cuff, and bloody or purulent drainage from the cuff. US or CT can define the size and location of an abscess or hematoma.
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Admit patients for parenteral antibiotics and possible drainage by interventional radiology or colpotomy. Give broad-spectrum antibiotics, such as imipenem-cilastatin, gentamicin and clindamycin, or ciprofloxacin and metronidazole, to cover gram-negative and gram-positive bacteria and anaerobic organisms.17
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DEHISCENCE AND EVISCERATION
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Wound dehiscence is the failure of normal healing and the disruption of fascia and peritoneum. Evisceration occurs when omentum or bowel presents through the incision. The classic sign of impending dehiscence is the sudden outpouring of serosanguineous blood from the incision. The patient may describe a "pop" or tearing sensation. Most often, dehiscence occurs between postoperative days 5 and 8 for abdominal surgeries.18
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Vaginal cuff dehiscence usually occurs 1.5 to 3.5 months after hysterectomy.19 Patients complain of postcoital bleeding, watery discharge, and pelvic pain. If bowel evisceration has occurred, patients note vaginal and pelvic pressure or a bulge.
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When abdominal evisceration has occurred, cover the abdomen with moist sterile towels and support the dressing with tape to prevent further gut extrusion. The patient should be taken directly to the operating room for closure. In cases in which there is a sudden appearance of blood but no bowel, it is best to follow the same procedure because evisceration usually is imminent. Vaginal cuff dehiscence can be managed conservatively if small or partial, whereas large or complete vaginal cuff dehiscence usually requires surgical closure.
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Genitourinary injury occurs more often during the performance of abdominal hysterectomy than during any other pelvic surgery. Most bladder injuries are apparent at the time of surgery, but some ureteral injuries go unrecognized. Ureteral injury occurs less frequently than bladder injury but is generally underestimated. Operative injury to the ureter results from one of three types of trauma: crushing, transection, or ligation. Each type of injury can be either partial or complete.
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Suspect ureteral injury in women who develop flank pain shortly after surgery. Fever, hematuria, and costovertebral angle tenderness may also be present. Obtain a urinalysis and abdominopelvic CT with IV contrast. Admit to the hospital for ureteral catheterization under cystoscopic guidance and possibly exploratory laparotomy. Percutaneous nephrostomy with delayed repair may also be considered. Provide parenteral antibiotics if infection is suspected.
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Vesicovaginal fistulas can become evident 10 to 14 days after surgery with a watery vaginal discharge. The diagnosis can be confirmed by inserting a cotton tampon into the vagina and then instilling methylene blue or indigo carmine dye via a transurethral catheter. If the tampon stains blue, a vesicovaginal fistula is present. If no staining occurs, a ureterovaginal fistula must be ruled out by injecting 5 mL of indigo carmine dye IV. If a ureterovaginal fistula is present, the tampon should stain blue within 20 minutes.
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Gynecologic consultation is necessary. Patients with a vesicovaginal fistula require prolonged urinary drainage with a Foley catheter. Although some fistulas close spontaneously, most require surgical repair.
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Urinary tract infection is a common complication.2 For detailed discussion, see chapter 91, "Urinary Tract Infections and Hematuria." Urinary retention in a healthy female after gynecologic surgery is uncommon. Urinary retention is usually a temporary result of pain or bladder atony resulting from anesthesia. However, many women experience either an inability to void or incomplete emptying of the bladder during the postoperative period, most frequently after radical hysterectomy or surgeries that involve the urethra and bladder neck (i.e., anterior repair or any modification of the retropubic urethropexy). Retention is initially relieved with insertion of a Foley catheter for 12 to 24 hours. Most patients are able to void after this period. For further discussion, see chapter 92, "Acute Urinary Retention."
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Pulmonary emboli account for nearly 40% of all deaths after gynecologic surgery.2 The prevalence of postoperative deep venous thromboembolism is 11% to 25%.2 Fifty percent of venous thromboembolic events occur in the first 24 hours after surgery, and 75% occur in the first 3 postoperative days. There is no difference in the incidence of venous thromboembolism between abdominal, vaginal, or laparoscopic hysterectomy, but risk factors include age >60 years, cancer, and other comorbidities.20 For complete discussion of diagnosis and treatment, see chapter 56, "Venous Thromboembolism."
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Septic pelvic thrombophlebitis complicates 0.1% to 0.5% of gynecologic procedures, more commonly after cesarean delivery than hysterectomy.21 The two forms of septic pelvic thrombophlebitis, ovarian vein thrombosis and deep septic pelvic thrombophlebitis, often occur together. Signs include abdominal pain and fever. The diagnosis may be aided by CT and MRI, but a negative study does not exclude disease.21,22 Treatment is heparin and parenteral antibiotics. Long-term anticoagulation is not needed unless septic pulmonary emboli develop.