The most common reasons for emergency department visits during the postoperative period after gynecologic procedures are pain, fever, and vaginal bleeding. A focused but thorough evaluation should be performed, including sterile speculum and bimanual examination. Consultation with the gynecologist who performed the procedure is indicated.
COMPLICATIONS OF ENDOSCOPIC PROCEDURES
The major complications associated with laparoscopy are thermal injury of the bowel, viscus perforation, hemorrhage, vascular injury, ureteral or bladder injuries, incisional hernia, and wound dehiscence. Bowel injury should be suspected if pain is greater than expected after laparoscopy. Thermal injury is easily missed due to delayed development of symptoms for several days to weeks postoperatively. Patients with the above typically present with bilateral lower abdominal pain, fever, elevated white blood cell count, and peritonitis. X-rays can show an ileus or free air under the diaphragm. Early gynecology consultation should be obtained.
Complications of hysteroscopy are rare but include uterine perforation, postoperative bleeding, fluid overload from absorption of distention media, gas embolism, and infection. Bleeding may originate from the uterus after resection or the cervix due to lacerations or tears. Management includes packing of the vaginal vault and consultation with a gynecologist.
OTHER COMPLICATIONS OF GYNECOLOGIC PROCEDURES
Cuff cellulitis, a common early complication after hysterectomy, is an infection of the contiguous retroperitoneal space immediately above the vaginal apex and the surrounding soft tissue. Patients typically present with fever, abdominal pain, pelvic pain, back pain, and purulent vaginal discharge. Cuff tenderness and induration plus purulent discharge are prominent during the gynecologic exam. Abscesses are rare, but will present as a fluctuant mass near the cuff approximately 10 to 14 days postoperatively. Treat with broad-spectrum antibiotics. Recommended regimens include imipenem-cilastatin, gentamicin and clindamycin, or ciprofloxacin plus metronidazole. Admit for continuation of antibiotics and consideration of drainage by interventional radiology.
Postoperative Wound Infection
Patients with wound infections generally present with fever and increasing pain at the surgical site. Onset is typically within 2 weeks of surgery. Exam will reveal erythema, tenderness, induration, and possibly incisional drainage. Treatment includes drainage and antibiotic treatment directed at methicillin-resistant Staphylococcus aureus and streptococci. Patients with invasive infections should be admitted.
Ureteral injury can occur during abdominal hysterectomy, resulting from crushing, transecting, or ligating trauma. These patients present soon after surgery with flank pain. They may also complain of fever, costovertebral angle tenderness, and hematuria. The workup includes a urinalysis and a CT scan with IV contrast or an intravenous pyelogram to evaluate for obstruction. These patients should be admitted for ureteral catheterization and possible repair, although delayed repair after percutaneous nephrostomy is also acceptable.